What is the treatment for akathisia?

Akathisia Treatment

Propranolol 10-30mg two to three times daily is the first-line treatment for akathisia, with evidence supporting its efficacy over other agents. 1

First-line Approaches

Medication Adjustments

1. Modify the causative antipsychotic:
   • Lower the dosage of the causative antipsychotic medication 1
   • Switch to an antipsychotic with lower risk of akathisia (e.g., quetiapine) 1
   • Initial quetiapine dosing: 12.5mg twice daily; maximum: 200mg twice daily 1

Pharmacological Interventions

1. Beta-blockers:

   • Propranolol 10-30mg two to three times daily 1
   • Use with caution in patients with asthma, diabetes, or cardiovascular disease 1
   • Most consistently effective treatment for acute akathisia 2

2. Benzodiazepines:

   • Lorazepam 0.5-2mg as needed 1
   • Note: Regular use can lead to tolerance and dependence 1

3. Anticholinergics:

   • Benztropine 1-4mg once or twice daily 3
   • For drug-induced extrapyramidal disorders: 1-2mg twice daily 3
   • Maximum daily dose: 6mg 3
   • Particularly useful for acute dystonic reactions 3

Second-line Treatments

1. 5-HT2A antagonists:

   • Mirtazapine (7.5-15mg once daily) has shown compelling evidence for efficacy 4
   • Recent evidence suggests mirtazapine may be more effective than propranolol (SMD -1.20 vs -0.78) 5
   • Other options include trazodone (50mg daily) and mianserin (15mg daily) 5

2. Other options:

   • Vitamin B6 (600-1200mg daily) has shown good efficacy and tolerance profile 5
   • Biperiden (6mg daily) has demonstrated efficacy 5
   • Amantadine or clonidine may be tried if other treatments fail 2

Treatment Algorithm

1. Initial assessment:

   • Use a validated scale (e.g., Abnormal Involuntary Movement Scale) to assess severity 1
   • Identify the causative medication

2. First steps:

   • Reduce dose of causative antipsychotic if clinically feasible 1
   • Consider switching to an antipsychotic with lower akathisia risk (e.g., quetiapine) 1

3. Adjunctive medication (if step 1 insufficient):

   • Start propranolol 10mg BID-TID (if no contraindications) 1
   • If propranolol contraindicated or ineffective, try benzodiazepines 1, 2
   • If still ineffective, consider mirtazapine 15mg daily 4, 5

4. Monitoring:

   • Regular assessment for abnormal movements 1
   • Monitor for medication-specific side effects (e.g., orthostatic hypotension with propranolol) 1

Special Considerations

• Elderly patients: Use lower doses due to increased sensitivity to CNS effects 1
• Patients with Parkinson's disease: Extremely sensitive to antipsychotic effects; consider pimavanserin, clozapine, or quetiapine 1
• Cardiovascular disease: Monitor for orthostatic hypotension, especially with propranolol 1
• Pregnancy: Avoid combination therapy with valproate and risperidone 1

Important Caveats

• Abrupt withdrawal of antipsychotics can worsen symptoms; changes should be gradual 1
• Second-generation (atypical) antipsychotics generally have lower risk of akathisia than first-generation agents 1
• Akathisia can significantly impact treatment adherence and quality of life 1, 2
• Evidence for tardive akathisia treatment is limited compared to acute akathisia 2

The most recent and comprehensive evidence from a 2024 network meta-analysis suggests mirtazapine, biperiden, and vitamin B6 may be more effective than propranolol for antipsychotic-induced akathisia 5, but clinical guidelines still recommend propranolol as first-line therapy 1.