Psycho-Babble Medication Thread 1010334

Shown: posts 1 to 25 of 32. This is the beginning of the thread.

 

tardive akathisia

Posted by Doc49 on February 15, 2012, at 12:49:34

I have a patient with treatment refractory depression who has tardive akathisia from adjunctive aripiprazole. She has been off ari for several months and I have tried B blocker artane even reserpine without effect. She got the akathisia during her treatment for depression so a hair of the dog that bit you approach seems futile. Ideas?

 

Re: tardive akathisia

Posted by Christ_empowered on February 15, 2012, at 14:27:56

In reply to tardive akathisia, posted by Doc49 on February 15, 2012, at 12:49:34

I read something online where a patient on Abilify who developed tardive akathisia (as an Abilify patient, this TERRIFIES me) was given Requip to good effect.

Have you tried opiates and/or benzos?

 

Re: tardive akathisia Christ_empowered

Posted by SLS on February 15, 2012, at 14:48:35

In reply to Re: tardive akathisia, posted by Christ_empowered on February 15, 2012, at 14:27:56

> I read something online where a patient on Abilify who developed tardive akathisia (as an Abilify patient, this TERRIFIES me) was given Requip to good effect.


Do you recall if low dosages of Requip were used rather than high dosages? It might work better at low dosages for akathisia if presynaptic receptors are the desired target.


- Scott

 

Re: tardive akathisia

Posted by Doc49 on February 15, 2012, at 15:50:21

In reply to Re: tardive akathisia, posted by Christ_empowered on February 15, 2012, at 14:27:56

Is taking clonazepam 1.5 mg TID. And Duragesic patch 50 mg q 72 h. Requip also tried over a year ago.

 

Re: tardive akathisia

Posted by ed_uk2010 on February 15, 2012, at 15:58:20

In reply to tardive akathisia, posted by Doc49 on February 15, 2012, at 12:49:34

>I have tried B blocker

Was the beta blocker propranolol?

 

Re: tardive akathisia

Posted by jono_in_adelaide on February 15, 2012, at 16:43:17

In reply to Re: tardive akathisia, posted by ed_uk2010 on February 15, 2012, at 15:58:20

Have you tried a benzo plus propanolol in combination?

 

Re: tardive akathisia

Posted by Doc49 on February 16, 2012, at 11:18:22

In reply to Re: tardive akathisia, posted by jono_in_adelaide on February 15, 2012, at 16:43:17

Yes, and yes. Propranolol plus clonazepam. Anybody tried tetrabenazine or clozapine? Does anyone know of a good review on akathisia? How is it like/unlike EPS? Thanks for all your help!

 

orthomolecular approach?

Posted by Christ_empowered on February 16, 2012, at 11:29:23

In reply to Re: tardive akathisia, posted by Doc49 on February 16, 2012, at 11:18:22

I know, sounds "crazy," but it sounds like everything else has been used. High-dose niacinamide, 800-1600 IU natural form vitamin C, several grams C, b-100, plus additional b-6. The b6 is apparently good for both TD and acute akathisia, according to what I've read.

 

Re: tardive akathisia Doc49

Posted by ed_uk2010 on February 16, 2012, at 14:30:46

In reply to Re: tardive akathisia, posted by Doc49 on February 16, 2012, at 11:18:22

> Yes, and yes. Propranolol plus clonazepam. Anybody tried tetrabenazine or clozapine? Does anyone know of a good review on akathisia? How is it like/unlike EPS? Thanks for all your help!

There are a couple of case reports of clonidine (Catapress) being used. Akathisia seems different to other EPS. It often occurs with atypical APs in spite of minimal EPS (dystonia, Parkinsonism etc.)

I believe that tetrabenazine has a similar mechanism of action to reserpine so it might not be useful for your patient.

 

Re: tardive akathisia

Posted by Doc49 on February 16, 2012, at 15:06:37

In reply to Re: tardive akathisia Doc49, posted by ed_uk2010 on February 16, 2012, at 14:30:46

I will consider orthomolecular. B6 sounds interesting. Clonidine too..I willreview chart to see if we have tried. Also I notice have not tried amantadine. Experience with this? Dosage?

 

Re: tardive akathisia Doc49

Posted by ed_uk2010 on February 16, 2012, at 15:37:05

In reply to Re: tardive akathisia, posted by Doc49 on February 16, 2012, at 15:06:37

>Also I notice have not tried amantadine. Experience with this? Dosage?

Risk of adverse effects is dose-dependent. Could try 100mg once daily, increasing to twice daily if necessary (and if tolerated).

