Cholinergic Functioning, Cognition, and Anticholinergic Medication Burden in Schizophrenia

Acetylcholine (ACh) signaling is critical for central nervous function and is known to be abnormal in schizophrenia (SZ), a chronic neuropsychiatric disorder in which cognitive deficits persist, despite treatment. This review provides a summary of the clinical evidence linking ACh abnormalities to SZ-associated cognitive deficits, an overview of ACh-based pro-cognitive strategies attempted in SZ, and a survey of recent studies that describe the impact of anticholinergic medication burden on cognitive outcomes in SZ. Methodological challenges that currently limit more substantial investigation of ACh in SZ patients and future directions are also discussed.

Fesoterodine treatment of pediatric patients with neurogenic detrusor overactivity: A 24-week, randomized, open-label, phase 3 study

BACKGROUND

Neurogenic detrusor overactivity (NDO) can damage the upper urinary tract leading to chronic renal impairment. Antimuscarinic therapy is used to improve urinary incontinence and protect the upper urinary tract in patients with NDO.

OBJECTIVE

This study investigated safety and efficacy of fesoterodine, a muscarinic receptor antagonist, in 6‒<18-year-old patients with NDO (NCT01557244).

STUDY DESIGN

This open-label phase 3 study included 2 pediatric cohorts. Patients in Cohort 1 (bodyweight >25 kg) were randomized to fesoterodine 4 or 8 mg extended-release tablets or oxybutynin XL tablets administered over the 12-week active comparator-controlled phase. The safety extension phase evaluated fesoterodine 4 and 8 mg for a further 12 weeks, with patients in the oxybutynin arm allocated to fesoterodine 4 or 8 mg. Patients in Cohort 2 (bodyweight ≤25 kg) were randomized to fesoterodine 2 or 4 mg extended-release beads-in-capsule (BIC) administered over a 12-week efficacy phase and 12-week safety extension phase. Patients with stable neurologic disease and clinically or urodynamically proven NDO were included. The primary endpoint was change from baseline to Week 12 in maximum cystometric bladder capacity (MCC). Secondary efficacy endpoints included detrusor pressure at maximum bladder capacity, bladder volume at first involuntary detrusor contraction, bladder compliance, and incontinence episodes. Safety endpoints included adverse event incidence, and specific assessments of cognition, behavior and vision. The pharmacokinetics of 5-hydroxymethyl tolterodine (5-HMT; fesoterodine's active metabolite) was determined using population-pharmacokinetic analysis.

RESULTS

In Cohort 1 (n = 124), fesoterodine 4 and 8 mg treatment resulted in significant increases from baseline in the primary endpoint of MCC at Week 12. In Cohort 2 (n = 57), fesoterodine 2 and 4 mg BIC treatment resulted in improvements in MCC from baseline. Fesoterodine 4 and 8 mg and fesoterodine 4 mg BIC led to improvements in some secondary efficacy endpoints. The most common treatment-related adverse reactions were gastrointestinal effects, such as dry mouth, which occurred more frequently with oxybutynin than fesoterodine. No detrimental effects on visual accommodation or acuity, or on cognitive function or behavior were observed.

DISCUSSION

These safety and efficacy results are consistent with limited published data on fesoterodine treatment in pediatric populations with overactive bladder or NDO. Study limitations include the lack of placebo control and the small sample size, which limits the ability to make formal efficacy comparisons and detect rare adverse reactions.

CONCLUSION

Fesoterodine has a favorable benefit-risk profile in 6‒<18-year-old patients with NDO and may represent an additional option for pediatric NDO treatment.

The effect of oral medications on fMRI brain activation: A randomized, double blind, controlled pilot trial of older women with overactive bladder

INTRODUCTION AND AIM

Observational studies have associated oral anticholinergic medications for overactive bladder (OAB) with cognitive impairment. This is the first pilot trial to compare the effects of two classes of OAB medications on brain activity in women. We evaluated the effect of anticholinergic versus non-anticholinergic (Non-Ach) interventions on regional brain activation during a cognitive task.

