Management

Acute reactions to neuroleptics may be relieved with:

• biperiden lactate 2-5 mg slowly over 3 minutes IM (may cause hypotension) or
• procyclidine hydrochloride 5-10 mg IM, repeated if necessary after 20 minutes (max dose 20mg/24h) or
• procyclidine hydrochloride 2.5mg orally t.d.s

In cases of tardive dystonia, additional treatment options include benzodiazepines, botulinum toxin for facial dystonia, muscle relaxants, such as baclofen, and dopamine-depleting agents, such as tetrabenazine. (1)

Strategies for treating akathisia include stopping or reducing the dosage of the offending medication and switching to clozapine, olanzapine, or quetiapine. Of this group, 7.5 mg or 15 mg of mirtazapine once daily has shown the greatest efficacy in alleviating akathisia symptoms. (2)

Medication-induced parkinsonism is managed by discontinuing or reducing the dosage of the causative medication, switching to another medication less likely to cause parkinsonian symptoms, and administrating antiparkinsonian medications, including amantadine, anticholinergic medications, L-dopa, and selegiline. (3)

Tardive dyskinesia and other tardive syndromes are treated by gradually tapering or discontinuing the causative medication. There may be transient worsening of symptoms during withdrawal of the causative medication. Anticholinergic medications and antiparkinsonian medications should be discontinued, as they may worsen tardive dyskinesia.

Reference

1. Cloud LJ, Jinnah HA. Treatment strategies for dystonia. Expert Opin Pharmacother. 2010 Jan;11(1):5-15
2. Inada T. [Drug-Induced Akathisia]. Brain Nerve. 2017 Dec;69(12):1417-1424.
3. Shin HW, Chung SJ. Drug-induced parkinsonism. J Clin Neurol. 2012 Mar;8(1):15-21