How are extrapyramidal symptoms (EPS) managed?

Management of Extrapyramidal Symptoms (EPS)

Anticholinergic medications are the first-line treatment for acute extrapyramidal symptoms, with benzodiazepines as an effective alternative when anticholinergics are contraindicated. 1, 2

Types of Extrapyramidal Symptoms

• Acute dystonia: Characterized by sudden spastic contractions of muscle groups, typically occurring within the first few days of antipsychotic treatment, with higher risk in young males 1
• Drug-induced parkinsonism: Presents with bradykinesia, tremors, and rigidity due to dopamine receptor blockade 1
• Akathisia: Subjective feeling of restlessness with physical agitation, often misinterpreted as anxiety or psychotic agitation 1
• Tardive dyskinesia: Involuntary movements associated with long-term antipsychotic use, with approximately 5% annual risk in young patients 1

Management Algorithm for EPS

Step 1: Identify the Type of EPS

• Determine specific EPS presentation to guide appropriate treatment 2
• Assess severity using standardized rating scales when available 3

Step 2: Acute Management by EPS Type

For Acute Dystonia:

• First-line: Anticholinergic medications (immediate administration) 2, 3
  • Benztropine 1-2 mg IM/IV or
  • Diphenhydramine 25-50 mg IM/IV 4
• Alternative: Benzodiazepines if anticholinergics are contraindicated 2

For Drug-induced Parkinsonism:

• First-line: Lower the antipsychotic dose if clinically feasible 2
• Second-line: Add anticholinergic agent (e.g., benztropine) or amantadine 5
• Third-line: Consider switching to a lower-potency antipsychotic or atypical antipsychotic 2

For Akathisia:

• First-line: Reduce antipsychotic dose if possible 2
• Second-line: Add beta-blocker (propranolol 20-40 mg three times daily) 2
• Third-line: Add benzodiazepine or anticholinergic agent 2
• Fourth-line: Switch to atypical antipsychotic with lower EPS risk 1

For Tardive Dyskinesia:

• First-line: Gradually reduce or discontinue antipsychotic if clinically feasible 6
• Second-line: Switch to atypical antipsychotic with lower risk (e.g., quetiapine, olanzapine) 1

Step 3: Long-term Management

• Dose adjustment: Use lowest effective dose of antipsychotic 2
• Medication selection: Consider switching to atypical antipsychotics with lower EPS risk 1
  • Lower risk options include olanzapine, quetiapine, and clozapine 1
• Regular monitoring: Assess for emergence or worsening of EPS symptoms 3
• Prophylaxis consideration: Anticholinergic agents may be used prophylactically in high-risk patients, but long-term use is controversial 2

Special Considerations

• Anticholinergic discontinuation: If a patient requires anticholinergic medication for ongoing management of EPS, maintain the anticholinergic well after the antipsychotic is discontinued to prevent delayed emergence of symptoms 7

• Overdose management: In cases of severe EPS due to antipsychotic overdose, anticholinergic medication should be administered promptly 8

• Pediatric patients: Children and adolescents are at higher risk for EPS and require vigilant monitoring with lower initial doses of antipsychotics 1, 3

• Elderly patients: Also at increased risk for EPS; use lower doses and more gradual titration 1

• Contraindications: Avoid anticholinergics in patients with narrow-angle glaucoma, prostatic hypertrophy, or significant cognitive impairment 2

• Alternative treatments: Amantadine may be effective for EPS without significant anticholinergic side effects 5

Prevention Strategies

• Medication selection: Choose antipsychotics with lower EPS risk when possible 1
• Dosing strategy: Use lowest effective dose and avoid rapid dose escalation 1
• Regular assessment: Monitor for early signs of EPS to allow prompt intervention 3
• Risk factor identification: Recognize patients at higher risk (young males, elderly, those with previous EPS) 1