What is the treatment for akathisia?

Treatment of Akathisia

The first-line treatment for akathisia is 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 10-30 mg two to three times daily. 1

Critical Diagnostic Pitfall

Before escalating treatment, recognize that akathisia is frequently misdiagnosed as psychotic agitation or anxiety, leading clinicians to inappropriately increase antipsychotic doses—which directly worsens the condition. 1 This misinterpretation is particularly dangerous in patients with suicidal ideation, as SSRI-induced akathisia is associated with increased suicidality (especially with fluoxetine), requiring systematic inquiry about suicidal thoughts before and after treatment changes. 1

Treatment Algorithm

Step 1: Modify the Causative Agent

• Reduce the antipsychotic dose to the lowest effective level within therapeutic range 1
• Switch to a lower-risk antipsychotic such as quetiapine or olanzapine 1
• Discontinue antipsychotic polypharmacy if present, as this increases side effect burden 1

Step 2: Add Propranolol (First-Line Adjuvant)

• Propranolol 10-30 mg two to three times daily is the most consistently effective pharmacological treatment for akathisia 1, 2, 3
• This lipophilic beta-blocker has the strongest evidence base among adjuvant medications 2, 3
• Consider contraindications including asthma, bradycardia, and orthostatic hypotension 3
• Monitor cardiovascular parameters, especially in patients with QT-prolonging antipsychotics 1

Step 3: Benzodiazepines (Second-Line)

• Clonazepam provides symptomatic relief and addresses the anxiety component of akathisia when first-line treatments fail 1
• Benzodiazepines are a sensible next choice if subjective distress persists despite beta-blocker therapy 2
• Short-term use as adjuncts may help stabilize acutely agitated patients 4

Step 4: Mirtazapine (Alternative Second-Line)

• Low-dose mirtazapine (7.5-15 mg once daily) has demonstrated compelling evidence for therapeutic efficacy through 5-HT2a receptor antagonism 3, 5
• Current evidence best supports propranolol and mirtazapine as the most effective rescue agents 6

Step 5: Anticholinergic Agents (Limited Efficacy)

• Benztropine 1-4 mg once or twice daily may be tried but is notably less effective for akathisia compared to other extrapyramidal side effects 1
• Monitor carefully for anticholinergic side effects, especially in children and adolescents 1
• Despite being commonly prescribed, anticholinergics provide only modest benefit 1

Step 6: Fourth-Line Options

If all above treatments fail, consider:

• Amantadine (mild dopaminergic agent with limited evidence) 1
• Clonidine 2
• Gabapentin or pregabalin (voltage-gated calcium channel blockers) 5

Special Population Considerations

Children and Adolescents

• 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
• Require careful monitoring for anticholinergic side effects when using anticholinergic agents 1

High-Risk Patients

• Consider prophylactic antiparkinsonian agents in patients with history of dystonic reactions or compliance concerns 1
• Reevaluate the need for antiparkinsonian agents after the acute phase, as many patients no longer require them during long-term therapy 1

Emergency Settings

• For acute akathisia, intramuscular administration is preferred over intravenous route 1

Monitoring and Long-Term Management

• Systematically assess akathisia with validated scales before starting antipsychotics and during dosage titration 7
• Akathisia has a good prognosis when managed early in the course of treatment 6
• Chronic and tardive akathisia may persist after drug withdrawal and prove resistant to pharmacological treatment 5
• Rotation between different pharmacological strategies may be optimal in resistant cases 5