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Lengthy medication lists and polypharmacy are increasingly common in general practice, and tasks such as transcribing extensive hospital prescriptions and addressing concerns about patients’ ability to manage complex medication regimens without error present real challenges.
Numerous factors contribute to this trend, including an aging population, a higher incidence of multimorbidity, and disease-specific treatment protocols. In general practice, making sense of prescriptions often falls to us.
Deprescribing can be a daunting task, particularly during busy consultations. I am always looking for easy-to-use and practical tools to integrate appropriate deprescribing into appointments where I think it may be helpful.
A recent GPnotebook TV video covers the deprescribing of proton pump inhibitors. In this month’s email, I look at new information on another deprescribing target – anticholinergic burden. It comes from a recent update to the GPnotebook page about the effect of anticholinergic burden (ACB) on cardiovascular outcomes, which highlights how assessing ACB can effectively rationalise medications and improve medication safety.
The page discusses evidence indicating that medications with anticholinergic properties may be associated with higher rates of mortality and cardiovascular disease in middle-aged or older individuals. Specifically, those with an ACB of three or greater experienced these outcomes more frequently than those with no anticholinergic burden.
Anticholinergic drugs are a class of medications that block the action of the neurotransmitter acetylcholine. By inhibiting acetylcholine, various anticholinergic agents reduce the effects of the parasympathetic nervous system, which can result in decreased smooth muscle spasms, lower secretions, increased heart rate and pupil dilation.
These medications are prescribed for several conditions, including overactive bladder, chronic obstructive pulmonary disease and motion sickness. Some drugs not primarily intended for their anticholinergic properties, such as certain antihistamines and antipsychotics, may also exhibit anticholinergic effects.
While anticholinergic medicines serve multiple clinical purposes, evidence indicates that they are linked to an increased risk of cognitive impairment, falls and delirium. In certain cases, their potential risks may outweigh their therapeutic benefits.
ACB refers to the cumulative effect of taking multiple medications with anticholinergic properties. The ACB scale is a user-friendly tool for quantifying the risk of harm to people taking medicines with anticholinergic activity. This GPnotebook page shows how the ACB scale works and could be worth bookmarking in case you also want to try it out.
The scale, which assigns a score between +1 and +3 to medications with anticholinergic properties and sums them into a total, reflects an increasing risk from anticholinergics with each additional point scored. A total ACB score of +3 corresponds to an increased likelihood of admission for falls and fractures, cognitive decline, dry mouth, constipation and blurred vision.
The following medications, which are frequently found on patient medication lists, contribute a score of +3: amitriptyline, chlorphenamine, clozapine, hydroxyzine, olanzapine, oxybutynin, paroxetine, promethiazine and tolterodine. Carbamazepine and pethidine carry a score of +2. Atenolol, codeine, colchicine, diazepam, digoxin, haloperidol, fentanyl, furosemide, loperamide, morphine, nifedipine, ranitidine and warfarin each have a score of +1.
Where a person has a high ACB score, we could consider tapering and then stopping anticholinergic medications where possible. Many patients find this to be an easy experience, although it can be helpful to advise that withdrawal effects of anticholinergics can occur and may include nausea and sweating.
I have started to use this in some of my older patients and those with multiple long-term conditions, and I have been surprised to see the correlation between ACB and the symptoms and side effects that patients are experiencing. It has also been a useful tool in older adults presenting with dizziness, falls or memory issues and a useful consideration in people presenting with overactive bladder (OAB) – a group that often end up on anticholinergics.
If you would like to take a look at the treatment options for OAB, this GPnotebook page goes through all the options.