What is the treatment for akathisia?

Treatment of Akathisia

The first-line treatment for akathisia is to lower the antipsychotic dose if clinically feasible, or switch to a lower-risk agent (quetiapine or olanzapine), combined with propranolol 10-30 mg two to three times daily as the most consistently effective pharmacological intervention. 1, 2

Initial Management Strategy

The treatment approach should follow this algorithmic sequence:

Step 1: Modify the Causative Agent

• Reduce the current antipsychotic dosage while maintaining therapeutic range as the primary intervention 1, 2
• Switch to an antipsychotic with lower akathisia risk, specifically quetiapine or olanzapine 1, 2
• Avoid antipsychotic polypharmacy, which increases side effect burden 1, 2

Step 2: Add Propranolol as First-Line Pharmacotherapy

• Propranolol (10-30 mg two to three times daily) is the most consistently effective treatment for akathisia 1, 2, 3, 4
• This beta-blocker has the strongest evidence base among all adjuvant medications 3, 5
• Consider cardiovascular contraindications (asthma, bradycardia, orthostatic hypotension) before initiating 6
• In patients with high cardiovascular risk, carefully evaluate QT-prolonging effects when switching antipsychotics 1, 2

Critical Diagnostic Pitfall

Akathisia is frequently misinterpreted as psychotic agitation or anxiety, leading clinicians to inappropriately increase antipsychotic doses, which worsens the condition. 1, 2 This misidentification is a common reason for medication noncompliance 7

Second-Line Treatment Options

If propranolol fails or is contraindicated, proceed sequentially:

Benzodiazepines

• Clonazepam can provide symptomatic relief and address the anxiety component of akathisia 1, 4
• Particularly useful when subjective distress persists despite other interventions 3

5-HT2A Receptor Antagonists

• Low-dose mirtazapine (7.5 mg or 15 mg once daily) has demonstrated compelling evidence for therapeutic efficacy 6, 4
• Other agents with 5-HT2A antagonism include trazodone, mianserin, and cyproheptadine 6, 8
• This represents an emerging class of anti-akathisia agents with accumulating evidence over the past two decades 6

Anticholinergic Agents

• Anticholinergics are notably less effective for akathisia compared to other extrapyramidal side effects, despite being commonly prescribed 1
• Benztropine 1-4 mg once or twice daily may be tried, though not consistently helpful 7, 9
• Monitor for anticholinergic side effects, especially in children and adolescents 1

Fourth-Line Options

• Amantadine (mild dopaminergic agent) has limited evidence 1, 3
• Clonidine can be attempted if all other treatments fail 3, 4

Special Population Considerations

Children and Adolescents

• Higher risk for extrapyramidal side effects including akathisia compared to adults 1, 2
• Careful monitoring for anticholinergic side effects is essential 1
• Young age and male gender are risk factors for acute dystonic reactions 7

SSRI-Induced Akathisia

• SSRI-induced akathisia is associated with increased suicidality, particularly with fluoxetine 1, 2
• Systematically inquire about suicidal ideation before and after treatment initiation 1, 2
• Be especially alert to suicidality if SSRI treatment coincides with akathisia onset 1

Acute Emergency Management

• For acute dystonic reactions (distinct from akathisia), 1-2 mL benztropine injection usually relieves the condition quickly 9
• In emergency settings, intramuscular administration is preferred over intravenous route 1

Monitoring and Prevention

• Assess akathisia with validated scales before starting antipsychotics and during dose titration 5
• Prophylactic antiparkinsonian agents may be considered in high-risk patients, particularly those with history of dystonic reactions or compliance concerns 7
• Reevaluate need for antiparkinsonian agents after the acute phase, as many patients no longer require them during long-term therapy 7