Akathisia is one of the most common symptoms associated with extrapyramidal symptoms (EPS) due to antipsychotics. There are a few different medications that we can use for the management of akathisia. Here’s a good summary of akathisia.
Prior to even considering medications for akathisia management, we need to remember that some antipsychotics carry a higher risk for extrapyramidal symptoms than others. Older generation antipsychotics like haloperidol carry higher risks for these adverse effects. Newer generation antipsychotics generally carry lower risks, but even in this category, there are variations. Aripiprazole is one of the highest for its risk of akathisia. Quetiapine and clozapine tend to carry the lowest risk for EPS-type effects.
In addition to trying to avoid high-risk agents, the first step in reducing akathisia symptoms is to try to reduce the antipsychotic dose. There are times when this won’t be clinically possible, but it should be our first consideration.
Medications For Akathisia – Propranolol
Propranolol is a jack of all trades and is a medication option for akathisia management. Recall that propranolol is a non-selective beta-blocker so it comes with some baggage. The risk of interference with asthma or COPD management is possible. I also try to assess the baseline age, blood pressure, and pulse of the patient with the understanding that the blood pressure and pulse are going to drop and increase the risk for dizziness and falls. The starting dose is not particularly high at about 10 mg BID and it is wise to try to titrate slowly as the clinical situation allows.
Benztropine is a highly anticholinergic medication that I typically only see used for various movement disorders. Because benztropine is highly anticholinergic, it can cause dry eyes, dry mouth, urinary retention, constipation, and contribute to falls and confusion, particularly in our elderly population.
Benzodiazepines, like lorazepam, have also been used as a medication for akathisia. They used to be utilized more often, but some literature from a few years ago may have curbed their use to some extent. There were associations with higher mortality compared to alternative therapies. This, coupled with the risk for addiction, dependence, and withdrawal symptoms generally have led to benzodiazepines falling down the list as a preferred agent for akathisia.
So there you have our list of common medications for akathisia management. Have you seen anything else used?
- 30 medication mistakes PDF
- 18+ Page Drug Interaction PDF
- 10 Commandments of Polypharmacy Webinar based on my experiences in clinical practice