What is the treatment for akathisia?

Akathisia Treatment

Propranolol 10-30mg two to three times daily is the first-line treatment for akathisia, with dose adjustments based on clinical response. 1

Understanding Akathisia

Akathisia is a distressing neuropsychiatric syndrome characterized by:

• Subjective feelings of inner restlessness and urge to move
• Objective components including rocking while standing/sitting, lifting feet as if marching, and crossing/uncrossing legs
• Significant distress that impacts treatment adherence and quality of life 1

Treatment Algorithm

First-line Approaches:

1. Medication Adjustment

   • Lower the dose of the causative antipsychotic medication 1
   • Consider switching to an antipsychotic with lower akathisia risk (e.g., quetiapine) 1

2. Pharmacological Interventions

   • Beta-blockers: Propranolol 10-30mg two to three times daily 1

     • Caution: Use carefully in patients with asthma, diabetes, or cardiovascular disease
     • Monitor for orthostatic hypotension in patients with cardiovascular disease

   • Benzodiazepines: Lorazepam 0.5-2mg as needed 1

     • Caution: Regular use can lead to tolerance and dependence

Second-line Options:

1. Anticholinergic Agents:

   • Benztropine 1-4mg once or twice daily 2
   • For acute dystonic reactions, 1-2mg usually provides relief 2
   • After initial treatment, 1-2mg twice daily usually prevents recurrence 2
   • Maximum dose: 6mg daily 2

2. Alternative Agents (based on recent evidence):

   • Mirtazapine 7.5-15mg once daily has shown compelling evidence for efficacy 3, 4
   • Vitamin B6 600-1200mg/day for ≥5 days 4
   • Biperiden 6mg/day for ≥14 days 4
   • Trazodone 50mg/day for ≥5 days 4
   • Mianserin 15mg/day for ≥5 days 4

Special Considerations

Elderly Patients

• More sensitive to medication effects
• Use lower doses of all medications 1
• Start with the lowest effective dose and titrate slowly

Patients with Parkinson's Disease

• Extremely sensitive to antipsychotic effects
• Consider pimavanserin, clozapine, or quetiapine as treatment options 1
• Pimavanserin is first-line for psychosis in Parkinson's disease 1

Monitoring

• Use the Abnormal Involuntary Movement Scale (AIMS) every 3-6 months to track progression 1
• Monitor for metabolic effects if switching to quetiapine (blood glucose, lipids, weight) 1
• For patients on benztropine, monitor for anticholinergic side effects (dry mouth, constipation, urinary retention, blurred vision)

Important Clinical Pearls

• Avoid abrupt withdrawal of antipsychotics as this can worsen symptoms; changes should be gradual 1
• Second-generation (atypical) antipsychotics generally have a lower risk of akathisia than first-generation agents 1
• Combination therapy with multiple psychotropics increases the risk of tardive dyskinesia 1
• The 2024 network meta-analysis found mirtazapine, biperiden, and vitamin B6 to have the greatest efficacy for antipsychotic-induced akathisia, with vitamin B6 having the best efficacy and tolerance profile 4

Treatment Failure

If initial treatments fail, consider:

1. Combining approaches (e.g., beta-blocker plus benzodiazepine)
2. Trial of mirtazapine if not already attempted
3. Consider amantadine or clonidine as alternative options 5
4. Consult with a specialist for refractory cases

Remember that akathisia symptoms might persist despite treatment, highlighting the importance of prevention through careful antipsychotic selection and dosing.