 

Re: tardive akathisia

Posted by novelagent on February 17, 2012, at 21:44:13

In reply to tardive akathisia, posted by Doc49 on February 15, 2012, at 12:49:34

> I have a patient with treatment refractory depression who has tardive akathisia from adjunctive aripiprazole. She has been off ari for several months and I have tried B blocker artane even reserpine without effect. She got the akathisia during her treatment for depression so a hair of the dog that bit you approach seems futile. Ideas?

>

memantine and amphetamine both work equally well for me.

 

Re: tardive akathisia Doc49

Posted by novelagent on February 17, 2012, at 21:50:32

In reply to tardive akathisia, posted by Doc49 on February 15, 2012, at 12:49:34

> I have a patient with treatment refractory depression who has tardive akathisia from adjunctive aripiprazole. She has been off ari for several months and I have tried B blocker artane even reserpine without effect. She got the akathisia during her treatment for depression so a hair of the dog that bit you approach seems futile. Ideas?
>

I also researched this by reading a book on wandering disorders, and it claimed donepezil had good results for akathisia, but it didn't seem to cite a specific study.

It appears there is evidence it is the prefrontal cortex that is involved, and not the stratum, which would explain why memantine and amphetamine also work... the research here lags far behind the anecdotal reports, in part because doctors are too often naively dismissive of any movement disorder complaints from antipsychotics to investigate the matter further. It's good to know someone cares.

 

Re: tardive akathisia Doc49

Posted by novelagent on February 17, 2012, at 22:06:10

In reply to Re: tardive akathisia, posted by Doc49 on February 16, 2012, at 11:18:22

> Yes, and yes. Propranolol plus clonazepam. Anybody tried tetrabenazine or clozapine? Does anyone know of a good review on akathisia? How is it like/unlike EPS? Thanks for all your help!

>>

http://www.medscape.com/viewarticle/703492_15

read the last sentence in this review article about tardive akathisia responding favorably to a dopamine agonist, ropinriole.

 

Re: tardive akathisia novelagent

Posted by SLS on February 18, 2012, at 6:22:48

In reply to Re: tardive akathisia Doc49, posted by novelagent on February 17, 2012, at 22:06:10

> > Yes, and yes. Propranolol plus clonazepam. Anybody tried tetrabenazine or clozapine? Does anyone know of a good review on akathisia? How is it like/unlike EPS? Thanks for all your help!
>
> >>
>
> http://www.medscape.com/viewarticle/703492_15
>
> read the last sentence in this review article about tardive akathisia responding favorably to a dopamine agonist, ropinriole.


I am frustrated by this article because it fails to approach the topic of how one recognizes or diagnoses akathisia. Many other articles omit a description of symptoms and how one rates severity. I see too many people on Psycho-Babble wrongly interpret their anxiety and restlessness as being akathisia. Akathisia usually consists of two components:

1. Subjective: inner restlessness and anxiety. Patients often describe feeling like they are "crawling out of their skin".

2. Objective: inabiity to sit still, shuffling of the legs, pacing, shifting weight from one leg to the other, and rocking movements of the trunk.


- Scott

 

Re: tardive akathisia SLS

Posted by ed_uk2010 on February 18, 2012, at 12:52:37

In reply to Re: tardive akathisia novelagent, posted by SLS on February 18, 2012, at 6:22:48

>I see too many people on Psycho-Babble wrongly interpret their anxiety and restlessness as being akathisia.

I've noticed that too.

In the past, I've experienced both intense akathisia (caused by a typical neuroleptic) and severe anxiety/panic.

Neuroleptic-induced akathisia feels very different to anxiety. The physical restlessness and inability to remain still is much stronger in akathisia - it is the primary symptom. There is an unbearable feeling of not being able to stay still, causing constant pacing or writhing movements, which are frankly exhausting. I remember feeling like my body was going to explode. I felt very afraid that the horrible symptoms would not go away.

In anxiety, it is much easier to remain still, but it is very unpleasant in a different way. There is fear or even dread, terror and panic. Physical tension can be pronounced in severe cases eg. muscle tension and shaking. There is often restlessness but it is easier to stay still than in akathisia. Restlessness is a secondary symptom of anxiety, it is not the primary problem.

Akathisia feels more physical, like pain - both of which have psychological consequences. Anxiety states are more psychological and are often related to specific anxiety-provoking situations.

In akathisia, you experience fear because the physical sensation of restlessness is so overwhelming. In anxiety, you experience physical restless because you are afraid or panicking. When severe, akathisia and anxiety states are both absolutely awful. Both can occur on a continuum of mild/moderate/severe/very severe.

