What is the treatment for Extrapyramidal Symptoms (EPS)?

Treatment of Extrapyramidal Symptoms (EPS)

The first-line treatment for EPS is to reduce the dose of the offending antipsychotic or switch to an atypical antipsychotic with lower EPS risk (olanzapine, quetiapine, or clozapine), while anticholinergic medications should be reserved only for acute dystonia or when dose reduction and switching strategies have failed. 1, 2

Immediate Management Based on EPS Type

Acute Dystonia

• For severe or life-threatening dystonia: Administer benztropine 1-2 mg IM/IV immediately 1, 2
• For non-life-threatening dystonia: Switch directly to an atypical antipsychotic rather than using anticholinergics 2
• After parenteral treatment, benztropine tablets 1-2 mg twice daily usually prevents recurrence 3
• Maintain anticholinergic medications even after antipsychotic discontinuation to prevent delayed symptom emergence 1

Drug-Induced Parkinsonism

• First strategy: Reduce the antipsychotic dose 1, 4
• Second strategy: Switch to an atypical antipsychotic with lower EPS risk (olanzapine, quetiapine, clozapine) 1
• If dose reduction and switching fail, consider adding an anticholinergic agent or amantadine 4
• Benztropine dosing for drug-induced EPS: 1-4 mg once or twice daily, individualized to patient need 3

Akathisia

• First approach: Reduce antipsychotic dose or switch to a less potent agent 4
• If dose reduction ineffective: Lipophilic beta-blockers (propranolol or metoprolol) are the most effective treatments 4
• Alternative options include benzodiazepines or anticholinergics if beta-blockers are contraindicated 4
• Akathisia is often misinterpreted as anxiety or psychotic agitation, leading to inappropriate dose increases that worsen the condition 1

Tardive Dyskinesia

• Use the same strategies as tardive dystonia: reduce dose or switch medication 1
• Maintain antipsychotic only if patient is in complete remission and medication change would precipitate relapse 1
• Clozapine has antidyskinetic and antidystonic effectiveness for more severe cases 5
• GABAergic benzodiazepines (clonazepam), propranolol, alpha-tocopherol, or nifedipine may be useful for severe cases 5

Switching to Atypical Antipsychotics

Olanzapine is the preferred atypical antipsychotic for managing haloperidol-induced EPS, starting at 2.5 mg per day at bedtime 2

• Direct switching to olanzapine (mean dose 11.4 mg/day) produces significant improvements: 87.2% reduction in Simpson-Angus Scale scores and 82.5% reduction in Barnes Akathisia Scale scores 6
• Anticholinergic use decreases from 47.9% to 12.8% after switching to olanzapine 6
• A direct switch is therapeutic even when patients cannot tolerate gradual switching 6
• The incidence of EPS is significantly higher with typical antipsychotics (46%) versus atypical antipsychotics (12%) 7

Critical Anticholinergic Considerations

Anticholinergics should NOT be used routinely for preventing EPS but reserved only for treatment of significant symptoms when dose reduction and switching strategies have failed. 1, 2

• Guidelines specifically advise against routine use of benztropine or trihexyphenidyl for haloperidol-induced EPS 2
• Anticholinergic medications can cause delirium, drowsiness, paradoxical agitation, and worsen cognitive function 1, 2
• In elderly patients or those with anticholinergic/sympathomimetic drug ingestions, anticholinergics can paradoxically exacerbate agitation 1
• Long-term anticholinergic use has significant side effect profiles that must be weighed against benefits 2

Special Medication Considerations

Metoclopramide-Induced EPS

• Immediately withdraw the drug upon reporting of symptoms 1

Neuroleptic Malignant Syndrome

• Bromocriptine and anticholinergic agents are useful in young patients 1
• Dantrolene has not shown efficacy in pediatric case reports 1

Risperidone-Specific Dosing

• Use the lowest effective dose (typically 2-4 mg/day in adults) to minimize EPS 1
• EPS risk increases significantly above 2 mg/day in elderly/dementia patients 1
• Start at 0.25 mg/day at bedtime in elderly patients, with maximum 2-3 mg/day 1

Prevention Strategies

• Use low doses within EPS limits: Maximum 4-6 mg haloperidol equivalent in first-episode psychosis 1
• Increase doses only at widely spaced intervals (14-21 days after initial titration) if response is inadequate 1
• Regular monitoring for early EPS signs is the preferred prevention strategy rather than prophylactic anticholinergics 1
• Select atypical antipsychotics with lower EPS risk from the outset when possible 1

Common Pitfalls to Avoid

• Do not misinterpret akathisia as anxiety or worsening psychosis, which leads to inappropriate antipsychotic dose increases that worsen the condition 1
• Do not use prophylactic anticholinergics routinely—this practice is not supported by guidelines and exposes patients to unnecessary side effects 1, 2
• Do not continue haloperidol long-term in elderly patients due to up to 50% risk of irreversible tardive dyskinesia after 2 years 2
• Do not abruptly terminate other antiparkinsonian agents when starting benztropine—gradual reduction is necessary 3
• When extrapyramidal disorders develop soon after neuroleptic initiation, they are likely transient; withdraw benztropine after 1-2 weeks to determine continued need 3