How should we manage a patient on aripiprazole (Abilify) who is experiencing nighttime muscle twitching and an uneasy feeling consistent with akathisia, as well as increased anger and aggression, while awaiting Medicaid coverage?

Management of Aripiprazole-Induced Akathisia with Behavioral Changes

The aripiprazole should be reduced to the lowest effective dose or discontinued if clinically feasible, with propranolol 10-30 mg two to three times daily initiated as first-line treatment for the akathisia. 1, 2

Immediate Assessment and Action

The nighttime muscle twitching with an uneasy feeling is consistent with akathisia, a common and distressing side effect of aripiprazole that affects approximately 27% of patients. 3 The new onset of anger and aggression is particularly concerning, as the FDA label specifically warns that aripiprazole can cause anxiety, agitation, irritability, hostility, and aggressiveness, especially when these symptoms emerge abruptly. 4

Critical Safety Consideration

Akathisia associated with aripiprazole has been directly linked to suicidal ideation, and this risk is heightened when patients develop new-onset agitation or aggression. 5, 6 The American Academy of Child and Adolescent Psychiatry emphasizes that akathisia is frequently misinterpreted as psychotic agitation, leading clinicians to inappropriately increase antipsychotic doses, which worsens both the akathisia and associated behavioral symptoms. 1, 7

Treatment Algorithm

Step 1: Medication Adjustment

• Reduce the aripiprazole dose immediately if psychiatric stability allows, as this is the primary intervention recommended by the American Academy of Pediatrics. 2
• If dose reduction risks psychiatric decompensation, consider switching to an antipsychotic with lower akathisia risk such as quetiapine or olanzapine. 1, 2, 8
• Avoid adding additional antipsychotics, as polypharmacy increases side effect burden. 1, 2

Step 2: Pharmacological Treatment for Akathisia

• Initiate propranolol 10-30 mg two to three times daily, which is the most consistently effective treatment for acute akathisia according to the American College of Clinical Pharmacology. 1, 2, 7
• If propranolol is contraindicated or ineffective, consider benzodiazepines such as clonazepam for symptomatic relief, particularly addressing the anxiety component. 1, 7
• Anticholinergic agents like benztropine are notably less effective for akathisia compared to other extrapyramidal symptoms and should not be first-line. 1

Step 3: Monitor for Suicidality

Given the FDA warning and case reports linking aripiprazole-induced akathisia with suicidal ideation, systematically assess for suicidal thoughts at every contact, especially with the new behavioral changes. 4, 5, 6 The American Academy of Child and Adolescent Psychiatry recommends being especially alert to suicidality when akathisia emerges. 1

Addressing the Insurance Barrier

While awaiting Medicaid approval, the following cost-effective strategies can be implemented:

• Propranolol is available as an inexpensive generic medication and can be started immediately. 2
• If aripiprazole discontinuation is necessary, consider a slow taper over 1-2 weeks to avoid withdrawal phenomena. 9
• Generic quetiapine or olanzapine are typically more affordable alternatives if switching is required. 8

Common Pitfalls to Avoid

Do not interpret the anger and aggression as worsening of the underlying psychiatric condition requiring higher doses of aripiprazole—this will worsen both the akathisia and behavioral symptoms. 1, 7 The temporal relationship between medication initiation and symptom onset strongly suggests a medication-induced phenomenon rather than disease progression. 4

Do not wait for symptoms to resolve spontaneously, as akathisia-associated behavioral changes can escalate rapidly and increase suicide risk. 5, 6 The combination of akathisia with new-onset aggression requires urgent intervention. 4

Monitoring Plan

• Assess akathisia severity using standardized scales like the Barnes Akathisia Rating Scale to objectively track response to treatment. 7
• Most patients who develop akathisia improve over time with dose reduction and propranolol treatment. 3
• Schedule close follow-up within 3-5 days to reassess symptoms and suicidality. 1