What is the typical dose of propranolol (beta blocker) for treating akathisia?

Propranolol Dosing for Akathisia

The typical dose of propranolol for treating akathisia is 30-80 mg per day, usually administered in divided doses. 1

Dosing Guidelines

• Initial dosing typically starts at 10-20 mg two to three times daily 1, 2
• Effective therapeutic range is generally 30-80 mg per day in divided doses 1
• Response to treatment is typically rapid, often occurring within 24 hours of initiating therapy 1
• Low doses are generally effective for akathisia, with minimal side effects reported at these dosages 1, 2

Administration Considerations

• Propranolol can be administered orally in immediate-release formulations 3
• For immediate-release propranolol, the typical administration schedule is 3-4 times daily due to its relatively short half-life (3-6 hours) 3
• Extended-release formulations have a longer half-life (8-20 hours) but are less commonly used for acute akathisia management 3

Clinical Evidence

• In open trials, propranolol has demonstrated substantial improvement in neuroleptic-induced akathisia, with complete remission in approximately 64% of patients 1
• Comparative studies have shown propranolol (80 mg/day) to be significantly more effective than placebo for reducing akathisia severity (29% reduction vs. 11% with placebo) 4
• Low-dose propranolol (20-30 mg/day) has been found to be dramatically effective in reducing akathisia when compared to periods of no treatment 2

Monitoring and Safety Considerations

• Blood pressure and heart rate should be monitored during treatment, particularly at initiation 3
• Hypotension and bradycardia are potential adverse effects that may necessitate dose adjustment or discontinuation 4
• Propranolol is contraindicated in patients with asthma, obstructive airway disease, decompensated heart failure, and certain cardiac conduction abnormalities 3

Special Populations

• In patients with comorbidities (especially cardiovascular or respiratory conditions), starting at lower doses (10 mg twice daily) and titrating slowly is recommended 5
• For patients with withdrawal akathisia, propranolol (40 mg/day) in combination with an appropriate antipsychotic has shown effectiveness 6

Treatment Duration

• Treatment duration is typically determined by clinical response and the persistence of the underlying cause of akathisia
• Propranolol can be continued as long as the patient remains on the causative agent (typically antipsychotics) 6
• If the causative agent is discontinued, propranolol can often be tapered and discontinued as well

Alternative Treatments

• If propranolol is ineffective or contraindicated, alternative treatments include mirtazapine (15 mg/day), which has shown comparable efficacy with better cardiovascular tolerability 4
• Benzodiazepines like lorazepam (2 mg/day) have also been used but may be less effective than propranolol 2