How are Extrapyramidal Symptoms (EPS) managed?

Management of Extrapyramidal Symptoms (EPS)

When EPS occurs, immediately treat acute dystonia with benztropine 1-2 mg IM/IV, reduce the antipsychotic dose when clinically feasible, or switch to an atypical antipsychotic with lower EPS risk such as quetiapine, olanzapine, or clozapine. 1

Types of EPS and Their Specific Management

Acute Dystonia

• Sudden spastic muscle contractions typically occur within the first 3-5 days of antipsychotic treatment, most commonly affecting the neck, eyes (oculogyric crisis), or torso 2, 3
• Young males are at highest risk for dystonic reactions, particularly when using high-potency typical antipsychotics like haloperidol 2, 1
• Immediate treatment with anticholinergic medications (benztropine 1-2 mg IM/IV) or antihistamines (diphenhydramine) provides rapid relief 2, 1
• Laryngospasm can be life-threatening and requires emergency intervention 2

Drug-Induced Parkinsonism

• Symptoms include bradykinesia, tremors, and rigidity appearing within the first three months of treatment due to dopamine D2 receptor blockade 2, 1
• First-line management: reduce the antipsychotic dose when clinically appropriate 1, 3
• Second-line: switch to an atypical antipsychotic with lower EPS risk (quetiapine, olanzapine, clozapine) 1
• Third-line: add anticholinergic agents (benztropine) or amantadine if dose reduction is not feasible 2, 3
• Be cautious differentiating parkinsonism from negative symptoms of schizophrenia or catatonia 2

Akathisia

• Severe subjective restlessness with motor agitation (pacing, inability to sit still) commonly misinterpreted as psychotic agitation or anxiety 2, 1
• Most difficult EPS to treat and a major cause of medication non-compliance 2
• Management hierarchy: 2, 3
  • First: Lower the antipsychotic dose if clinically feasible
  • Second: Lipophilic beta-blockers (propranolol, metoprolol) are most effective 3
  • Third: Benzodiazepines may provide relief
  • Fourth: Anticholinergic agents are inconsistently helpful

Tardive Dyskinesia

• Involuntary choreic or athetoid movements, typically orofacial, associated with long-term antipsychotic use 2, 1
• Risk is approximately 5% per year in young patients, with elderly patients having up to 50% risk after 2 years of continuous typical antipsychotic use 1, 4
• Management strategy: reduce dose or switch to an atypical antipsychotic; maintain current medication only if patient is in complete remission and medication change would precipitate relapse 1

Medication Selection Based on EPS Risk

EPS Risk Hierarchy (Lowest to Highest)

• Quetiapine has the lowest EPS risk among commonly used antipsychotics 1, 4, 5
• Aripiprazole has low EPS risk but requires careful dosing 4
• Olanzapine and clozapine have moderate-to-low EPS risk 1, 4, 5
• Risperidone has higher EPS risk, especially at doses exceeding 2-6 mg/day 4, 6, 5
• Typical antipsychotics (haloperidol, chlorpromazine) have the highest EPS risk 2, 1, 4

Prophylactic Anticholinergic Use: A Controversial Practice

Anticholinergic medications should NOT be used routinely for preventing EPS but reserved for treatment of significant symptoms when dose reduction and switching strategies have failed. 1, 7

• Consider prophylactic anticholinergics only in high-risk patients: young males, those with history of dystonic reactions, or paranoid patients where compliance is critical 2
• Reevaluate need for anticholinergics after the acute treatment phase or if antipsychotic doses are lowered, as many patients no longer need them during long-term therapy 2
• Avoid anticholinergics in elderly patients due to heightened sensitivity causing delirium, drowsiness, and paradoxical agitation 1, 7

Special Population Considerations

Children and Adolescents

• May be at higher risk for EPS than adults and have greater difficulty communicating concerns due to developmental issues 2
• Monitor carefully with at least weekly visits initially to establish rapport and ensure compliance 2
• Side effects are a common reason for medication non-compliance, increasing relapse risk 2

Elderly Patients

• Use quetiapine (starting 25 mg PO) as preferred antipsychotic when minimizing EPS is priority 4, 7
• Avoid typical antipsychotics due to significant cholinergic, cardiovascular, and extrapyramidal side effects 4
• Haloperidol is contraindicated in patients with Parkinson's disease or dementia with Lewy bodies due to severe EPS risk 7
• Use lowest effective dose for shortest duration; try behavioral interventions first 4

Monitoring and Clinical Pitfalls

• Regular monitoring for early signs of EPS is essential throughout antipsychotic treatment 1
• Akathisia is frequently misdiagnosed as anxiety or psychotic agitation, leading to inappropriate dose increases that worsen the problem 2, 1
• Anticholinergic medications can worsen delirium in patients with anticholinergic drug intoxication 2
• Monitor for orthostatic hypotension, especially with quetiapine during initial dose titration 4
• Avoid combining quetiapine with benzodiazepines when possible due to increased sedation risk 4

Dosing Strategy to Minimize EPS

• Use the lowest effective antipsychotic dose and avoid rapid dose escalation 1, 3
• For risperidone in elderly: start 0.25-0.5 mg daily; EPS risk increases significantly above 2 mg daily 4, 7
• For olanzapine in elderly: start 2.5-5 mg daily with moderate EPS risk 4, 7
• For quetiapine in elderly: start 25 mg every 12 hours; maximum typically 200 mg twice daily 4