METHODS

Twelve cognitively normal women seeking OAB therapy were recruited to a randomized, double-blind, parallel, controlled pilot trial. Whole-brain regional activity at baseline and 29 ± 1 days postintervention was assessed with functional magnetic resonance imaging during a working memory task. Average activation strength by region was compared after anticholinergic, beta-3 agonist, or placebo. Two-way ANOVA compared effects of group and time on average activation strength in anticholinergic versus Non-Ach (beta-3 agonists or placebo) groups.

RESULTS

The mean (SD) age and body mass index of 12 women were 61 (7) years and 36 (7) kg/m². Baseline depression and learning scores differed in the anticholinergic group (n = 3) versus the Non-Ach group (n = 9). Right mamillary body activation postintervention was higher after Non-Ach exposure (F 4.9, p < 0.04). In the full sample of participants at follow-up, there was less activation of the right middle frontal gyrus (p = 0.02), superior frontal gyrus (p < 0.01), and supramarginal (p < 0.01) gyrus.

CONCLUSION

Activation strength in brain regions underlying working memory was lower over time, and recognition scores improved. A powered trial is needed to adequately evaluate for differential effects of OAB oral medications on regional brain activation.

Neurogenic bladder in patients with paraplegia: a two-center study of the real-life experience of the patients' journey

INTRODUCTION

Several patterns of urological dysfunctions have been described following spinal cord injury (SCI), depending on the level and the completeness of the injury. A better understanding of the natural history of neurogenic bladder in patients with SCI, and the description of their successive therapeutic lines based on their clinical and urodynamic pattern is needed to improve their management. This study aimed to describe the real-life successive therapeutic lines in patients with neurogenic lower urinary tract dysfunction (NLUTD) following SCI.

METHODS

We conducted a two-center retrospective review of medical files of patients with SCI followed in two French specialized departments of Physical Medicine and Rehabilitation between January 2000 and January 2018. All patients with SCI with a level of lesion bellow T3 and older than 18 years old were eligible. The primary outcome was the description of the natural journey of neurogenic bladder in this population, from the awakening bladder contraction to the last therapeutic line. Survival curves were calculated with a 95-confidence interval using the Kaplan-Meier method.

RESULTS

One hundred and five patients were included in this study. Most of the patients were young men with a complete SCI lesion. The median time of treatment introduction was 1 and 9 years for anticholinergics and intradetrusor injection of BoNT/A, respectively. Median duration of effect of treatments was 4 and 6 years post-introduction of anticholinergics and BoNT/A, respectively.

CONCLUSION

This study describes NLUTD journey of patients with SCI demonstrating the mid-term efficacy of the two first therapeutic lines of NDO management. An improvement of non-surgical therapeutics is needed.

Anticholinergic treatment for sialorrhea in children: A systematic review

Background

Sialorrhea in children can be associated with adverse physical and social effects. Treatment using anticholinergic medications has been shown to offer symptomatic relief, but there is no consensus regarding which treatment is the most efficacious.

Objective

To examine the effectiveness of anticholinergic medications for sialorrhea in children.

Methods

A systematic review was carried out in Medline, EMBASE, Cochrane, Scopus, and the Web of Science from inception until April 29, 2020. Studies reporting original data on the efficacy of anticholinergic medications in the management of sialorrhea in children aged 0 to 17 years of age were included. This review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. Data on study design, setting, population, pharmacologic intervention(s), comparator(s), outcomes, and results were extracted and summarized.

Results

The search strategy identified 2,800 studies of which 27 articles were included in the synthesis, including five randomized controlled trials. Each anticholinergic undergoing experimental study (glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine) showed evidence of efficacy. Adverse side effects were common. Significant heterogeneity exists in the studies' methodology and the variability of outcome measures used between studies precluded a meta-analysis.

