I recently came across a case scenario of drug induced akathisia. It is important to remember that aripiprazole is one of the most common causes of this adverse effect. Here’s the case – LY is a 72-year-old man with a 10-year history of Parkinson’s disease controlled on carbidopa/levodopa. He was started on aripiprazole (podcast) 5 mg daily by his primary provider for new-onset visual hallucinations. He was hallucinating that there were wild, aggressive animals in his bedroom, and they were causing significant anxiety and fear.
Within one week, Mr. L reports an overwhelming sense of inner restlessness, pacing constantly, rocking in his chair, and repeatedly standing up during the clinic visit. He says, “I know I should sit still, but I can’t stop moving. My skin feels like it is crawling”. His symptoms of Parkinson’s, including tremor and rigidity, also appear slightly worse.
Neurology evaluates him and determines he is experiencing drug-induced akathisia. Aripiprazole is one of the highest-risk antipsychotics for drug-induced akathisia (excellent board exam nugget), and this likely was not an ideal choice for him given his Parkinson’s disease. His aripiprazole was discontinued.
He is switched to quetiapine (Seroquel) 25 mg at night, a low-EPS antipsychotic commonly used in Parkinson’s disease psychosis. Within several days, his restlessness resolves completely, and his Parkinsonian symptoms return to baseline. Over the next two weeks, quetiapine is titrated to 50 mg nightly, with improved sleep and resolution of hallucinations and no recurrence of akathisia.
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