What is the treatment for Akathisia?

Treatment of Akathisia

Propranolol 10-30mg two to three times daily is the first-choice treatment for akathisia, with cautious use in patients with asthma, diabetes, or cardiovascular disease. 1

First-Line Management Strategies

1. Modify the causative medication:

   • Lower the dosage of the causative antipsychotic medication
   • Switch to an antipsychotic with lower EPS risk:
     • Consider quetiapine (initial: 12.5 mg twice daily; maximum: 200 mg twice daily)
     • Consider olanzapine (initial: 2.5 mg at bedtime; maximum: 10 mg daily) 1
   • Second-generation (atypical) antipsychotics generally have lower risk of akathisia than first-generation agents 1

2. Pharmacological interventions:

   • Beta-blockers:

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

   • Low-dose mirtazapine:

     • 7.5-15mg once daily has compelling evidence for efficacy 3
     • Acts through serotonin 5-HT2a receptor antagonism 3

   • Benzodiazepines:

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

Second-Line Options

1. Anticholinergic agents:

   • Benztropine 1-2mg daily (maximum 6mg daily) 1
   • For elderly patients: start at 0.5mg and titrate slowly 1
   • Provides symptomatic relief but may not address underlying cause 4

2. Alternative agents:

   • Gabapentin or pregabalin (voltage-gated calcium channel blockers) 4
   • Amantadine or clonidine if other treatments fail 2
   • Other agents with 5-HT2a antagonism: ritanserin, cyproheptadine, trazodone, mianserin 3

Monitoring and Assessment

• Use standardized scales to assess akathisia before starting antipsychotics and during dosage titration 5
• Monitor for:
  • Orthostatic hypotension with anticholinergics or beta-blockers 1
  • Cognitive impairment 1
  • Metabolic parameters (blood glucose, lipids, weight) if switching to quetiapine 1

Akathisia Risk with Newly Approved Antipsychotics

Incidence rates vary significantly among newer antipsychotics 6:

• Iloperidone: 3.9% (lowest risk)
• Asenapine: 6.8%
• Brexpiprazole: 10.0%
• Lurasidone: 12.7%
• Cariprazine: 17.2% (highest risk)

Clinical Pearls and Pitfalls

• Recognize akathisia presentation: Subjective inner restlessness and objective psychomotor restlessness (rocking while standing/sitting, marching movements) 4
• Don't miss akathisia in: Patients with motor disabilities, drug-induced parkinsonism, or those under mechanical restraint 4
• Chronic and tardive akathisia may persist after discontinuation of the causative agent and can be resistant to treatment 4
• Even antipsychotics with low EPS profiles (clozapine, quetiapine, aripiprazole, cariprazine) can induce akathisia 4
• Duration of adjunctive medications: Limited evidence exists regarding optimal duration of treatment; cautious prescribing is warranted 5
• Treatment rotation: For resistant cases, rotation between different pharmacological strategies may be optimal 4