Conclusions

Glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine have all shown efficacy in the treatment of sialorrhea in children. The small number of reports and the variability in study design precluded a meta-analysis. More studies are needed with uniformity in outcome measures to help guide evidence-based decision making. A guidance table is presented.

The use of anticholinergic medication is associated with an increased risk of stroke-associated pneumonia

BACKGROUND

Pneumonia is a frequent medical complication after stroke. A few studies showed that the use of anticholinergic medication is associated with a higher risk of community acquired pneumonia in the elderly. We aimed to determine if there is any association between anticholinergic medication used before stroke and stroke-associated pneumonia (SAP).

METHODS

We analysed prospectively collected data of 675 patients with acute stroke (mean age 71.4 ± 13.3; 53.1% female). We used the Anticholinergic Drug Scale to assess anticholinergic exposure during a month preceding stroke onset.

RESULTS

We diagnosed SAP in 14.7% of patients. The use of anticholinergic medication was associated with an elevated risk of SAP (OR 2.56, 95% CI 1.59-4.11, P < 0.01) in univariate analysis. This association remained significant in multivariable analysis adjusted for age, stroke severity, atrial fibrillation, previous myocardial infarction and respiratory tract diseases (OR 2.06, 95% CI 1.01-4.22, P = 0.04).

CONCLUSIONS

The use of anticholinergic medication before stroke is associated with an increased risk of SAP.

Comparison and characteristics of children successfully treated for daytime urinary incontinence

INTRODUCTION

Daytime urinary incontinence (DUI) is defined as an involuntary leakage of urine during daytime in children 5 years or older. It is a common disorder in the pediatric population most often caused by an overactive bladder (OAB). A stepwise approach is recommended in the treatment of DUI, with standard urotherapy (SU) being first line treatment followed by pharmacological treatment when SU is unsuccessful. To our knowledge few studies have compared patients achieving continence solely on urotherapy with patients achieving continence on a combination of urotherapy and pharmacological treatment in the pediatric population.

OBJECTIVE

The aim of the study was to characterize and compare children suffering from OAB and DUI who became continent solely on urotherapy with patients achieving continence on a combination of urotherapy and pharmacological treatment.

METHODS

All children successfully treated for DUI from 2015 to 2020 were retrospectively analyzed and compared using data from patient's records, 48-h flow-volume charts, and uroflowmetry analysis.

RESULTS

180 children were successfully treated for DUI. Of these 23 (13%) had bowel dysfunction, 94 (52%) were successfully treated with standard urotherapy (SU) and 64 (35%) needed pharmacological treatment. Children who achieved continence on a combination of SU and pharmacological treatment had a significantly higher baseline voiding frequency (7.6 and 6.5 respectively, p=0.007) and more baseline incontinence episodes during daytime when compared to children who became dry solely on urotherapy (2.2 and 1.1 respectively, p < 0.001). Both groups had a similar baseline age (p=0.96) and received a similar duration of standard urotherapy prior to the eventual pharmacological treatment (p = 0.73).

DISCUSSION

Most children achieved daytime continence solely on standard urotherapy. We found that children requiring additional pharmacological treatment to achieve continence suffer from a more severe overactive bladder. As such it could be speculated that children with high voiding frequencies and multiple daily incontinence episodes may benefit from adding anticholinergics to SU earlier during the course of treatment, than what is recommended by the International Children's Continence Society (ICCS) today. However prospective interventional studies are needed for safe conclusions.

CONCLUSION

Our comparison showed that children requiring a combination of SU and pharmacological treatment to achieve continence, had a significantly higher baseline voiding frequency and more baseline incontinence episodes when compared to children requiring only SU to achieve continence.

[Introduction of an anticholinesterase drug in the context of myasthenia, in a severe asthmatic patient]

Association of asthma with myasthenia gravis presents a twofold peculiarity. First, as dyspnea characterizes both conditions, diagnostic orientation is difficult. Second, from a therapeutic standpoint, the initiation of anticholinesterase treatment requires a multidisciplinary approach due to possible contraindication for asthma. We report on the case of a patient monitored for severe asthma and treated with biotherapy, and also monitored for myasthenia gravis, and treated with anticholinesterase.