It would be dangerous if a doctor misinterpreted akathisia as a worsening of the patient's condition and increased the dose of the antipsychotic. With typical neuroleptics in particular, akathisia can rapidly occur after a high initial dose or after a abrupt increase in dose. It is often accompanied by a strong dysphoria. I am concerned than akathisia may not be diagnosed correctly in patients who cannot communicate properly (eg. in dementia) or in patients with limited mobility. The resulting agitation and distress may be misdiagnosed, especially by inexperienced doctors who assume that antipsychotics are always calming.

With atypical antipsychotics, akathisia seems to occur more often than standard EPS. Severe akathisia is less likely with atypicals than with say, haloperidol, but it's still a risk. Aripiprazole seems to cause initial restless quite often but it doesn't always last. I've not heard of this scenario with typical APs.

 

Re: tardive akathisia ed_uk2010

Posted by SLS on February 18, 2012, at 13:24:37

In reply to Re: tardive akathisia SLS, posted by ed_uk2010 on February 18, 2012, at 12:52:37

Perfect post!


> >I see too many people on Psycho-Babble wrongly interpret their anxiety and restlessness as being akathisia.
>
> I've noticed that too.
>
> In the past, I've experienced both intense akathisia (caused by a typical neuroleptic) and severe anxiety/panic.
>
> Neuroleptic-induced akathisia feels very different to anxiety. The physical restlessness and inability to remain still is much stronger in akathisia - it is the primary symptom. There is an unbearable feeling of not being able to stay still, causing constant pacing or writhing movements, which are frankly exhausting. I remember feeling like my body was going to explode. I felt very afraid that the horrible symptoms would not go away.
>
> In anxiety, it is much easier to remain still, but it is very unpleasant in a different way. There is fear or even dread, terror and panic. Physical tension can be pronounced in severe cases eg. muscle tension and shaking. There is often restlessness but it is easier to stay still than in akathisia. Restlessness is a secondary symptom of anxiety, it is not the primary problem.
>
> Akathisia feels more physical, like pain - both of which have psychological consequences. Anxiety states are more psychological and are often related to specific anxiety-provoking situations.
>
> In akathisia, you experience fear because the physical sensation of restlessness is so overwhelming. In anxiety, you experience physical restless because you are afraid or panicking. When severe, akathisia and anxiety states are both absolutely awful. Both can occur on a continuum of mild/moderate/severe/very severe.
>
> It would be dangerous if a doctor misinterpreted akathisia as a worsening of the patient's condition and increased the dose of the antipsychotic. With typical neuroleptics in particular, akathisia can rapidly occur after a high initial dose or after a abrupt increase in dose. It is often accompanied by a strong dysphoria. I am concerned than akathisia may not be diagnosed correctly in patients who cannot communicate properly (eg. in dementia) or in patients with limited mobility. The resulting agitation and distress may be misdiagnosed, especially by inexperienced doctors who assume that antipsychotics are always calming.
>
> With atypical antipsychotics, akathisia seems to occur more often than standard EPS. Severe akathisia is less likely with atypicals than with say, haloperidol, but it's still a risk. Aripiprazole seems to cause initial restless quite often but it doesn't always last. I've not heard of this scenario with typical APs.

 

Re: tardive akathisia

Posted by novelagent on February 18, 2012, at 14:09:32

In reply to Re: tardive akathisia SLS, posted by ed_uk2010 on February 18, 2012, at 12:52:37

to address the idea that restlessness can be misdiagnosed anxiety:

anxiety doesn't cause rythmic movement of the legs...

also, to address the notion of it being an intial incident that passes: this is treatment-onset akathisia. (postural tremor is the name for the rythmic movement of the legs-- this can be helpful in searching databases for research). For the first seven days of starting or stopping an SSRI or antipsychotic or changing the dose, this can occur and go away, just as can dystonia

Yet we're dealing with tardive akathisia, unlikely to respond to proprananol, and requiring a dopamine agonist. I advise against amantadine-- tolerance to its effect frequently develops, according to a book, Medication-Induced Movement Disorders.

 

Re: tardive akathisia novelagent

Posted by SLS on February 18, 2012, at 14:56:54

In reply to Re: tardive akathisia, posted by novelagent on February 18, 2012, at 14:09:32

> Yet we're dealing with tardive akathisia, unlikely to respond to proprananol, and requiring a dopamine agonist.

Do you know what relative dosage ranges are used when employing DA agonists to treat akathisia? Are low dosages better than high dosages?


