From the Guidelines
Extrapyramidal symptoms (EPS) are best managed by using atypical antipsychotics, which have a lower risk of EPS, and starting with low doses, with gradual titration, as recommended by 1.
Treatment Options
- Anticholinergic medications, such as benztropine (Cogentin) 1-2 mg orally twice daily or trihexyphenidyl 2-5 mg orally three times daily, are first-line options for treating EPS, as noted in 1.
- For acute dystonic reactions, intramuscular benztropine 1-2 mg or diphenhydramine 25-50 mg can provide rapid relief, as seen in 1.
- Amantadine 100 mg twice daily offers an alternative with fewer cognitive side effects, as mentioned in 1.
- Beta-blockers like propranolol 10-30 mg three times daily are particularly effective for akathisia, as stated in 1.
Prevention Strategies
- Using atypical antipsychotics, which have a lower EPS risk, is a key prevention strategy, as highlighted in 1.
- Starting with low doses and titrating slowly can also help prevent EPS, as recommended in 1.
Important Considerations
- Regular monitoring for anticholinergic side effects (dry mouth, blurred vision, urinary retention) is important, especially in elderly patients who are more susceptible to these effects, as noted in 1.
- Treatment duration varies—acute dystonia may require only short-term treatment, while chronic symptoms might need ongoing management, as seen in 1.
Medication Side Effects
- Atypical antipsychotics, such as risperidone, may still produce extrapyramidal symptoms, as mentioned in 1.
- Clozapine has significant side effects, including seizures and agranulocytosis, and requires extensive monitoring, as described in 1.
From the FDA Drug Label
In treating extrapyramidal disorders due to neuroleptic drugs (e.g., phenothiazines), the recommended dosage is 1 to 4 mg once or twice a day orally, or parenterally. Dosage must be individualized according to the need of the patient. In acute dystonic reactions, 1 to 2 mL of the injection usually relieves the condition quickly After that, the tablets, 1 to 2 mg twice a day, usually prevents recurrence.
Treatments for EPS include benztropine mesylate tablets, with a recommended dosage of 1 to 4 mg once or twice a day orally, or parenterally. The dosage must be individualized according to the need of the patient. In cases of acute dystonic reactions, 1 to 2 mL of the injection can relieve the condition quickly, followed by 1 to 2 mg tablets twice a day to prevent recurrence 2.
- Key considerations:
- Dosage individualization
- Treatment of acute dystonic reactions
- Prevention of recurrence
- Concomitant use with other medications, such as neuroleptic drugs.
From the Research
Treatments for Extrapyramidal Symptoms (EPS)
- EPS are a common side effect of antipsychotic medications, and can also be caused by other agents such as antidepressants, lithium, and anticonvulsants 3.
- The use of atypical antipsychotics has been shown to reduce the incidence of EPS compared to typical antipsychotics 4, 5.
- Strategies for avoiding EPS include using low-dosage typical antipsychotics or atypical antipsychotics, and monitoring patients for early signs of EPS 4, 5.
- Effective treatment of EPS is crucial to improve patient compliance and long-term treatment outcomes 5.
- The Yale Extrapyramidal Symptom Scale (YESS) is a standardized scale that can be used to assess the occurrence and severity of EPS 6.
Management of EPS
- The management of EPS often involves discontinuing or reducing the dose of the offending medication, and switching to an alternative antipsychotic with a lower risk of EPS 7.
- Other treatment options for EPS include the use of anticholinergic agents, beta blockers, and dopamine agonists, although these may have limited efficacy and can have significant side effects 7.
- Future research is needed to identify more effective treatments for EPS and to develop new antipsychotic agents that do not cause EPS 7.