Centrally Acting Anticholinergic Drugs Used for Urinary Conditions Associated with Worse Outcomes in Dementia

OBJECTIVES

To investigate the associations between central anticholinergic burden and mortality, hospitalization, and cognitive impairment in people with dementia prescribed anticholinergic drugs for urinary symptoms.

DESIGN

Retrospective cohort study.

SETTING AND PARTICIPANTS

Patients diagnosed with dementia receiving anticholinergic medication for bladder conditions (N = 540), assembled from a large healthcare database.

METHODS

Central anticholinergic burden related to bladder drugs was estimated using the anticholinergic effect on cognition scale. Data were linked to national mortality and hospitalization data sources, and serially recorded Mini-Mental State Examination scores were used to investigate cognitive decline.

RESULTS

Patients had a median survival of 4.1 years. Urinary drugs with a high anticholinergic effect on cognition score (tolterodine, oxybutynin) were associated with a 55% increased mortality risk (hazard ratio 1.55; 95% confidence interval 1.19‒2.01; P = .001) compared with drugs with low or no central anticholinergic burden (darifenacin, fesoterodine, trospium, mirabegron, solifenacin). Cognitive decline over a 24-month period around diagnosis was only detectable in the high central anticholinergic group, but there was no significant difference in cognitive trajectories between the high and low/no anticholinergic bladder drug groups. No increase of emergency hospitalization risk was seen in relation to central anticholinergic burden.

CONCLUSIONS AND IMPLICATIONS

Urinary drugs with high central anticholinergic burden cause more harm than those acting peripherally and should be avoided in people with dementia. Further research is needed to test whether centrally acting anticholinergic agents in general cause worse outcomes in dementia.

Impact of anticholinergic load on functioning and cognitive performances of persons with psychosis referred to psychosocial rehabilitation centers

BACKGROUND

Few studies have explored whether high-anticholinergic load may hamper rehabilitation in persons with schizophrenia. We aim to explore the associations between anticholinergic load of psychotropic treatment and functioning or cognitive performances of persons with psychosis engaged in psychosocial rehabilitation.

METHODS

The study was performed using data collected at baseline assessment in the REHABase cohort including persons referred to a French network of psychosocial rehabilitation centers. The composite-rating scale developed by Salahudeen et al. was used to rate the anticholinergic load of psychotropic drugs prescribed at baseline assessment. The associations between total anticholinergic load score (categorized as 'low' <3 v. 'high' ⩾3) and functioning or cognitive characteristics were explored using multivariate analyses.

RESULTS

Of the 1012 participants with schizophrenia spectrum disorders identified in the REHABase, half used at least two psychotropic drugs with anticholinergic activity and one out of three was prescribed at least one psychotropic drug with high-anticholinergic activity. High-anticholinergic load was significantly associated with lower stage of recovery [odds ratio (OR) = 1.70, 95% confidence interval (CI) 1.05-2.76, p = 0.03], poor mental well-being (OR = 1.55, 95% CI 1.02-2.33, p = 0.04) and poor self-rated medication adherence (OR = 2.14, 95% CI 1.29-3.53, p = 0.003). Regarding cognition, a high-anticholinergic score was associated with poorer delayed-episodic memory (OR = 1.69, 95% CI 1.01-2.85, p = 0.05) and at the trend level with faster completion time on the test exploring executive performance (OR = 0.67, 95% CI 0.43-1.04, p = 0.07).

CONCLUSIONS

The psychosocial rehabilitation plan of persons with psychosis should integrate optimization of psychotropic treatment in order to lessen the functional and cognitive impact of high-anticholinergic load.

