What is the treatment for Extrapyramidal Symptoms (EPS) caused by psychotropic medications?

Treatment of Extrapyramidal Symptoms from Psychotropic Medications

For extrapyramidal symptoms (EPS) caused by psychotropic medications, first implement dose reduction and switching strategies, and if these are ineffective or symptoms are acute/severe, use short-term anticholinergic medications like benztropine 1-2 mg. 1

First-Line Management Approach

• Dose reduction or medication switch should be attempted first when EPS occurs, as this addresses the root cause rather than adding another medication 1
• When switching antipsychotics, consider medications with lower EPS risk such as atypical antipsychotics (olanzapine, quetiapine, clozapine) rather than high-potency typical antipsychotics (haloperidol) 1
• Anticholinergics should not be used routinely for preventing EPS but reserved for treatment of significant symptoms when dose reduction and switching strategies have failed 2

Pharmacological Management When Needed

Acute Dystonia

• For acute dystonic reactions, administer benztropine 1-2 mg IM/IV immediately to quickly relieve symptoms 1, 3
• Follow with oral benztropine 1-2 mg twice daily to prevent recurrence 3

Drug-Induced Parkinsonism

• Benztropine 1-4 mg daily in divided doses (usually 1-2 mg twice daily) 3
• Start with lower doses (0.5-1 mg) in elderly or frail patients 3
• Alternative: Amantadine 100-300 mg daily (lacks anticholinergic side effects) 4

Akathisia

• Beta-blockers (particularly propranolol) are often most effective 5
• Benzodiazepines may be used as an alternative or adjunct 5
• Anticholinergics are less effective for akathisia than for other forms of EPS 5

Important Clinical Considerations

• EPS risk varies significantly between medications - high-potency typical antipsychotics carry the highest risk (50-75% of patients) while atypicals have much lower risk (approximately 12%) 6
• Young males are at particularly high risk for acute dystonia 1
• Elderly patients require lower doses of anticholinergic medications and are more susceptible to adverse effects 3
• Duration of anticholinergic treatment:
  • For acute dystonia: Continue treatment for 1-2 weeks after antipsychotic discontinuation 1
  • For drug-induced parkinsonism: After 1-2 weeks, attempt to withdraw anticholinergic medication to determine continued need 3

Monitoring and Adverse Effects

• Monitor for anticholinergic side effects: dry mouth, blurred vision, constipation, urinary retention, cognitive impairment 4
• Long-term anticholinergic use may exacerbate tardive dyskinesia and should be avoided 4, 7
• Patients with EPS often experience more negative symptoms and poorer functional outcomes 6

Special Considerations

• For patients with contraindications to anticholinergic medications, amantadine is an effective alternative with fewer anticholinergic side effects 4
• Certain drug-induced extrapyramidal disorders that develop slowly may not respond to benztropine 3
• The lowest effective dose of both antipsychotic and anti-EPS medications should be used to maximize benefits while minimizing risks 7