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Free PDF Download European Review for Medical and Pharmacological Sciences 2021; 25: 4746-4756 Pathophysiology and management of Akathisia 70 years after the introduction of the chlorpromazine, the first antipsychotic N. ZAREIFOPOULOS1, M. KATSARAKI1, P. STRATOS1, V. VILLIOTOU, M. SKALTSA1, A. DIMITRIOU1, M. KARVELI1, P. EFTHIMIOU2, M. LAGADINOU2, D. VELISSARIS3 1Department of Psychiatry, General Hospital of Nikea and Pireus Hagios Panteleimon, Athens, Greece 2Emergency Department, University General Hospital of Patras, Athens, Greece 3Department of Internal Medicine, University of Patras School of Medicine, Athens, Greece Abstract. – OBJECTIVE: Akathisia is among CONCLUSIONS: Pharmacological manage- the most troubling effects of psychiatric drugs ment may pose a challenge in chronic akathi- as it is associated with significant distress on sia. Rotation between different pharmacologi- behalf of the patients, and it limits treatment ad- cal management strategies may be optimal in re- herence. Though it most commonly presents sistant cases. Discontinuation of the causative during treatment with antipsychotic drugs which drug and use of b-blockers, mirtazapine, benzo- block dopamine D2 receptors, Akathisia has al- diazepines or gabapentinoids for symptomatic so been reported during treatment with selec- relief is the basis of management. tive serotonin reuptake inhibitors (SSRIs), se- rotonin norepinephrine reuptake inhibitors (SN- Key Words: RIs), stimulants, mirtazapine, tetrabenazine and Aripiprazole, Extrapyramidal symptoms, Haloperi- other drugs. dol, Locus coeruleus, Propranolol. MATERIALS AND METHODS: This article was designed as a narrative review on akathisia with a focus on its clinical presentation, pathophys- iology and management. A PubMed search for akathisia was conducted which returned 8481 Introduction articles. RESULTS: Akathisia is experienced as severe Akathisia is a common adverse effect of treat- restlessness commonly accompanied by dys- ment with antipsychotic drugs, with incidence phoria and purposeless movement which re- rates ranging from 5-50% depending on the du- lieves subjective tension. It has been attribut- ration of treatment and the drug used1. It is a ed to an imbalance between dopaminergic and common cause of treatment non-adherence and noradrenergic neurotransmission in the bas- 2,3 al ganglia. Acute akathisia commonly resolves has been associated with violence and suicide . upon treatment discontinuation but tardive and Though most commonly observed with dopa- chronic akathisia may persist after the caus- mine D2 receptor antagonists, it may also compli- ative agent is withdrawn and prove resistant to cate treatment with other psychiatric drugs which pharmacological treatment. Even drugs which do not interact with dopamine receptors directly, induce no other extrapyramidal side effects including selective serotonin reuptake inhibitors (such as clozapine, quetiapine, aripiprazole and cariprazine) may induce akathisia. A high (SSRIs), serotonin norepinephrine reuptake in- index of suspicion should be maintained in hibitors (SNRIs) tricyclic antidepressants, mir- patients with motor disabilities, drug-induced tazapine and vesicular monoamine transporter parkinsonism and those under mechanical re- 2 (VMAT2) inhibitors which deplete dopamine straint. Propranolol and low-dose mirtazapine and other monoamine neurotransmitters4. Drugs are the most thoroughly studied pharmacolog- of this class include reserpine (used as an antipsy- ical interventions for akathisia, though ben- chotic in the 1950s, now prescribed only rarely in zodiazepines, voltage- gated calcium channel blockers (gabapentin, pregabalin) and opioids low doses as an antihypertensive), tetrabenazine may be effective. (indicated for the treatment of Huntington’s dis- 4746 Corresponding Author: Nicholas Zareifopoulos, MD; email: [email protected] Pathophysiology and management of Akathisia ease) and valbenazine, the only drug indicated treatment initiation or dose adjustment11. Acute for the treatment of antipsychotic-induced tardive akathisia after a single dose of haloperidol has dyskinesia5. also been described by physicians who took the It is difficult to comprehend the concept of drug to understand its action12. akathisia as it is not a normal component of hu- Objective of this article is to review the pre- man experience. It is typically encountered as sentation, pathophysiology and management of a side effect of psychiatric drugs but may also akathisia. A comprehensive review would be occur during opioid or stimulant withdrawal and valuable for clinicians and researchers alike due rarely as a result of traumatic brain injury6. It to its distressing nature, high prevalence and can be described as an intense sensation of