How to manage akathisia in a patient already on propranolol (beta blocker) 20 mg twice a day (bid) when reducing or switching antipsychotic is not an option?

Management of Akathisia When Propranolol and Antipsychotic Adjustment Are Not Options

Add a benzodiazepine (clonazepam preferred) as the next-line agent for akathisia management in patients already on propranolol 20 mg BID when antipsychotic modification is not feasible. 1

Optimize Current Propranolol Dosing First

Before adding additional agents, ensure the propranolol dose is maximized:

• Increase propranolol to 30 mg three times daily (up to 90 mg/day total), as the current dose of 20 mg BID (40 mg/day) is below the typical therapeutic range for akathisia 1
• The evidence supports propranolol dosing of 10-30 mg two to three times daily for akathisia management 1
• Propranolol remains the most consistently effective treatment for acute akathisia across multiple studies 2, 3, 4

Add Benzodiazepines as Second-Line

If maximizing propranolol fails to control symptoms:

• Add clonazepam 0.5-1 mg twice daily as the preferred benzodiazepine for akathisia 2
• Benzodiazepines are particularly effective for the subjective distress component of akathisia even when objective restlessness persists 3
• The American Psychiatric Association guidelines suggest benzodiazepines as an adjunctive option for akathisia management 1

Consider Mirtazapine as Alternative Add-On

If benzodiazepines are contraindicated or ineffective:

• Add low-dose mirtazapine 15 mg at bedtime, which has strong evidence for akathisia management 2, 4
• Mirtazapine is one of the two agents (along with propranolol) with the best current evidence for akathisia treatment 2
• This option provides dual benefit if the patient has comorbid insomnia or depression

Additional Pharmacological Options

If the above strategies fail, consider these alternatives in sequence:

• Clonidine 0.1 mg twice daily can be tried, though evidence is more limited 2, 3
• Gabapentin 300-900 mg/day or pregabalin may provide relief through voltage-gated calcium channel modulation 4
• Vitamin B6 300-600 mg twice daily showed equivalence to propranolol in one small trial, though evidence is preliminary 5
• Anticholinergic agents (benztropine 1-2 mg) are less consistently effective for akathisia compared to dystonia or parkinsonism, but may provide some benefit 6, 3

Critical Monitoring Considerations

• Reassess akathisia severity using the Barnes Akathisia Rating Scale to objectively track response to interventions 5
• Distinguish akathisia from anxiety or psychotic agitation, as misdiagnosis commonly leads to inappropriate antipsychotic dose escalation, worsening the akathisia 6
• Monitor for paradoxical agitation with anticholinergics, particularly in elderly patients or those with anticholinergic burden 6
• Evaluate medication compliance, as akathisia is a major cause of treatment non-adherence and may precipitate relapse 6

Important Caveats

The guideline evidence consistently prioritizes dose reduction or switching antipsychotics as first-line management 1. When these options are truly unavailable, the pharmacological rescue strategy outlined above represents the best evidence-based approach. However, if akathisia remains severe and refractory despite maximal medical management, reconsider whether the risk-benefit ratio truly justifies maintaining the current antipsychotic regimen unchanged 1.