Acute angle closure glaucoma precipitated by homeopathic eyedrops containing Atropa belladonna

Acute angle closure glaucoma is a sight-threatening condition that may lead to blindness. This is a case report of a woman who presented to the emergency department (ED) with acute angle closure glaucoma following use of an over-the-counter (OTC) homeopathic eye drop containing atropa belladonna (deadly nightshade). A 55-year-old woman presented to the ED with a 5-day history of left eye redness, swelling, tearing, and foreign-body sensation that had acutely worsened in the last two days. Her exam revealed mild left conjunctival injection with watery tearing and a hazy appearance of her left cornea. Fluorescein staining was negative, while tonometry revealed elevated intraocular pressure on the left, suggestive of acute angle closure glaucoma. She was urgently referred to ophthalmology. The etiology of the acute angle closure glaucoma was initially unclear however, with additional prompting, she revealed that two days prior she had started using homeopathic OTC eye drops. Inspection of the eyedrop's ingredients revealed that atropa belladonna was the primary ingredient and likely precipitated her isolated episode of acute angle closure glaucoma. A high level of clinical suspicion and focused ophthalmic exam including tonometry is essential to identify acute angle closure glaucoma in the ED. We present a case report of acute angle closure glaucoma associated with the use of homeopathic belladonna-containing eyedrops. Our report reinforces the necessity to perform thorough medication and supplement history given the prevalence of physiologically active substances available in OTC medications.

Deprescribing to reduce polypharmacy: study protocol for a randomised controlled trial assessing deprescribing of anticholinergic and sedative drugs in a cohort of frail older people living in the community

BACKGROUND

Targeted deprescribing of anticholinergic and sedative medications in older people may improve their health outcomes. This trial will determine if pharmacist-led reviews lead to general practitioners deprescribing anticholinergic and sedative medications in older people living in the community.

METHODS AND ANALYSIS

The standard protocol items: Recommendations for Interventional Trials (SPIRIT) checklist was used to develop and report the protocol. The trial will involve older adults stratified by frailty (low, medium, and high). This will be a pragmatic two-arm randomized controlled trial to test general practitioner uptake of pharmacist recommendations to deprescribe anticholinergic and sedative medications that are causing adverse side effects in patients.

STUDY POPULATION

Community-dwelling frail adults, 65 years or older, living in the Canterbury region of New Zealand, seeking publicly funded home support services or admission to aged residential care and taking at least one anticholinergic or sedative medication regularly.

INTERVENTION

New Zealand registered pharmacists using peer-reviewed deprescribing guidelines will visit participants at home in the community, review their medications, and recommend anticholinergic and sedative medications that could be deprescribed to the participant's general practitioner. The total use of anticholinergic and sedative medications will be quantified using the Drug Burden Index (DBI).

OUTCOMES

The primary outcome will be the change in total DBI between baseline and 6-month follow-up. Secondary outcomes will include entry into aged residential care, prolonged hospitalization, and death.

DATA COLLECTION POINTS

Data will be collected at the time of interRAI assessments (T0), at the time of the baseline review (T1), at 6 months following the baseline review (T2), and at the end of the study period, or end of study participation for participants admitted into aged residential care, or who died (T3).

ETHICS AND DISSEMINATION

Ethical approval has been obtained from the Human, Disability and Ethics Committee: ethical number (17CEN265).

TRIAL REGISTRATION

ClinicalTrials.gov ACTRN12618000729224 . Registered on May 2, 2018, with the Australian New Zealand Clinical Trials Registry.

Anticholinergics and clinical outcomes amongst people with pre-existing dementia: A systematic review

