What is the recommended dosage of propranolol (propranolol) for treating akathisia (restlessness) caused by Cariprazine (cariprazine)?

Propranolol Dosing for Cariprazine-Induced Akathisia

Start propranolol at 30 mg daily in divided doses (10 mg three times daily) and titrate up to 30-80 mg/day as needed for symptom control, with most patients responding within 24 hours at these low doses. 1

Initial Dosing Strategy

• Begin with 30 mg/day divided into 2-3 doses (e.g., 10 mg three times daily or 15 mg twice daily), as this represents the lower end of the effective range demonstrated in clinical trials of neuroleptic-induced akathisia 1
• Response occurs rapidly, typically within 24 hours, so you can assess effectiveness quickly 1
• The therapeutic range for akathisia is 30-80 mg/day, which is substantially lower than doses used for other indications like hypertension (80-160 mg/day) 2, 1

Titration Approach

• If symptoms persist after 24-48 hours on 30 mg/day, increase by 10-20 mg increments every 1-2 days 1
• Most patients achieve complete or substantial remission at doses between 30-80 mg/day 1
• Maximum effective dose for akathisia rarely exceeds 80 mg/day 1
• Administer propranolol with food to reduce hypoglycemia risk, and hold doses during times of diminished oral intake or vomiting 2, 3

Critical Pre-Treatment Assessment

Before initiating propranolol, you must screen for absolute contraindications:

• Second or third-degree heart block 2, 3
• Decompensated heart failure 2, 3
• Asthma or obstructive airway disease 2, 3, 4
• Cardiogenic shock 2, 3
• Sinus node dysfunction without pacemaker 2

Perform baseline assessment including:

• Heart rate and blood pressure measurement 2, 3
• Cardiovascular examination with auscultation 2, 3
• Screen for history of bronchospasm, diabetes, and concurrent medications affecting cardiac conduction 2, 3

Monitoring During Treatment

• Monitor for hypotension and bradycardia, especially during dose escalation 2, 3
• Watch for common adverse effects including fatigue, dizziness, and cold extremities 2, 3
• In diabetic patients, counsel that propranolol masks hypoglycemia symptoms 2, 3
• No routine vital sign monitoring is required between appointments if the patient is stable and asymptomatic 2

Alternative Considerations

If propranolol is contraindicated or poorly tolerated, consider:

• Low-dose mirtazapine (7.5-15 mg once daily) has the most compelling evidence as an alternative, working through 5-HT2a receptor antagonism 4, 5
• Benzodiazepines provide symptomatic relief but are less effective than propranolol 4, 5
• Gabapentin or pregabalin may be effective alternatives 5

Duration and Discontinuation

• Continue propranolol as long as cariprazine is maintained and akathisia symptoms persist 5
• Never abruptly discontinue propranolol after chronic use—taper gradually over 1-3 weeks to prevent rebound hypertension, tachycardia, or angina 2, 3
• Consider reducing cariprazine dose if akathisia persists despite adequate propranolol dosing, as lower cariprazine doses (1.5 mg/day vs 3 mg/day) are associated with lower akathisia incidence 6

Important Clinical Context

• Cariprazine-induced akathisia typically occurs early in treatment (first 3 weeks) and is usually mild to moderate in severity 6
• The incidence of akathisia with cariprazine is dose-dependent: 5.5% at 1.5 mg/day versus 9.6% at 3 mg/day 6
• Most cariprazine-related akathisia resolves within approximately 1 week after the last dose if the medication is discontinued 6
• Even atypical antipsychotics with minimal extrapyramidal side effects like cariprazine can induce akathisia 5, 7