What is the treatment for extrapyramidal symptoms?

Treatment of Extrapyramidal Symptoms

The first-line treatment for extrapyramidal symptoms (EPS) is anticholinergic medication, with benztropine being the standard agent at a dosage of 1-4 mg once or twice daily, adjusted according to symptom severity and patient response. 1

Types of Extrapyramidal Symptoms and Their Management

Acute Dystonic Reactions

• Present as muscle spasms and abnormal postures, typically occurring 3-5 days after starting antipsychotics or increasing dosage
• Treatment:
  • Benztropine 1-2 mg orally or parenterally for immediate relief 1
  • Continue with 1-2 mg twice daily to prevent recurrence 1

Pseudoparkinsonism

• Presents with rigidity, tremor, bradykinesia, and masked facies
• Treatment:
  • Benztropine 1-2 mg daily, with a range of 0.5-6 mg 1
  • Start with lower doses (0.5-1 mg) in elderly or thin patients 1
  • May be given as a single bedtime dose or divided doses throughout the day 1

Akathisia

• Characterized by subjective restlessness and objective motor restlessness
• Treatment algorithm:
  1. Beta-blockers: Propranolol 10-30 mg 2-3 times daily (first choice) 2
     • Use cautiously in patients with asthma, diabetes, or cardiovascular disease
  2. Benzodiazepines: Lorazepam 0.5-2 mg as needed 2
     • Note: Regular use can lead to tolerance and dependence
  3. Anticholinergics: May be less effective for akathisia than for other EPS 3

General Management Strategies

Medication Adjustments

1. Lower the dosage of the causative antipsychotic 3
2. Switch to an atypical antipsychotic with lower EPS risk:
   • Quetiapine (initial: 12.5 mg twice daily; maximum: 200 mg twice daily) 4, 2
   • Olanzapine (initial: 2.5 mg at bedtime; maximum: 10 mg daily) 4
   • Aripiprazole or cariprazine (for negative symptoms) 4

Anticholinergic Medications

• Benztropine is the standard treatment 1
  • For drug-induced EPS: 1-4 mg once or twice daily 1
  • Start with low doses and increase gradually at 5-6 day intervals 1
  • Maximum daily dose: 6 mg 1
• Important considerations:
  • Do not abruptly discontinue anticholinergics when starting treatment 1
  • When EPS develops soon after starting antipsychotics, it may be transient 1
  • After 1-2 weeks, consider withdrawing anticholinergics to assess continued need 1

Alternative Agents

• Amantadine: Effective alternative for patients who cannot tolerate anticholinergic side effects 5
  • Comparable efficacy to benztropine but with fewer anticholinergic side effects 5
  • Particularly useful when anticholinergic effects are contraindicated 5

Special Considerations

Tardive Dyskinesia

• For patients developing tardive dyskinesia:
  • Consider VMAT2 inhibitors (valbenazine or deutetrabenazine) 2
  • Switch to quetiapine or another atypical antipsychotic with lower TD risk 2
  • Avoid abrupt withdrawal of antipsychotics as this can worsen TD symptoms 2
  • Monitor using Abnormal Involuntary Movement Scale (AIMS) every 3-6 months 2

High-Risk Populations

• Elderly patients:
  • More sensitive to medication effects - use lower doses 2
  • Start benztropine at 0.5 mg and titrate slowly 1
• Parkinson's disease patients:
  • Extremely sensitive to antipsychotic effects 2
  • Consider pimavanserin, clozapine, or quetiapine if antipsychotics are needed 2

Monitoring

• Regular assessment for abnormal movements using standardized scales like AIMS 2
• Monitor for orthostatic hypotension in patients with cardiovascular disease 2
• For patients switched to quetiapine, monitor metabolic parameters (blood glucose, lipids, weight) 2

Prevention

• When starting high-potency antipsychotics in high-risk patients, consider prophylactic anticholinergics 3
• Consider using atypical antipsychotics with lower EPS risk as first-line treatment 6
• If anticholinergics are added during initial treatment, they may be discontinued after stabilization 4
• However, if ongoing management of EPS is required, maintain anticholinergic medication well after antipsychotic discontinuation to prevent delayed emergence of symptoms 4