I switched from aripiprazole (Abilify) to lurasidone (Latuda) for akathisia but still have tremor; how should I manage this?

Management of Persistent Tremor After Switching from Aripiprazole to Lurasidone

Your continued shakiness after switching from aripiprazole to lurasidone likely represents persistent akathisia or drug-induced parkinsonism that requires either dose reduction of lurasidone, addition of propranolol 20-40 mg twice daily, or switching to a lower-risk atypical antipsychotic such as quetiapine, olanzapine, or clozapine. 1

Understanding Your Current Situation

Why Lurasidone May Still Cause Movement Symptoms

• Lurasidone carries a documented risk of akathisia and extrapyramidal symptoms, with akathisia being one of the five most consistently encountered adverse events, occurring with a number-needed-to-harm (NNH) ranging from 6 to 30 depending on dose. 2
• Even though lurasidone is an atypical antipsychotic with lower EPS risk than typical agents, akathisia can occur in a minority of patients and may manifest as the "shakiness" you're experiencing. 3
• A recent 2025 case report documented severe akathisia developing with lurasidone at low, introductory doses, which resolved completely only after discontinuation. 4

Distinguishing Between Akathisia and Tremor

Your "shakiness" could represent either:

• Akathisia: Subjective inner restlessness with objective motor findings like pacing, foot tapping, or movements resembling stretching. 5
• Drug-induced parkinsonism: Characterized by bradykinesia, tremors, and rigidity without the subjective restlessness component. 1

Immediate Management Algorithm

Step 1: Reduce Lurasidone Dose First

• Lower your current lurasidone dose as the initial strategy, since both akathisia and parkinsonism with lurasidone can be managed effectively with dose adjustment. 3
• This approach is preferred over adding more medications because it addresses the root cause. 1

Step 2: Add Propranolol if Dose Reduction Insufficient

• If dose reduction is not practical or symptoms persist, add propranolol 20-40 mg twice daily, as lipophilic beta-blockers (especially propranolol) are the most effective treatments for akathisia. 6, 7
• Propranolol has demonstrated efficacy specifically for antipsychotic-induced akathisia and was successfully used in a case of withdrawal akathisia with aripiprazole. 7

Step 3: Consider Switching to Lower-Risk Atypical

If symptoms continue despite dose reduction and propranolol, switch to quetiapine, olanzapine, or clozapine, which have minimal EPS risk compared to lurasidone. 1

• Quetiapine and olanzapine carry significantly lower akathisia risk than lurasidone or aripiprazole. 1
• Clozapine exhibits the lowest EPS risk among all antipsychotics and may even alleviate parkinsonian-like symptoms, though it requires regular blood monitoring for agranulocytosis. 1

Why Anticholinergics Are NOT First-Line

Limited Efficacy for Akathisia

• Anticholinergic agents like benztropine are consistently helpful for parkinsonian symptoms but have variable efficacy in akathisia, unlike their reliable effectiveness for acute dystonia. 1
• Anticholinergics should not be used routinely for preventing EPS and should be reserved only when dose reduction and switching strategies have failed. 1

Potential Adverse Effects

• Anticholinergic medications can cause delirium, drowsiness, and paradoxical agitation, particularly problematic if you need to function normally. 1

Critical Monitoring Points

Document Specific Symptoms

Clarify whether you experience:

• Subjective inner restlessness with urge to move (suggests akathisia) 5
• Resting tremor, slowed movements, muscle stiffness (suggests parkinsonism) 1
• Pacing, foot tapping, or inability to sit still (objective signs of akathisia) 5

Timeline Matters

• Akathisia typically appears days to weeks after starting or increasing an antipsychotic dose. 6
• The fact that symptoms persisted after switching from aripiprazole suggests you may be particularly susceptible to movement side effects from dopamine-modulating agents. 4

Common Pitfalls to Avoid

Don't Assume All Atypicals Are Equal

• Both aripiprazole and lurasidone can cause significant akathisia despite being second-generation antipsychotics, as documented in a 2025 case report where both agents sequentially caused severe akathisia. 4
• The partial dopamine agonist properties of aripiprazole and the serotonin-dopamine activity modulation of lurasidone do not eliminate akathisia risk. 4

Don't Continue Same Dose Hoping Symptoms Resolve

• Most side effects with lurasidone like somnolence are transitory, but akathisia and EPS require active management through dose adjustment or medication change, not watchful waiting. 3

Don't Add Multiple Adjunctive Agents

• Avoid polypharmacy by systematically trying dose reduction first, then a single adjunctive agent (propranolol), then switching—rather than layering multiple medications. 1

Long-Term Considerations

• Monitor for tardive dyskinesia every 3-6 months using standardized scales, as the risk is approximately 5% per year in younger patients on long-term antipsychotics. 1
• If you achieve symptom control with propranolol added to lurasidone, attempt to taper propranolol after 2-3 months of stability to determine if it remains necessary. 1