What is the role of propranolol (beta blocker) in treating akathisia?

Propranolol for Akathisia Treatment

Propranolol is the first-line pharmacological treatment for antipsychotic-induced akathisia, with doses of 10-30 mg two to three times daily being effective in most cases. 1

Understanding Akathisia

Akathisia is characterized by a distressing sense of inner restlessness and inability to remain still, often manifesting as:

• Constant pacing or physical agitation
• Subjective feelings of restlessness
• Inability to sit still or remain in one position

It is commonly misinterpreted as psychotic agitation, anxiety, or worsening of psychiatric symptoms, making it a frequent reason for medication non-adherence.

Evidence for Propranolol in Akathisia

Mechanism and Efficacy

• Propranolol, a non-selective beta-adrenergic receptor antagonist, has consistently demonstrated effectiveness in treating akathisia
• Response is typically rapid, often occurring within 24 hours 2
• Complete remission can be achieved in approximately 64% of cases 2
• Effective at relatively low doses (30-80 mg/day) 2

Dosing Recommendations

• Starting dose: 10 mg two to three times daily
• Can be titrated up to 30 mg three times daily if needed
• Lower doses may be considered in patients with cardiovascular concerns

Clinical Guidelines Support

The 2025 INTEGRATE guidelines specifically recommend propranolol for akathisia management:

• "Akathisia can potentially be managed with dose reduction. A switch to quetiapine or olanzapine can also be considered. Alternatively, adjunctive propranolol may be an option (10 mg or up to 30 mg, two to three times daily)." 1

The American Academy of Child and Adolescent Psychiatry also recognizes akathisia as a common extrapyramidal side effect of antipsychotics and notes that it "is often misinterpreted as psychotic agitation or anxiety and is a common reason for medication noncompliance." They further state that "relief has been reported with β-blockers and benzodiazepines." 1

Alternative Options When Propranolol Is Contraindicated

If propranolol is contraindicated (e.g., asthma, bradycardia, heart block):

• Anticholinergic agents may provide symptomatic relief 3
• Benzodiazepines can be considered as alternatives 1
• Serotonin 5-HT2a receptor antagonists (particularly mirtazapine 7.5-15 mg daily) have emerging evidence 3
• Vitamin B6 (300-600 mg twice daily) has shown comparable efficacy to propranolol in a small trial 4

Important Clinical Considerations

• Akathisia is often confused with anxiety or agitation, leading to inappropriate management
• Propranolol's side effects include orthostatic hypotension and bradycardia 3
• Contraindications include asthma, heart block greater than first degree, and cardiogenic shock
• Monitor for cardiovascular effects, especially in patients with pre-existing cardiac conditions
• Propranolol has also shown efficacy in tardive akathisia, a variant that can persist even after antipsychotic discontinuation 5

Treatment Algorithm

1. First-line: Propranolol 10-30 mg two to three times daily
2. If ineffective or contraindicated:
   • Consider dose reduction of the causative antipsychotic
   • Switch to an antipsychotic with lower risk of akathisia (quetiapine or olanzapine)
   • Try mirtazapine 7.5-15 mg daily
   • Consider vitamin B6 300-600 mg twice daily
3. For persistent cases:
   • Combination therapy may be necessary
   • Benzodiazepines can provide symptomatic relief

Propranolol remains the most evidence-based treatment for akathisia, with a favorable side effect profile at the doses typically used for this indication.