inner lack of high-quality clinical trials regarding its restlessness accompanied by an urge to remain management. constantly in motion. It is typically accompanied by intense dysphoria which worsens when will- ingly remaining still. It was initially classified as Materials and Methods part of the extrapyramidal syndrome (EPS) in- duced by antipsychotic drugs, but some evidence A review of the literature was conducted on suggests that akathisia is fundamentally distinct PubMed using akathisia as a search term. The from other EPS manifestations7. The underlying search returned 8481 articles. This work was mechanism is the inhibition of dopaminergic conceived as a narrative review with added neurotransmission in the nigostriatal pathway for emphasis placed on uncommon presentations of acute events, whereas tardive dyskinesia has been akathisia and management options. All articles attributed to D2 receptor upregulation and sub- were however screened for relevance (by title sequent hypersensitivity to dopamine following and abstract) and the full text of those consid- prolonged exposure to D2 antagonists5. Patients ered likely to be relevant was retrieved. A hand are characteristically indifferent to EPS and the search of the references of these articles was presentation is far more distressing to observers also conducted. All recommendations regarding of the movement disorders than to those actually management of akathisia were made based on experiencing them8. the available empirical evidence (clinical trials Akathisia by definition has a strong subjective and naturalistic studies) and on the pharmaco- component and may cause significant distress logical properties of the drugs if no other evi- in patients even in the absence of typical motor dence was available. A meta-analysis of clinical symptoms (pacing, adjusting position constantly trials regarding the management of akathisia in bed). This is indicative of cortical involvement may not be feasible as relatively few studies in the pathogenesis of the condition, whereas the have been conducted which are characterized by indifference typical of EPS suggests that only high heterogeneity and small sample sizes. As subcortical structures are involved1. The contro- this work is a narrative review we did not strictly versial entity of pseudoakathisia is defined as the adhere to a systematic review methodology as presence of behavior typical of akathisia in the dictated by the PRISMA guidelines. absence of the subjective component. This may be encountered in chronic schizophrenic patients with prominent negative symptoms9. Akathisia Results is considered acute if its duration is less than 3 months, chronic if its duration is greater than 3 Presentation and Differential Diagnosis months and tardive if it presents after long-term of Akathisia treatment. Historically it was assumed that it The presentation of akathisia is distinct from presents some time (2 weeks or more) after ini- restless leg syndrome (RLS), though the patho- tiation of neuroleptic treatment or dose increase, physiological underpinnings may be similar. Pa- but recent evidence10 suggests that this is accurate tients with RLS complain of an uncomfortable only for drugs with a long half-life (aripirpazole, sensation in the legs and an insurmountable cariprazine) which require weeks to reach their urge to move them13,14. It is worse during the therapeutic steady state concentration. Drugs night and the discomfort associated with it is which attain therapeutic concentrations follow- primarily due to its disruptive effect on sleep. ing administration of a single dose (haloperidol, Patients may have a history of substance abuse, risperidone) can induce akathisia within hours of as RLS is commonly present in the post-acute 4747 N. Zareifopoulos, M. Katsaraki, P. Stratos, V. Villiotou, M. Skaltsa, et al. withdrawal syndrome of many illicit drugs. It is of haloperidol to reliably induce akathisia even also associated with iron deficiency15. Akathisia in restrained individuals may explain why it on the other hand affects the entire body, is as- was used as a pharmacological torture agent24. sociated with intense dysphoria and symptoms Restrained patients should be frequently evalu- are constant throughout the day. It may dissi- ated for akathisia. It is recommended to inquire pate entirely when the patient is asleep, though directly about the nature of the patient’s discom- it is not uncommon for patients to experience fort (whether he feels as if he needs to move, if frequent awakenings (every 15-30 minutes) in it is localised to a particular limb, whether it order to pace for a few moments prior to going started after a drug was administered) and offer back to bed16. This is especially common when benzodiazepines to
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