What are the treatment options for akathisia?

Treatment Options for Akathisia

For patients with akathisia associated with antipsychotic therapy, the recommended treatment options include lowering the dosage of the antipsychotic medication, switching to another antipsychotic medication, adding a benzodiazepine medication, or adding a beta-adrenergic blocking agent. 1

First-Line Approaches

Modification of Antipsychotic Therapy

1. Dose reduction of the causative antipsychotic if clinically feasible
2. Switching antipsychotics to one with lower risk of akathisia:
   • Consider quetiapine or olanzapine which have lower risk profiles 2, 3

Pharmacological Interventions

Beta-Blockers

• Propranolol (non-selective beta-blocker):
  • Most consistently effective treatment for acute akathisia 4
  • Dosage: 30-80 mg/day 5
  • Complete remission in approximately 64% of cases 5
  • Onset of action is rapid, typically within 24 hours

Benzodiazepines

• Can be added when beta-blockers fail 4
• Options include:
  • Lorazepam: 1 mg SC or IV (up to 2 mg maximum)
  • Use lower doses (0.25-0.5 mg) in older/frail patients or those with COPD 1

Second-Line Approaches

Alternative Medications

1. Anticholinergic agents (e.g., benztropine) 6

   • Particularly useful when akathisia co-occurs with other extrapyramidal symptoms

2. Serotonin 5-HT2a antagonists 7

   • Mirtazapine: 7.5-15 mg once daily
   • Trazodone
   • Cyproheptadine

3. Vitamin B6 8

   • 300 mg twice daily has shown efficacy similar to propranolol

4. Selective beta-1 blockers 9

   • Metoprolol: 25-100 mg/day
   • May be useful when non-selective beta-blockers are contraindicated

Clinical Presentation and Assessment

Akathisia presents as:

• Subjective symptoms: Inner restlessness and urge to move
• Objective manifestations: Rocking while standing/sitting, marching in place, crossing/uncrossing legs 2, 4

Special Considerations

Elderly Patients

• Use lower doses of medications
• Monitor closely for extrapyramidal symptoms as elderly are more susceptible 2
• Avoid benzodiazepines in patients with cognitive impairment due to risk of decreased cognitive performance 1

Patients with Comorbidities

• Respiratory conditions: Caution with beta-blockers in asthma; consider selective beta-1 blockers
• Cardiovascular disease: Monitor for orthostatic hypotension, especially when combining medications
• Hepatic/renal impairment: Reduce doses of medications accordingly 1

Prevention Strategies

1. Standardized titration of antipsychotics ("start low, go slow") 4
2. Use of newer atypical antipsychotics with lower risk profiles 2
3. Early recognition and intervention at first signs of restlessness 2

Monitoring

• Assess for improvement in subjective and objective symptoms
• Monitor for side effects of treatments:
  • Beta-blockers: Hypotension, bradycardia
  • Benzodiazepines: Sedation, respiratory depression, falls
  • Anticholinergics: Dry mouth, blurred vision, constipation, urinary retention

By following this algorithmic approach to akathisia management, clinicians can effectively address this distressing side effect while minimizing additional adverse effects and improving patient quality of life.