What is the role of propranolol (beta blocker) in treating akathisia?

Propranolol for Akathisia Treatment

Propranolol is the most consistently effective first-line pharmacological treatment for akathisia, with rapid onset of action typically within 24 hours at doses of 10-80 mg daily divided into 2-3 doses. 1, 2

First-Line Treatment Approach

When akathisia occurs, the American Psychiatric Association recommends three initial strategies: lowering the antipsychotic dosage (while remaining in therapeutic range), switching to an antipsychotic with lower akathisia risk (such as quetiapine or olanzapine), or adding propranolol. 1

Propranolol Dosing and Efficacy

• Start propranolol at 10-30 mg two to three times daily (total daily dose 30-80 mg/day) 1, 3
• Clinical improvement occurs rapidly, typically within 24 hours in most patients 3
• Complete remission of akathisia symptoms was achieved in 9 of 14 patients (64%) in controlled trials, with all patients showing substantial improvement 3
• Low doses are effective (30-80 mg/day), and side effects are minimal 3

Mechanism and Drug Selection

The efficacy of lipophilic beta-blockers like propranolol (and betaxolol) versus the failure of hydrophilic beta-blockers like sotalol suggests a central nervous system mechanism of action is required for treating akathisia. 4 This is critical because propranolol crosses the blood-brain barrier due to its lipophilic properties, while water-soluble beta-blockers do not. 4

Treatment Algorithm When Propranolol Fails

If propranolol is ineffective or contraindicated:

1. Add benzodiazepines (such as clonazepam) to address the anxiety component and provide symptomatic relief 1

   • Benztropine 1-4 mg once or twice daily may be tried, though anticholinergic agents are notably less effective for akathisia compared to other extrapyramidal symptoms 1, 5
   • Monitor carefully for anticholinergic side effects, especially confusion or forgetfulness 5

2. Consider amantadine as a fourth-line dopaminergic agent, though evidence is limited 1

3. Other agents with some evidence include clonidine, ritanserin, piracetam, or valproic acid 2

Critical Clinical Pitfalls

Akathisia is frequently misdiagnosed as psychotic agitation or anxiety, leading clinicians to inappropriately increase antipsychotic doses, which paradoxically worsens the condition. 1 This is especially dangerous in patients with suicidal ideation.

SSRI-induced akathisia (particularly with fluoxetine) is associated with increased suicidality, requiring systematic inquiry about suicidal ideation before and after treatment initiation. 1

Avoid antipsychotic polypharmacy, which increases side effect burden without improving akathisia. 1

Special Populations

• Children and adolescents have higher risk for extrapyramidal side effects including akathisia compared to adults 1
• Young age and male gender are additional risk factors for acute dystonic reactions 1
• In emergency settings, intramuscular administration is preferred over intravenous route 1

Tardive Akathisia

Propranolol has demonstrated effectiveness for tardive akathisia in case reports, though evidence is less robust than for acute akathisia. 6 The same dosing strategy applies, but response may be less predictable. 2