How to treat extrapyramidal symptoms (EPS)?

Treatment of Extrapyramidal Symptoms (EPS)

The first-line treatment for extrapyramidal symptoms includes lowering the dosage of the causative antipsychotic medication, switching to another antipsychotic with lower EPS risk, or adding specific medications such as propranolol (10-30mg two to three times daily) for akathisia or anticholinergic agents for dystonia and parkinsonism symptoms. 1

Initial Management Approach

1. Identify the type of EPS:

   • Acute dystonia: Abnormal muscle spasms and postures (typically 3-5 days after starting/increasing antipsychotic)
   • Pseudoparkinsonism: Tremor, rigidity, bradykinesia (within first 3 months)
   • Akathisia: Subjective restlessness and objective motor restlessness (days to weeks after exposure)

2. First steps in management:

   • Reduce the dose of the causative antipsychotic when possible 1, 2
   • Consider switching to an antipsychotic with lower EPS risk (e.g., quetiapine, olanzapine) 1

Specific Treatments by EPS Type

For Acute Dystonia

• Anticholinergic medications:
  • Benztropine: 1-2 mg orally or parenterally 3
    • Initial dose: 1-2 mg
    • Maintenance: 1-4 mg daily (maximum 6 mg)
  • Trihexyphenidyl: Start with low dose and titrate as needed 4
• Benzodiazepines as alternative 2

For Drug-Induced Parkinsonism

• Anticholinergic agents:
  • Benztropine: 1-4 mg once or twice daily 3
  • Trihexyphenidyl (with caution in patients with glaucoma risk) 4
• Amantadine as an alternative (especially when anticholinergic side effects are a concern) 5
• Dose reduction of the antipsychotic medication 2

For Akathisia

• Beta-blockers:
  • Propranolol: 10-30 mg two to three times daily (first choice) 1
  • Use with caution in patients with asthma, diabetes, or cardiovascular disease
• Benzodiazepines (e.g., lorazepam 0.5-2 mg as needed) 1
• Anticholinergics (less effective for akathisia than for other EPS) 2

Important Considerations

• Anticholinergics should not be used routinely for preventing EPS but reserved for treatment of significant symptoms when dose reduction and switching strategies have proven ineffective 6

• Elderly patients require lower starting doses of anticholinergics:

  • Benztropine: Start at 0.5 mg and titrate slowly 1

• Monitor for side effects:

  • Anticholinergics: Blurred vision, dry mouth, constipation, urinary retention, cognitive impairment
  • Beta-blockers: Hypotension, bradycardia, bronchospasm
  • Regular assessment for abnormal movements using standardized scales every 3-6 months 1

• Second-generation (atypical) antipsychotics generally have lower risk of EPS than first-generation agents 1

• For patients with Parkinson's disease requiring antipsychotics, consider pimavanserin, clozapine, or quetiapine to minimize EPS 1

Prevention Strategies

• Use the lowest effective dose of antipsychotic medication 2
• Consider atypical antipsychotics with lower EPS risk for patients requiring long-term treatment 7
• Avoid abrupt discontinuation of anticholinergic medications once started 1

Common Pitfalls to Avoid

• Failure to recognize EPS as side effects of non-antipsychotic medications (some antidepressants, lithium, anticonvulsants, antiemetics) 8
• Prolonged anticholinergic use without reassessment of continued need 1
• Overlooking neuroleptic malignant syndrome (hyperpyrexia, muscle rigidity, altered mental status, autonomic instability) which requires immediate medical attention 4, 9
• Confusing akathisia with anxiety or psychotic agitation, leading to inappropriate dose increases that worsen symptoms 2