Treatment for Akathisia
The first-line treatment for akathisia is to reduce the antipsychotic dose or switch to a lower-risk agent (quetiapine or olanzapine), while simultaneously initiating propranolol 10-30 mg two to three times daily. 1, 2
Immediate Management Steps
Primary Interventions (Choose One or Both)
- Reduce the current antipsychotic dosage while maintaining therapeutic range, or switch to an antipsychotic with lower akathisia risk such as quetiapine or olanzapine 1, 2
- Initiate propranolol 10-30 mg two to three times daily, which is the most consistently effective pharmacological treatment for akathisia 1, 2
- Avoid antipsychotic polypharmacy, as this increases side effect burden 1
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 misinterpretation is particularly dangerous in patients with suicidal ideation 1
Second-Line Treatment Options (When First-Line Fails)
If Propranolol is Ineffective or Contraindicated
- Add benzodiazepines (clonazepam) to provide symptomatic relief and address the anxiety component of akathisia 1, 3
- Consider low-dose mirtazapine (7.5-15 mg once daily), which has demonstrated compelling evidence for therapeutic efficacy through 5-HT2a receptor antagonism 4, 5
Third-Line Options
- Anticholinergic agents (benztropine 1-4 mg once or twice daily) may be tried, though they are notably less effective for akathisia compared to other extrapyramidal side effects 1, 6
- Monitor carefully for anticholinergic side effects, especially in children and adolescents 1
Fourth-Line Options
- Amantadine (mild dopaminergic agent) is considered a fourth-line option with limited evidence 1, 3
- Clonidine can be tried if other agents are unsuccessful 3, 6
- Gabapentin or pregabalin (voltage-gated calcium channel blockers) may be effective in resistant cases 5
Special Population Considerations
Children and Adolescents
- Children and adolescents are at higher risk for extrapyramidal side effects including akathisia compared to adults 1, 2
- Monitor especially carefully for anticholinergic side effects when using anticholinergic agents 1
- Prophylactic antiparkinsonian agents may be considered in high-risk patients with history of dystonic reactions 1
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 the possibility of suicidality if SSRI treatment is associated with onset of akathisia 1
Cardiovascular Risk Patients
- Carefully consider QT-prolonging effects of certain antipsychotics when switching medications in patients with high cardiovascular risk 1, 2
- Propranolol's side effects (orthostatic hypotension, bradycardia) and contraindications (asthma) may limit its use 4
Emergency Settings
- For acute akathisia in emergency settings, intramuscular administration of medications is preferred over intravenous route 1