What beta blocker should I give for akathisia?

Beta-Blocker Selection for Akathisia

Propranolol is the first-line beta-blocker for akathisia, dosed at 10-30 mg two to three times daily (total 30-80 mg/day), with clinical response typically occurring within 24 hours. 1, 2

First-Line Treatment: Propranolol

• Propranolol demonstrates the most consistent efficacy among beta-blockers for akathisia treatment, with complete remission achieved in approximately 64% of patients (9 of 14) in controlled trials 2
• The American Academy of Psychiatry and the Law identifies propranolol (10-30 mg two to three times daily) as the most consistently effective pharmacological treatment for this condition 1
• Response is rapid, typically occurring within 24 hours of initiation, with low doses (30-80 mg/day total) required for therapeutic benefit 2
• Side effects are generally minimal at these doses, though monitoring for orthostatic hypotension and bradycardia remains important 3

Mechanism and Beta-Blocker Selection

• Beta-1 selective agents (like betaxolol) appear equally effective to non-selective propranolol, suggesting beta-1 adrenoceptor blockade is sufficient for anti-akathisia effects 4
• However, preliminary evidence indicates other beta-blockers may be less effective than propranolol specifically, making propranolol the preferred agent despite theoretical equivalence 2
• Lipophilic beta-blockers (which cross the blood-brain barrier) are more consistently effective than hydrophilic agents for acute akathisia 5

Practical Dosing Algorithm

Starting regimen:

• Begin propranolol 10 mg three times daily (30 mg/day total) 1, 2
• Assess response within 24-48 hours 2
• If partial response, increase to 20-30 mg three times daily (maximum 80 mg/day) 1, 2

Monitoring parameters:

• Check blood pressure and heart rate before each dose increase 3
• Watch for orthostatic hypotension (>20 mmHg drop in systolic BP upon standing) 3
• Monitor for bradycardia (heart rate <60 bpm with symptoms) 3

Contraindications to Propranolol

Absolute contraindications:

• Active asthma or reactive airway disease 3
• Second or third-degree heart block without pacemaker 3
• Decompensated heart failure 3
• Severe bradycardia (heart rate <50 bpm) 3

Relative contraindications requiring caution:

• Chronic obstructive pulmonary disease 3
• Peripheral vascular disease 3
• Diabetes mellitus (may mask hypoglycemia symptoms) 3

Alternative Beta-Blockers When Propranolol Fails or Is Contraindicated

• Metoprolol can be considered as an alternative, though evidence is less robust than for propranolol 6
• Beta-1 selective agents like betaxolol (10-20 mg/day) showed equivalent efficacy to propranolol in one controlled trial, suggesting they may be preferable in patients with mild reactive airway disease 4
• Atenolol and nadolol have been studied for other conditions but lack specific evidence for akathisia 6

When Beta-Blockers Fail

Second-line options if propranolol is ineffective or contraindicated:

• Add benzodiazepines (clonazepam) for symptomatic relief, particularly addressing the anxiety component 1, 5
• Consider mirtazapine 7.5-15 mg once daily, which has compelling evidence as an alternative first-line agent through 5-HT2a receptor antagonism 3, 7
• Amantadine or clonidine can be tried as third-line options, though evidence is limited 5

Critical Clinical Pitfalls

• Do not use anticholinergic agents as first-line treatment—they are notably less effective for akathisia compared to other extrapyramidal side effects, despite being commonly prescribed 1
• Avoid misinterpreting akathisia as psychotic agitation or anxiety, which leads to inappropriate antipsychotic dose increases that worsen the condition 1
• Screen for suicidality in SSRI-induced akathisia, particularly with fluoxetine, as this subtype is associated with increased suicidal ideation 1
• Consider dose reduction or switching the offending antipsychotic before adding propranolol, as this addresses the root cause rather than just treating symptoms 1, 5