Propranolol Dosing for Akathisia
For akathisia treatment, propranolol should be initiated at 20-40 mg/day in divided doses, with most patients responding to doses between 30-80 mg/day. 1
Dosing Algorithm
- Start with 10-20 mg twice daily or three times daily (total 20-40 mg/day) 1, 2
- Response typically occurs rapidly, often within 24 hours of initiating treatment 1
- If inadequate response, increase dose gradually up to 80 mg/day 1
- Complete remission of akathisia symptoms occurs in approximately 64% of patients at these doses 1
- Substantial improvement is seen in most remaining patients even without complete remission 1
Monitoring and Administration
- Baseline cardiovascular assessment (heart rate and blood pressure) should be performed before initiating propranolol 3
- Check for contraindications including heart block, asthma, decompensated heart failure, and hypotension 3
- No routine monitoring is required for most patients after baseline assessment 3
- Administer with food to reduce the risk of hypoglycemia 4
- Hold doses during times of diminished oral intake or vomiting 4
Special Considerations
- Lower doses may be required for patients with comorbidities or those experiencing adverse effects 4
- Avoid abrupt discontinuation to prevent rebound symptoms 3
- Monitor for potential adverse effects including hypotension, bradycardia, and bronchospasm 3
- Be aware that propranolol may mask symptoms of hypoglycemia in susceptible patients 3
Evidence for Efficacy
- Propranolol has demonstrated superior efficacy compared to some other beta-blockers (such as sotalol) for akathisia treatment 5
- Low-dose beta-1 selective blockers like metoprolol (25-100 mg/day) and betaxolol have also shown efficacy, suggesting that beta-1 blockade may be sufficient for treating akathisia 2, 6
- In one study, 9 out of 14 patients (64%) achieved complete remission of akathisia with propranolol at doses of 30-80 mg/day 1
- Propranolol can be effective for both neuroleptic-induced akathisia and withdrawal akathisia 7
Clinical Pearls
- Response to propranolol for akathisia is typically rapid (within 24 hours) compared to other treatment approaches 1
- Side effects at these relatively low doses are minimal 1
- Propranolol does not significantly improve symptoms of parkinsonism or tardive dyskinesia, so additional treatments may be needed if these symptoms coexist with akathisia 1
- Consider propranolol in combination with antipsychotic adjustment when managing akathisia, particularly in cases of withdrawal akathisia 7