Does akathisia (involuntary movement disorder) improve with continued use of Abilify (aripiprazole)?

Management of Akathisia Associated with Aripiprazole (Abilify)

Akathisia associated with aripiprazole (Abilify) typically does not improve with continued use and often requires intervention rather than waiting for adaptation.

Understanding Akathisia with Aripiprazole

Akathisia is a common and distressing movement disorder characterized by:

• Subjective feeling of inner restlessness
• Objective component of excessive movements
• Typically occurs within the first few days of antipsychotic therapy 1

Among newer antipsychotics, aripiprazole has a significant association with akathisia:

• Estimated weighted incidence rate of 17.2% with cariprazine, 12.7% with lurasidone, 10.0% with brexpiprazole, 6.8% with asenapine, and 3.9% with iloperidone 2
• Aripiprazole-induced akathisia can be severe enough to cause treatment discontinuation in some cases

Management Approach for Aripiprazole-Induced Akathisia

First-line Interventions:

1. Dose reduction of aripiprazole if clinically feasible

   • Akathisia is dose-dependent; lower doses may reduce symptoms while maintaining therapeutic effect

2. Add beta-blocker (propranolol)

   • Recommended dosage: 10-30 mg two to three times daily 1
   • Has shown efficacy in multiple guidelines for akathisia management

Second-line Options:

1. Switch to an antipsychotic with lower akathisia risk

   • Consider quetiapine or olanzapine which have lower propensity for akathisia 1

2. Add benzodiazepine

   • Short-term use can help manage acute symptoms
   • Caution with respiratory conditions and risk of dependence

Third-line Options:

1. Add anticholinergic agent (e.g., benztropine)

   • May help with concurrent extrapyramidal symptoms
   • Less effective for isolated akathisia than for dystonia

2. Consider mirtazapine

   • Low dose (15 mg) has shown efficacy in treatment-resistant akathisia 3
   • Can be particularly helpful when other approaches fail

Important Considerations

Monitoring

• Assess for suicidal ideation, as akathisia has been associated with increased suicide risk 4, 5
• Use standardized rating scales (e.g., Barnes Akathisia Rating Scale) to objectively track symptoms

Warning Signs

• Severe akathisia may present with intense anxiety and agitation
• Particularly concerning when combined with other medications like lamotrigine 4

Special Populations

• Lower starting doses of aripiprazole are recommended in older or frail patients
• Higher vigilance needed in patients with previous history of akathisia

Clinical Pearls

• Akathisia is often misdiagnosed as anxiety, agitation, or worsening of psychiatric symptoms
• Unlike some side effects that diminish with continued use, akathisia typically requires active management rather than waiting for tolerance to develop
• Withdrawal akathisia can also occur when tapering antipsychotics too quickly 6
• The combination of aripiprazole with antidepressants may increase akathisia risk 4

Remember that akathisia significantly impacts quality of life and medication adherence. Prompt recognition and management are essential for improving patient outcomes and preventing treatment discontinuation.