Many medicines have anticholinergic properties, which have previously been correlated with a range of adverse effects, including cognitive impairment, hallucinations and delirium. These effects are potentially of concern for people with dementia. This systematic review investigated the effect of anticholinergic medicines on the health outcomes of people with pre-existing dementia. Embase, Medline and the Cochrane Library were searched from January 2000 to January 2021. Studies were included if they matched the following criteria: (1) the intervention involved anticholinergic medications; (2) the study was conducted in people with pre-existing dementia; (3) there was at least one comparator group; and (4) the outcome of interest was clinically measurable. A total of 14 studies met the inclusion criteria. Most studies used an anticholinergic burden scale to measure anticholinergic exposure. Five high-quality studies consistently identified a strong association between anticholinergic medications and all-cause mortality. Anticholinergics were also found to be associated with longer hospital length of stay in three studies. Inconsistent findings were reported for cognitive function (in 4 studies) and neuropsychiatric functions (in 2 studies). In single studies, anticholinergic medications were associated with the composite outcome of stroke and mortality, pneumonia, delirium, poor physical performance, reduced health-related quality of life and treatment modifications due to reduced treatment response or symptom exacerbation. While the evidence suggests that anticholinergic medication use for people with dementia has a strong association with all-cause mortality, the association with cognitive and other clinical outcomes remains uncertain. Hence, further studies are needed to substantiate the evidence for other outcomes.

Unintentional cetirizine overdose causing anticholinergic syndrome: A case report

The incidence of anticholinergic syndrome due to second generation antihistamines is infrequently reported. Largely due to their decreased affinity for central nervous system (CNS) receptors, second generation antihistamines are rarely associated with anticholinergic symptoms, though toxicity is still possible particularly when taken in excess. We report a case of a six year old boy who presented with agitation, hallucinations, fixed and dilated pupils, tachycardia, and hyperthermia consistent with anticholinergic toxicity several hours after accidental overdose of a second generation antihistamine, cetirizine. Early identification of this rare phenomenon is important not only for appropriate emergency management but also for avoidance of potentially invasive and unnecessary tests which may further increase patient morbidity.

A systematic review of neurocognitive dysfunction with overactive bladder medications

INTRODUCTION AND HYPOTHESIS

The aim of this study is to report cognitive dysfunction with commonly used antimuscarinic overactive bladder medications in patients suffering from overactive bladder disorder with and without baseline neurologic conditions.

METHODS

We conducted an Ovid MEDLINE, Embase, and PsycINFO search from January 1998 to December 2018 using PRISMA guidelines. Eighteen studies met the inclusion criteria, including 5 randomized controlled trials and 13 observational studies.

RESULTS

Cognitive decline was reported with oxybutynin use (5 of 8 studies) and tolterodine use (4 of 7 studies) among patients with and without baseline cognitive impairment. Oxybutynin use was linked to functional, mental, and behavioral decline among patients with Alzheimer's disease (2 studies). No cognitive decline was detected among patients with and without baseline cognitive impairment taking trospium (6 studies), darifenacin (3 studies), imidafenacin (2 studies), and fesoterodine (1 study). Solifenacin was not associated with cognitive decline (2 studies) but was linked to an increased risk of dementia among patients with diabetes (1 study).

CONCLUSION

In this review, cognitive decline was reported with oxybutynin and tolterodine use and should be used with caution in adults over 65 years of age. Solifenacin, fesoterodine, and imidafenacin showed mixed results related to central nervous system effect. Trospium and darifenacin were not associated with cognitive decline among patients with and without baseline cognitive impairment.

Safety of denervation following targeted lung denervation therapy for COPD: AIRFLOW-1 3-year outcomes

Background

Targeted lung denervation (TLD) is a novel bronchoscopic therapy that disrupts parasympathetic pulmonary nerve input to the lung reducing clinical consequences of cholinergic hyperactivity. The AIRFLOW-1 study assessed safety and TLD dose in patients with moderate-to-severe, symptomatic COPD. This analysis evaluated the long-term impact of TLD on COPD exacerbations, pulmonary function, and quality of life over 3 years of follow up.

Methods

TLD was performed in a prospective, energy-level randomized (29 W vs 32 W power), multicenter study (NCT02058459). Additional patients were enrolled in an open label confirmation phase to confirm improved gastrointestinal safety after procedural modifications. Durability of TLD was evaluated at 1, 2, and 3 years post-treatment and assessed through analysis of COPD exacerbations, pulmonary lung function, and quality of life.

