What are the treatment options for akathisia?

Treatment Options for Akathisia

For akathisia management, the recommended first-line approach is to lower the dosage of the antipsychotic medication, switch to another antipsychotic medication, add a benzodiazepine, or add a beta-adrenergic blocking agent such as propranolol. 1

Initial Management Strategies

Antipsychotic Medication Adjustments

1. Dose reduction

   • Lower the dose of the current antipsychotic while remaining within the therapeutic range 1
   • This is often the simplest and most effective first step

2. Medication switch

   • Consider switching to quetiapine or olanzapine which have lower risk of akathisia 1
   • Second-generation (atypical) antipsychotics generally have lower risk of akathisia than first-generation agents

First-Line Pharmacological Interventions

1. Beta-blockers

   • Propranolol: 10-30 mg two to three times daily 1
   • Most consistently effective treatment for acute akathisia 2
   • Contraindications: asthma, bradycardia, heart block
   • Monitor for hypotension and bradycardia

2. Benzodiazepines

   • Effective for acute symptom relief
   • Useful when subjective distress persists despite beta-blocker therapy 2
   • Caution: risk of dependence, sedation, and cognitive impairment
   • Avoid in elderly patients with cognitive impairment 3

Second-Line Pharmacological Options

1. Anticholinergic medications

   • Benztropine: 1-2 mg once or twice daily 4
   • Particularly effective for drug-induced extrapyramidal disorders 4
   • For acute dystonic reactions, 1-2 mg usually provides relief 4
   • Less consistently effective for akathisia than for other extrapyramidal symptoms

2. 5-HT2A antagonists

   • Mirtazapine: 7.5-15 mg once daily
   • Demonstrated the most compelling evidence for efficacy among serotonin antagonists 5
   • Recent network meta-analysis (2024) found mirtazapine to be highly effective (SMD -1.20) 6

3. Other options with evidence of efficacy

   • Vitamin B6: 600-1200 mg/day for ≥5 days 6
   • Trazodone: 50 mg/day 6
   • Mianserin: 15 mg/day 6
   • Biperiden: 6 mg/day 6

Treatment Algorithm

1. First step: Reduce antipsychotic dose if clinically feasible
2. Second step: If dose reduction is not possible or ineffective, add propranolol (10-30 mg 2-3 times daily)
3. Third step: If propranolol fails or is contraindicated, consider:
   • Adding a benzodiazepine (short-term use)
   • Switching to mirtazapine (7.5-15 mg daily)
4. Fourth step: For refractory cases, consider:
   • Anticholinergic agents (benztropine 1-2 mg daily)
   • Vitamin B6 (600-1200 mg daily)
   • Amantadine or clonidine 2

Special Considerations

Assessment

• Use a validated scale to systematically assess akathisia before starting antipsychotics and during dosage titration 7
• Differentiate akathisia from anxiety or psychotic agitation, as misdiagnosis can lead to inappropriate dose increases 1

Monitoring

• Monitor for improvement in subjective and objective symptoms
• Watch for side effects of treatments (hypotension, bradycardia, sedation)
• Reassess the need for anti-akathisia medications periodically

Pitfalls to Avoid

1. Misdiagnosis: Akathisia is often misinterpreted as psychotic agitation or anxiety, leading to inappropriate antipsychotic dose increases 1
2. Overtreatment: Avoid long-term use of adjunctive medications when possible
3. Undertreatment: Untreated akathisia is associated with medication non-compliance and increased suicide risk 6
4. Inappropriate combinations: Be cautious with multiple anticholinergic agents which can lead to anticholinergic toxicity

By following this structured approach to akathisia management, clinicians can effectively address this distressing side effect while maintaining therapeutic control of the underlying psychiatric condition.