- Scott

 

Re: tardive akathisia novelagent

Posted by ed_uk2010 on February 18, 2012, at 15:10:29

In reply to Re: tardive akathisia, posted by novelagent on February 18, 2012, at 14:09:32

>Anxiety doesn't cause rhythmic movement of the legs...

When I had akathisia, my legs were extremely restless but movements were not necessarily rhythmic. I also felt restless in other parts of my body. Despite a strong urge to move, the akathisia was so severe that movement did not really relieve the distress, it just caused exhaustion.

 

Re: tardive akathisia SLS

Posted by novelagent on February 18, 2012, at 16:41:26

In reply to Re: tardive akathisia novelagent, posted by SLS on February 18, 2012, at 14:56:54

amphetamine and memantine both do not respond to low doses-- therapeutic levels of the medication should suffice.

> > Yet we're dealing with tardive akathisia, unlikely to respond to proprananol, and requiring a dopamine agonist.
>
> Do you know what relative dosage ranges are used when employing DA agonists to treat akathisia? Are low dosages better than high dosages?
>
>
> - Scott

 

Re: tardive akathisia-- try botox Doc49

Posted by novelagent on February 19, 2012, at 0:08:33

In reply to tardive akathisia, posted by Doc49 on February 15, 2012, at 12:49:34

> I have a patient with treatment refractory depression who has tardive akathisia from adjunctive aripiprazole. She has been off ari for several months and I have tried B blocker artane even reserpine without effect. She got the akathisia during her treatment for depression so a hair of the dog that bit you approach seems futile. Ideas?
>>>>>>>>

A dopamine agonist should work, but if it doesn't, one sure fire way to solve the problem is a botox injection into the arch of the foot. It is the joint of the primary (starting) foot in which the sensation to move is focused in. If these nerve endings are paralyized, so is the akathisia. There is research of this in tardive dykensia, yet not likely in tardive akathisia. Yet if it's bad, I suspect the patient will be welcoming of any hope.

Fortunately, the dopamine agnoists (Aricept, etc.) should do the trick.

 

Re: tardive akathisia

Posted by ed_uk2010 on February 19, 2012, at 5:31:44

In reply to Re: tardive akathisia-- try botox Doc49, posted by novelagent on February 19, 2012, at 0:08:33

>A dopamine agonist should work, but if it doesn't, one sure fire way to solve the problem is a botox injection into the arch of the foot. It is the joint of the primary (starting) foot in which the sensation to move is focused in. If these nerve endings are paralyized, so is the akathisia. There is research of this in tardive dykensia, yet not likely in tardive akathisia. Yet if it's bad, I suspect the patient will be welcoming of any hope.
>
> Fortunately, the dopamine agnoists (Aricept, etc.) should do the trick.

I'm not sure how Botox could be used in akathisia. Distress is akathisia is often substantial and restlessness is widespread. Botox is used to paralyse specific muscle groups. Even a completely paralysed patient could experience akathisia subjectively, the feeling of restlessness comes from within the central nervous system.

Donepezil (Aricept) is an acetylcholinesterase inhibitor. There are case reports of its use in tardive dyskinesia. I have no idea how it might affect akathisia. I have a theory that it might help TD patient whose symptoms are aggravated by anticholinergics.

http://www.ncbi.nlm.nih.gov/pubmed/11816865

 

Re: tardive akathisia ed_uk2010

Posted by SLS on February 19, 2012, at 6:13:23

In reply to Re: tardive akathisia, posted by ed_uk2010 on February 19, 2012, at 5:31:44

Hi Ed.

> Donepezil (Aricept) is an acetylcholinesterase inhibitor. There are case reports of its use in tardive dyskinesia. I have no idea how it might affect akathisia. I have a theory that it might help TD patient whose symptoms are aggravated by anticholinergics.
>
> http://www.ncbi.nlm.nih.gov/pubmed/11816865


This is very interesting.

I didn't know that anticholinergics could make TD worse.


- Scott

 

Re: tardive akathisia SLS

Posted by ed_uk2010 on February 19, 2012, at 10:10:50

In reply to Re: tardive akathisia ed_uk2010, posted by SLS on February 19, 2012, at 6:13:23

>I didn't know that anticholinergics could make TD worse.

Despite their efficacy in acute EPS (especially dystonic reactions), anticholinergics have been observed to aggravate TD symptoms in some patients.

Anticholinergics are not always effective for acute akathisia, but are often used, especially for patients who also suffer dystonia due to high-potency neuroleptics such as haloperidol. For acute akathisia caused by antipsychotics which are anticholinergic in their own right, diazepam would be a better choice, followed by a dose reduction or change in AP.


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