Results

Three-year follow-up data were available for 73.9% of patients (n = 34). The annualized rate of moderate to severe COPD exacerbations remained stable over the duration of the study. Lung function (FEV₁, FVC, RV, and TLC) and quality of life (SGRQ-C and CAT) remained stable over 3 years of follow-up. No new gastrointestinal adverse events and no unexpected serious adverse events were observed.

Conclusion

TLD in COPD patients demonstrated a positive safety profile out to 3 years, with no late-onset serious adverse events related to denervation therapy. Clinical stability in lung function, quality of life, and exacerbations were observed in TLD treated patients over 3 years of follow up.

Clinical outcomes associated with anticholinergic burden in older hospitalized patients with advanced cancer: a single-center database study

PURPOSE

Although anticholinergic burden has been known to be associated with adverse outcomes in older adults, its clinical importance has been less studied in patients with advanced cancer. We aimed to assess clinical impacts of using anticholinergic medications in older patients with cancer.

METHODS

This is a single-center retrospective database study. This study included patients with stage IV solid cancer aged 65 years or older who were hospitalized in a hospitalist-operated medical unit of a tertiary hospital. We calculated anticholinergic cognitive burden (ACB) scores on admission and during hospitalization by reviewing all medications during hospital stays and collected the following data: demographic, medical history and clinical severity, occurrence of delirium, location of discharge, in-hospital mortality, and after discharge mortality data.

RESULTS

When we divided the patients into two groups based on the change in ACB during hospitalization, the in-hospital mortality rate, incidence of delirium, frequency of transfers to long-term care hospitals, and length of hospital stay were higher in the ACB-increased group than those in the non-increased group. Even after excluding patients with clinically detected delirium, increased ACB were associated with increased in-hospital mortality. Patients in the ACB-increased group showed higher mortality risk after discharge than those in the non-increased group based on the Cox proportional hazard model.

CONCLUSION

Increased ACB during hospitalization is a predictor of worsening clinical features and higher mortality in older patients with cancer. Further studies investigating causal relationship between an increased ACB and poor prognosis are warranted.

[Accountability of anti-cholinergic drugs in increase of psychotic episodes: A case of tropatepine overdose]

INTRODUCTION

Corrective treatments for some neurological side effects due to antipsychotic treatments can induce anticholinergic adverse effects. However, the risk of triggering or increasing psychotic symptoms induced by these drugs is unknown with only one case-report concerning the tropatepine. In addition, recommendations for the use of these drugs remain imprecise regarding the management of this type of adverse effect.

CASE REPORT

We report the case of a psychotic episode in an 18-year-old patient potentially acutised after an auto-intoxication with tropatepine.

CONCLUSION

At high doses, anticholinergic treatments, including tropatepine, might increase psychotic episodes. In addition, the available epidemiological data reveal an inappropriate and excessive prescription of these drugs. Their use and risks should be better known and need an update of the available recommendations.

Anticholinergic medications and risk of dementia in older adults: Where are we now?

INTRODUCTION

Anticholinergic medications are effective for a wide variety of indications, but are associated with significant central adverse effects, especially cognitive decline and dementia in older adults.

AREAS COVERED

We conducted a review of relevant literature in the past decade to address anticholinergic scales and evidence of anticholinergic-related dementia/cognitive decline in older adults. We discussed various anticholinergic scales used to classify anticholinergic medications. The review focused on the evidence from previous reviews and individual studies evaluating the anticholinergic-related risk of developing cognitive decline/dementia. This review also discussed clinical and methodological issues of studies along with recommendations for practice and research.

EXPERT OPINION

The review demonstrates moderate to strong risk of dementia with anticholinergic use in multiple studies involving older adults, irrespective of the study design, analytical approach, anticholinergic exposure and outcome definition. This risk is particularly significant with the cumulative burden and high-level anticholinergics. There also exists a dose-response relationship between anticholinergic use and increased risk for dementia. Therefore, anticholinergic agents can be considered as a modifiable risk factor for dementia and cognitive decline in older adults. Based on the current evidence, regular assessment and optimization of anticholinergic burden prior to prescribing these medications can minimize anticholinergic-related morbidity in older adults.

