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Treating Extrapyramidal Symtpoms

The following treatment guidelines are meant as a reference tool only, and are not intended as treatment advice or to replace the clinical decision-making process of psychiatrists or other health professionals who administer these treatments. In clinical practice there are often good reasons why treatment approaches differ from what is described here.

Treating Parkinsonian symptoms

The first step is to try to reduce the dose of the antipsychotic medication that may be causing the Parkinsonian symptoms.  If this does not work, one option is to switch the medication to a different antipsychotic that has less potent dopamine-blocking actions. Quetiapine and Clozapine are the antipsychotics with the least dopamine-blockade, followed by Olanzapine.

The second option is to add an anticholinergic medication. The anticholinergic medication will need to be used on a daily basis in order to control the Parkinsonian symptoms.   It should be used at the lowest possible effective dose, and once the Parkinsonian symptoms subside it can be tapered and discontinued, as sometimes the Parkinsonian symptoms will improve with time. 

Treating akathisia

The first step is to try to reduce the dose of the antipsychotic medication that may be causing the akathisia.  If this does not work, one option is to switch the medication to a different antipsychotic that has less potent dopamine-blocking actions, such as Quetiapine, Clozapine, or Olanzapine.

A second option is to add a medication to treat the akathisia. Propranolol used at low doses is a first-line option [ref, ref], though there is some evidence that Mirtazapine used at 15mg nightly can be as effective and better tolerated [ref]. Benzodiazepines have been shown to be effective at least for short-term relief of akathisia [ref]. Although anticholinergics are sometimes used for treating akathisia, there is actually no evidence that this is effective [ref].

Treating dystonia

A person with a dystonic reaction should be brought to medical attention immediately as it is considered a medical emergency, especially if it is affecting the person's neck or head muscles or their ability to breathe easily.  Dystonia can be relieved quickly and effectively with an intramuscular dose of an anticholingergic (eg. Benztropine at 1-2mg, repeated every 15-30min as required until the dystonia resolves). 

For dystonias that are mild but that tend to occur repeatedly or continuously, the same treatment approach should be used as for Parkinsonian symptoms described above.

Treating tardive dyskinesia

Tardive dyskinesia takes months or years to develop, and once it sets in it can be very difficult to treat. For this reason, the best treatment of tardive dyskinesia is prevention. Choosing antipsychotics with low dopamine-blocking action, such as the Atypical Antipsychotics - especially Quetiapine and Clozapine, as well as Olanzapine - would be the options with the lowest risk of causing tardive dyskinesia.

Once tardive dyskinesia has set-in, the main treatment option is to switch the antipsychotic to one with lower dopamine-blocking action; again, Quetiapine and Clozapine would be the best options in this regard. Initially, this may cause the tardive dyskinesia to become more pronounced, but over the course of several weeks the dyskinesia should improve.

Various medications have been proposed over the years for treating tardive dyskinesia, but most of them do not have good enough evidence to support their use in clinical practice [ref, ref, ref, ref]. Tetrabenazine is one medication that may be beneficial for some patients [ref, ref].

 

Treating Negative Symptoms