Treatment of Akathisia
The first-line treatment for akathisia is to reduce the antipsychotic dose (if clinically feasible) or switch to a lower-risk agent, combined with propranolol 10-30 mg two to three times daily for symptomatic relief. 1, 2
Initial Management Strategy
The treatment algorithm should proceed systematically:
- Immediately lower the dose of the offending antipsychotic while maintaining therapeutic range, or switch to an antipsychotic with lower akathisia risk such as quetiapine or olanzapine 1, 2
- Avoid increasing the antipsychotic dose, as akathisia is frequently misinterpreted as psychotic agitation or anxiety, leading to inappropriate dose escalation that worsens the condition 1, 2, 3
- Discontinue antipsychotic polypharmacy if present, as this increases side effect burden 1
First-Line Pharmacological Treatment
When dose reduction alone is insufficient or not feasible:
- Propranolol is the most consistently effective treatment, dosed at 10-30 mg two to three times daily 1, 2, 4, 5
- Other lipophilic beta-blockers may be used as alternatives if propranolol is contraindicated 4
- In patients with cardiovascular risk, carefully consider QT-prolonging effects when switching antipsychotics 2
Second-Line Options
If beta-blockers fail or are contraindicated:
- Benzodiazepines (such as clonazepam) provide symptomatic relief and address the anxiety component of akathisia 1, 3, 4, 5
- These are particularly useful for the subjective distress component when beta-blockers are insufficient 4
Third and Fourth-Line Treatments
When first and second-line treatments are unsuccessful:
- Low-dose mirtazapine has evidence for efficacy 6
- Anticholinergic agents (such as benztropine 1-4 mg once or twice daily) are notably less effective for akathisia compared to other extrapyramidal side effects, despite being commonly prescribed 7, 1, 3, 8
- Amantadine (a mild dopaminergic agent) is considered a fourth-line option with limited evidence 1
- Voltage-gated calcium channel blockers (gabapentin, pregabalin) may be effective in resistant cases 6
Critical Pitfalls to Avoid
- Do not misdiagnose akathisia as worsening psychosis or anxiety, which leads to dose escalation of the causative agent 1, 2, 3, 9
- Anticholinergic agents are not consistently helpful for akathisia specifically, unlike other extrapyramidal symptoms 7, 1, 3
- In patients with underlying Parkinson's disease, avoid anticholinergic agents and consider switching to quetiapine or clozapine if antipsychotic continuation is necessary 3
Special Population Considerations
Children and Adolescents
- Higher risk for extrapyramidal side effects including akathisia compared to adults 7, 1, 2, 3
- Monitor carefully for anticholinergic side effects when using anticholinergic agents 7, 1
- Young age and male gender are additional risk factors 3
SSRI-Induced Akathisia
- Associated with increased suicidality, particularly with fluoxetine 1, 2
- Systematically inquire about suicidal ideation before and after treatment initiation 1, 2
- Be especially alert if SSRI treatment is associated with onset of akathisia 1
Antiemetic-Induced Akathisia
- Metoclopramide and prochlorperazine commonly cause akathisia in palliative care settings 9
- The same treatment algorithm applies: discontinue or reduce the offending agent, then use beta-blockers or benzodiazepines 9
Prophylaxis Considerations
- Prophylactic antiparkinsonian agents should not be routinely prescribed except in high-risk patients (history of dystonic reactions, paranoid patients with compliance concerns) 7, 3
- Reevaluate the need for antiparkinsonian agents after the acute phase, as many patients no longer require them during long-term therapy 7