What is the treatment for extrapyramidal symptoms (EPS) caused by antipsychotic medications?

Treatment for Extrapyramidal Symptoms from Antipsychotics

For acute dystonia, administer benztropine 1-2 mg IM/IV immediately as first-line treatment. 1

Immediate Management by EPS Type

Acute Dystonia (sudden muscle spasms, typically within first few days)

• Administer benztropine 1-2 mg IM/IV immediately 1
• Alternative option: benzodiazepines can be used if anticholinergics are contraindicated 2
• Continue anticholinergic medications even after antipsychotic discontinuation to prevent delayed symptom emergence 1
• Critical pitfall: Young males are at highest risk for acute dystonia, requiring immediate recognition and treatment 1

Drug-Induced Parkinsonism (bradykinesia, tremors, rigidity)

• First strategy: reduce the antipsychotic dose 1
• Second strategy: switch to atypical antipsychotic with lower EPS risk (olanzapine, quetiapine, or clozapine) 1
• If dose reduction/switching fails: add anticholinergic agent or amantadine 2
• Anticholinergics should NOT be used routinely for prevention, only for treatment of significant symptoms after other strategies fail 1

Akathisia (subjective restlessness, motor agitation)

• First-line: lipophilic beta-blockers, particularly propranolol or metoprolol 2
• If beta-blockers ineffective or contraindicated: try anticholinergics or benzodiazepines 2
• Common pitfall: Akathisia is frequently misinterpreted as anxiety or psychotic agitation, leading to inappropriate dose increases that worsen the problem 1
• This symptom carries high risk of medication non-compliance 1

Tardive Dyskinesia (involuntary movements from long-term use)

• Use same strategies as dystonia: reduce dose or switch medication 1
• Maintain current antipsychotic only if patient is in complete remission and medication change would precipitate relapse 1
• Important note: Clozapine has therapeutic value in established tardive dyskinesia cases 3

Severe EPS Management

• In cases of severe extrapyramidal symptoms, anticholinergic medication should be administered immediately 4
• Critical warning: Anticholinergic medications like benztropine can cause delirium, drowsiness, and paradoxical agitation 1

Prevention Strategy (Not Routine Prophylaxis)

• Use lowest effective antipsychotic dose: maximum 4-6 mg haloperidol equivalent in first-episode psychosis 1
• For risperidone specifically: keep doses at 2-4 mg/day in adults; EPS risk increases significantly above 2 mg/day 1
• Regular monitoring for early EPS signs is the preferred prevention strategy, NOT prophylactic anticholinergics 1
• Prophylactic anticholinergics should be reserved only for high-risk patients (young males starting high-potency typical antipsychotics) and discontinued after 2 weeks 1, 5

Medication Selection to Minimize Future EPS

• Atypical antipsychotics with lowest EPS risk: olanzapine, quetiapine, clozapine 1
• High-potency typical antipsychotics (haloperidol) carry highest risk 1
• Risperidone has dose-dependent EPS risk higher than other atypicals 1

Key Clinical Pitfalls

• Never use epinephrine or dopamine for hypotension in antipsychotic overdose with EPS, as beta stimulation worsens hypotension with quetiapine-induced alpha blockade 4
• Long-term antiparkinsonian treatment is not therapeutically beneficial; gradual withdrawal does not produce EPS recurrence 5
• Patients with EPS have significantly more negative symptoms and poorer functional outcomes 6, 7
• EPS prevalence remains 13.2% for parkinsonism and 8.3% for tardive dyskinesia even in stabilized community patients 7