What is the treatment for akathisia?

Treatment of Akathisia

The first-line treatment for akathisia is lowering the antipsychotic dose if clinically feasible, or adding propranolol 10-30 mg two to three times daily, which is the most consistently effective pharmacological intervention. 1

Initial Management Strategy

Dose reduction or medication switching should be attempted first when clinically possible, as akathisia is fundamentally a drug-induced adverse effect where prevention is superior to treatment. 1, 2

• Reduce the current antipsychotic dosage while remaining within therapeutic range 1
• Switch to an antipsychotic with lower akathisia risk, such as quetiapine, olanzapine, or clozapine 1, 3
• Avoid antipsychotic polypharmacy, which increases side effect burden 1

Critical pitfall: Akathisia is frequently misinterpreted as psychotic agitation or anxiety, leading clinicians to inappropriately increase antipsychotic doses, which worsens the condition rather than improving it. 1

Pharmacological Treatment Algorithm

First-Line Pharmacotherapy: Beta-Blockers

Propranolol (10-30 mg two to three times daily) is the most consistently effective treatment based on available evidence. 1, 2, 4

• Lipophilic beta-blockers demonstrate the strongest evidence for acute akathisia 2
• Propranolol has limitations including orthostatic hypotension, bradycardia, contraindications in asthma, and complex titration requirements 5

Second-Line Options: When Beta-Blockers Fail or Are Contraindicated

If propranolol is unsuccessful or contraindicated, add benzodiazepines (particularly clonazepam), especially if subjective distress persists. 6, 2, 4

• Benzodiazepines provide symptomatic relief and address the anxiety component 6, 2
• They are part of the "B-CALM" mnemonic for akathisia management 4

Third-Line: Serotonin 5-HT2a Antagonists

Low-dose mirtazapine (7.5-15 mg once daily) has the most compelling evidence among serotonergic agents and represents an emerging treatment class. 5, 4, 7

• Mirtazapine demonstrates strong efficacy with good tolerability 5, 4
• Other 5-HT2a antagonists with evidence include trazodone, mianserin, and cyproheptadine 5, 3

Fourth-Line: Additional Options

If the above treatments fail, consider:

• Amantadine (mild dopaminergic agent) 6, 2
• Clonidine (alpha-2 agonist) 2, 4
• Anticholinergic agents - though these are not consistently helpful for akathisia specifically and are more effective for other extrapyramidal symptoms 6, 2
• Gabapentin or pregabalin (voltage-gated calcium channel blockers) 4, 7

Important caveat: Anticholinergic agents are notably less effective for akathisia compared to other extrapyramidal side effects like dystonia or parkinsonism, despite being commonly prescribed. 6, 2

Special Populations and Considerations

Children and Adolescents

• Children and adolescents may be at higher risk for extrapyramidal side effects, including akathisia, compared to adults 6
• Monitor carefully for anticholinergic side effects when using anticholinergic agents 1

Acute Emergency Settings

• Intramuscular administration is preferred over intravenous route for acute akathisia management 1

Cardiovascular Risk Patients

• Carefully consider QT-prolonging effects when switching antipsychotics in patients with high cardiovascular risk 1

Chronic and Tardive Akathisia

Evidence for treating tardive akathisia is unsatisfactory and these cases may prove resistant to standard pharmacological interventions. 2, 7

• Chronic akathisia may persist even after discontinuing the causative agent 7
• Rotation between different pharmacological management strategies may be optimal in resistant cases 7
• Discontinuation of the causative drug remains the foundation of management 7