Management of Akathisia with Propranolol
Recommended Dosage
For neuroleptic-induced akathisia, propranolol should be initiated at 30-40 mg daily in divided doses, with rapid titration up to 80 mg daily as needed for symptom control. 1
Dosing Algorithm
Initial Dosing
- Start with 30-40 mg daily divided into 2-3 doses 1
- Low doses (30-80 mg/day) are typically sufficient for akathisia management, which is substantially lower than cardiovascular indications 1
- Response occurs rapidly, usually within 24 hours of initiation 1
Dose Titration
- If partial response at 30-40 mg/day, increase to 60-80 mg daily 1
- Maximum effective dose for akathisia is typically 80 mg daily, though higher doses may be used if needed 1
- Most patients achieve complete remission at doses between 30-80 mg/day 1
Alternative Beta-Blocker Options
- Betaxolol 10-20 mg/day is equally effective as propranolol 20-40 mg/day, suggesting beta-1 receptor blockade is sufficient 2
- Metoprolol 25-100 mg/day (selective beta-1 blocker) also demonstrates efficacy, with seven of nine patients improving 3
- Sotalol appears ineffective, supporting a central mechanism of action rather than peripheral beta-blockade 4
Pre-Treatment Assessment
Mandatory Screening for Contraindications
- Absolute contraindications: second or third-degree heart block, decompensated heart failure, asthma/obstructive airway disease, cardiogenic shock 5
- Screen for relative contraindications: history of bronchospasm, diabetes (propranolol masks hypoglycemia symptoms), hypotension 5
- Baseline heart rate and blood pressure measurement required 5, 6
Cardiovascular Assessment
- Perform cardiovascular examination with auscultation 5
- ECG and echocardiogram only needed if cardiac abnormalities suspected 5
- No routine blood work required in otherwise healthy adults 5
Monitoring Requirements
During Treatment
- Monitor for hypotension and bradycardia, especially during dose escalation 5, 6
- Watch for common adverse effects: fatigue, dizziness, cold extremities 5
- In diabetic patients, counsel about masked hypoglycemia symptoms 5
- No routine vital sign monitoring required between appointments if patient is stable and asymptomatic 5
Special Considerations for Akathisia
- Response is typically rapid (within 24 hours), allowing quick assessment of efficacy 1
- Akathisia symptoms improve substantially, with complete remission in approximately 64% of patients (9 of 14) 1
- Lithium-induced tremor may also improve, but parkinsonism and tardive dyskinesia show little change 1
Critical Safety Warnings
Discontinuation Protocol
- Never abruptly discontinue propranolol after chronic use, as this can precipitate rebound hypertension, tachycardia, or angina 5
- Taper gradually over several weeks when discontinuing 5
Drug Interactions
- Avoid routine combination with non-dihydropyridine calcium channel blockers (diltiazem, verapamil) due to increased risk of bradycardia and heart block 5
Administration Guidelines
- Administer with food to reduce risk of hypoglycemia 5
- Hold doses during times of diminished oral intake or vomiting 5
Clinical Pearls
Mechanism of Action
- The efficacy of propranolol and betaxolol (but not sotalol) suggests a central beta-1 adrenoceptor mechanism rather than peripheral beta-2 blockade 4, 2
- Selective beta-1 blockade appears sufficient for therapeutic effect 3, 2
Combination Therapy
- In cases of withdrawal akathisia (e.g., from amisulpride), propranolol 40 mg/day combined with aripiprazole 10 mg/day may be effective 7
- This combination addresses both the akathisia and underlying antipsychotic needs 7