Mirtazapine for antipsychotic-induced acute akathisia: a systematic review and meta-analysis of randomized placebo-controlled trials

Praharaj, Samir Kumar; Kongasseri, Sreejayan; Behere, Rishikesh V.; Sharma, Podila Satya Venkata Narasimha

doi:10.1177/2045125315601343

Cited by 18 publications

(13 citation statements)

References 44 publications

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“… 101 Comparative studies have shown cyproheptadine, zolmitriptan, and vitamin B6 produce similar levels of DRBA-A symptom reduction when compared with a range of doses (40–120 mg/day) of propranolol. 102 – 104 Serotonin 5-HT 2A receptor antagonists, such as mirtazapine, 105 – 110 trazodone, 111 fluvoxamine, 112 zolmitriptan, 103 mianserin, 113 and cyproheptadine, 102 represent another class of treatments for DRBA-A. 114 Blocking this receptor likely plays a role in reducing symptoms by increasing downstream dopamine signaling in areas of the brain affected by DRBAs.…”

Section: Discussionmentioning

confidence: 99%

Dopamine-receptor blocking agent-associated akathisia: a summary of current understanding and proposal for a rational approach to treatment

Schwartz

McAllister

Caudle

2020

Therapeutic Advances in Psychopharmacology

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Dopamine-receptor blocking agent-associated akathisia (DRBA-A) is an adverse effect that can significantly limit the use of these important medications for the treatment of a variety of psychiatric diseases, yet there is no unifying theory regarding its pathophysiology. This knowledge gap limits clinicians’ ability to effectively manage DRBA-A and mitigate negative outcomes in an already vulnerable patient population. Based on a review of the current literature on the subject, it is hypothesized that dopaminergic and noradrenergic signaling is perturbed in DRBA-A. Accordingly, it is proposed that the optimal agent to manage this extrapyramidal symptom should increase dopamine signaling in the affected areas of the brain and counteract compensatory noradrenergic signaling via antagonism of adrenergic or serotonergic receptors.

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Section: Discussionmentioning

confidence: 99%

Dopamine-receptor blocking agent-associated akathisia: a summary of current understanding and proposal for a rational approach to treatment

Schwartz

McAllister

Caudle

2020

Therapeutic Advances in Psychopharmacology

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“…The antidepressant mirtazapine at 15 mg/day has shown propranolol equivalency in several trials and seems to be well tolerated in the short term, though its potential to cause weight gain is a particular consideration among those receiving antipsychotics. The specific 5‐HT2A/C antagonists mianserin and ritanserin have also shown efficacy in small open‐label studies. Zolmitriptan (a 5‐HT1B/1D agonist) and cyproheptadine (which has 5‐HT2 antagonism in addition to anticholinergic and antihistaminergic properties) were both found to be as effective as propranolol in small randomized trials.…”

Section: Specific Adverse Effectsmentioning

confidence: 99%

Management of common adverse effects of antipsychotic medications

2018

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The benefits of antipsychotic medications are sometimes obscured by their adverse effects. These effects range from relatively minor tolerability issues (e.g., mild sedation or dry mouth) to very unpleasant (e.g., constipation, akathisia, sexual dysfunction) to painful (e.g., acute dystonias) to disfiguring (e.g., weight gain, tardive dyskinesia) to life-threatening (e.g., myocarditis, agranulocytosis). Importantly, adverse effect profiles are specific to each antipsychotic medication and do not neatly fit into first- and second-generation classifications. This paper reviews management strategies for the most frequent side effects and identifies common principles intended to optimize net antipsychotic benefits. Only use antipsychotics if the indication is clear; only continue antipsychotics if a benefit is discernible. If an antipsychotic is providing substantial benefit, and the adverse effect is not life-threatening, then the first management choice is to lower the dose or adjust the dosing schedule. The next option is to change the antipsychotic; this is often reasonable unless the risk of relapse is high. In some instances, behavioral interventions can be tried. Finally, concomitant medications, though generally not desirable, are necessary in many instances and can provide considerable relief. Among concomitant medication strategies, anticholinergic medications for dystonias and parkinsonism are often effective; beta-blockers and anticholinergic medications are useful for akathisia; and metformin may lead to slight to moderate weight loss. Anticholinergic drops applied sublingually reduce sialorrhea. Usual medications are effective for constipation or dyslipidemias. The clinical utility of recently approved treatments for tardive dyskinesia, valbenazine and deutetrabenazine, is unclear.

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“…On the patient first encounter to emergency department he was discharged without medications, few days later on the second encounter with the same initial presentation of anxiety and insomnia he was started on Olanzapine 10 mg and discharged home, the dose was increased by the patient himself to 20 mg daily on the following day, next morning he presented again to emergency with severe anxiety, insomnia and new development of severe restlessness , Olanzapine was stopped by the emergency department and the patient provided with urgent referral to psychiatry hospital in three days where he was started on Mirtazapine 15 mg and propranolol of 20 mg twice a day [5].…”

Section: Treatmentmentioning

confidence: 99%

The Possibility of the Second Generation Antipsychotic-Olanzapine to Cause Severe Akathisia in a Drug Naive Patient -A Case Report

2020

IJP

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Here we are presenting this case of 26 years old gentleman with no past psychiatric history who presented initially to the emergency department with anxiety and depressive symptoms in the context of ongoing stressors, diagnosed as a case of severe anxiety and started on neuroleptic medication. A few days later, it was reported by the family that the patient was moving around and only sit for a few minutes before starting to move again in response to an urge to keep moving. Barnes Akathisia-Rating Scale was administered and indicated severe akathisia. The patient started on Mirtazapine 15 mg and Propranolol 20 mg twice daily, and he dramatically improved in a few days.

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Mirtazapine for antipsychotic-induced acute akathisia: a systematic review and meta-analysis of randomized placebo-controlled trials

Abstract: Although limited to only two studies and small sample, existing data support the efficacy of mirtazapine for the treatment of AIAA, with one in four patients showing partial response and one in five patients showing complete remission.

Cited by 18 publications

References 44 publications

Dopamine-receptor blocking agent-associated akathisia: a summary of current understanding and proposal for a rational approach to treatment

Dopamine-receptor blocking agent-associated akathisia: a summary of current understanding and proposal for a rational approach to treatment

Management of common adverse effects of antipsychotic medications

The Possibility of the Second Generation Antipsychotic-Olanzapine to Cause Severe Akathisia in a Drug Naive Patient -A Case Report

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