How to treat extrapyramidal symptoms?

Treatment of Extrapyramidal Symptoms

The first-line treatment for extrapyramidal symptoms (EPS) is anticholinergic medication, with benztropine 1-2 mg being the treatment of choice for acute dystonia, while dose reduction or switching to an atypical antipsychotic with lower EPS risk should be considered for long-term management. 1

Types of Extrapyramidal Symptoms and Their Management

Acute Dystonia

• Characterized by sudden spastic muscle contractions, typically occurring within days of starting antipsychotic treatment 1
• Treatment: Benztropine 1-2 mg IM/IV for immediate relief of acute dystonic reactions 1, 2
• After acute management, oral benztropine 1-2 mg twice daily can prevent recurrence 2

Drug-induced Parkinsonism

• Features include bradykinesia, tremors, and rigidity due to dopamine receptor blockade 1
• Treatment: Benztropine 1-4 mg daily in divided doses, with dosage individualized according to patient needs 2
• Amantadine is an alternative treatment option for parkinsonian symptoms 3

Akathisia

• Presents as subjective restlessness and physical agitation, often misinterpreted as anxiety 1
• Treatment: Beta-blockers (particularly propranolol) are most effective; benzodiazepines may also help 4
• Anticholinergics are less effective for akathisia compared to other EPS 4

Tardive Dyskinesia

• Characterized by involuntary movements associated with long-term antipsychotic use 1
• Management: Prevention is key as this condition is often irreversible 5
• Consider switching to atypical antipsychotics with lower risk of tardive dyskinesia 6, 1

Pharmacological Management Algorithm

1. For acute dystonic reactions:

   • Administer benztropine 1-2 mg IM/IV for rapid relief 1, 2
   • Alternative: Diphenhydramine can be effective for severe EPS when benztropine is unavailable 7

2. For ongoing EPS management:

   • Start with benztropine 0.5-1 mg orally 1-2 times daily, increasing as needed 2
   • Maximum dose: 6 mg daily, with increases made in 0.5 mg increments at 5-6 day intervals 2
   • Dosage must be individualized based on age, weight, and symptom severity 2

3. Medication selection considerations:

   • Older and thinner patients generally cannot tolerate large doses 2
   • Some patients experience greatest relief with a single bedtime dose; others require divided doses 2-4 times daily 2

Non-pharmacological Approaches

1. Antipsychotic medication adjustment:

   • Reduce the dose of the causative antipsychotic when possible 5, 4
   • Consider switching to atypical antipsychotics with lower EPS risk (quetiapine, olanzapine, clozapine) 6, 1
   • Avoid high doses of atypical antipsychotics (e.g., risperidone >2 mg/day can cause EPS) 6, 5

2. Discontinuation of anticholinergic treatment:

   • Long-term use of anticholinergic agents is not recommended 5
   • If prophylactic treatment is initiated, it should be discontinued after approximately two weeks 5
   • Gradual withdrawal of anticholinergic medication typically does not cause EPS recurrence 5

Special Considerations

• High-risk patients: Young males are at higher risk for acute dystonia and may benefit from prophylactic anticholinergic treatment 1
• Elderly patients: More sensitive to anticholinergic side effects; use lower doses 2
• Children and adolescents: May respond well to diphenhydramine for EPS management 7
• Medication combinations: Avoid combining typical and atypical antipsychotics as this increases EPS risk 5

Common Pitfalls and Caveats

• Misdiagnosis: Akathisia is often misinterpreted as anxiety or psychotic agitation, leading to inappropriate dose increases of the causative antipsychotic 1
• Overuse of prophylaxis: Routine prophylactic use of anticholinergics is not recommended as it exposes many patients unnecessarily to side effects 5
• Anticholinergic side effects: Monitor for confusion, urinary retention, dry mouth, blurred vision, and constipation 4
• Delayed discontinuation: After EPS resolution, anticholinergics should be maintained briefly even after antipsychotic discontinuation to prevent delayed emergence of symptoms 1