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

First-Line Treatment for Extrapyramidal Symptoms (EPS) from Psychotropic Medications

Benztropine is the first-line treatment for extrapyramidal symptoms (EPS) caused by psychotropic medications, with a recommended dosage of 1-2 mg orally once or twice daily. 1

Pharmacological Management of EPS

First-Line Agents

• Anticholinergic medications, specifically benztropine, are the first-line treatment for acute dystonic reactions and other EPS at a dose of 1-4 mg once or twice daily 1
• For drug-induced extrapyramidal disorders due to neuroleptic drugs (e.g., phenothiazines), the recommended dosage of benztropine is 1-4 mg once or twice daily orally 1
• In acute dystonic reactions, 1-2 mg of benztropine usually relieves the condition quickly, followed by 1-2 mg twice daily to prevent recurrence 1

Alternative Agents

• Amantadine (100-300 mg/day) is an effective alternative for patients in whom anticholinergic side effects are problematic, as it has comparable efficacy to benztropine but with fewer anticholinergic side effects 2
• For akathisia specifically, beta-blockers (particularly propranolol) may be more effective than anticholinergic agents 3
• Benzodiazepines can be used as an alternative or adjunctive treatment for acute dystonic reactions 3

EPS Management by Specific Type

Acute Dystonia

• Acute dystonias typically occur 3-5 days after starting antipsychotic therapy or increasing the dosage 3
• Treatment: Immediate administration of benztropine 1-2 mg orally or parenterally 1
• Maintenance: Continue benztropine 1-2 mg twice daily for at least 1-2 weeks to prevent recurrence 1

Drug-Induced Parkinsonism

• Symptoms generally appear within the first three months of antipsychotic treatment 3
• Treatment: Benztropine 1-2 mg daily, with gradual titration as needed up to 6 mg daily 1
• Alternative: Amantadine 100-300 mg/day if anticholinergic side effects are problematic 2

Akathisia

• Appears days to weeks after antipsychotic exposure begins 3
• Treatment options (in order of preference):
  • Reduce antipsychotic dose if clinically feasible 3
  • Add propranolol or other lipophilic beta-blocker 3
  • Add benztropine 1-2 mg twice daily 1

Special Considerations

Duration of Treatment

• When EPS develop soon after initiation of antipsychotic treatment, they are likely to be transient 1
• After 1-2 weeks of treatment with benztropine, consider withdrawing the medication to determine continued need 1
• Some drug-induced extrapyramidal disorders that develop slowly may not respond to benztropine 1

Prevention Strategies

• Consider using atypical antipsychotics with lower EPS risk (quetiapine, aripiprazole) when possible 4, 5
• Among atypical antipsychotics, quetiapine has the lowest risk of EPS, followed by aripiprazole, olanzapine, and risperidone 4
• Typical antipsychotics have the highest overall risk of EPS 4
• For high-risk patients, prophylactic anticholinergic treatment may be appropriate when initiating high-potency antipsychotics 3

Monitoring

• Regular assessment for both EPS and anticholinergic side effects is essential 6
• Be aware that anticholinergic agents themselves can cause significant side effects including confusion, blurred vision, dry mouth, constipation, and urinary retention 3
• Long-term use of anticholinergic agents may potentially exacerbate tardive dyskinesia 2

By following this algorithmic approach to EPS management, clinicians can effectively treat these troublesome side effects while maintaining the therapeutic benefits of antipsychotic medications.