Adverse drug reactions associated with amitriptyline - protocol for a systematic multiple-indication review and meta-analysis

BACKGROUND

Unwanted anticholinergic effects are both underestimated and frequently overlooked. Failure to identify adverse drug reactions (ADRs) can lead to prescribing cascades and the unnecessary use of over-the-counter products. The objective of this systematic review and meta-analysis is to explore and quantify the frequency and severity of ADRs associated with amitriptyline vs. placebo in randomized controlled trials (RCTs) involving adults with any indication, as well as healthy individuals.

METHODS

A systematic search in six electronic databases, forward/backward searches, manual searches, and searches for Food and Drug Administration (FDA) and European Medicines Agency (EMA) approval studies, will be performed. Placebo-controlled RCTs evaluating amitriptyline in any dosage, regardless of indication and without restrictions on the time and language of publication, will be included, as will healthy individuals. Studies of topical amitriptyline, combination therapies, or including < 100 participants, will be excluded. Two investigators will screen the studies independently, assess methodological quality, and extract data on design, population, intervention, and outcomes ((non-)anticholinergic ADRs, e.g., symptoms, test results, and adverse drug events (ADEs) such as falls). The primary outcome will be the frequency of anticholinergic ADRs as a binary outcome (absolute number of patients with/without anticholinergic ADRs) in amitriptyline vs. placebo groups. Anticholinergic ADRs will be defined by an experienced clinical pharmacologist, based on literature and data from Martindale: The Complete Drug Reference. Secondary outcomes will be frequency and severity of (non-)anticholinergic ADRs and ADEs. The information will be synthesized in meta-analyses and narratives. We intend to assess heterogeneity using meta-regression (for indication, outcome, and time points) and I2 statistics. Binary outcomes will be expressed as odds ratios, and continuous outcomes as standardized mean differences. Effect measures will be provided using 95% confidence intervals. We plan sensitivity analyses to assess methodological quality, outcome reporting etc., and subgroup analyses on age, dosage, and duration of treatment.

DISCUSSION

We will quantify the frequency of anticholinergic and other ADRs/ADEs in adults taking amitriptyline for any indication by comparing rates for amitriptyline vs. placebo, hence, preventing bias from disease symptoms and nocebo effects. As no standardized instrument exists to measure it, our overall estimate of anticholinergic ADRs may have limitations.

SYSTEMATIC REVIEW REGISTRATION

Submitted to PROSPERO; assignment is in progress.

[Effects of polypharmacy and anticholinergic/sedative drugs on the physical/cognitive/mental related outcomes of community-dwelling elderly people: The Kawasaki Wellbeing Project]

AIM

To assess the burdens of polypharmacy and the drug burden index in community-dwelling elder people.

METHODS

The survey was conducted on 396 participants who participated in The Kawasaki Wellbeing Project from March to December 2017. We investigated the associations between the drug burden and the physical/cognitive/mental outcomes. The drug burden was determined by calculating the number of medications and the drug burden index (DBI) based on the use of anticholinergic and sedative drugs. A multivariate regression analysis was conducted for the outcome measures ADL, IADL, MMSE, J-CHS, and EQ5D5L after adjusting for the sex, age, number of diseases, education level, smoking history, and alcohol history.

RESULTS

A total of 389 subjects were analyzed, the mean age of the population was 86 years old, and 187 people (48%) were male. Polypharmacy was reported in 243 people (62%), and DBI exposure was reported for 142 people (36.5%). We found that this population was physically healthy, with a median ADL of 100, and had high quality of life, with a median EQ5D5L of 0.895. Polypharmacy was found to be related to the J-CHS (β: 0.04) and EQ5D5L (-0.01). The DBI was also related to the EQ5D5L (-0.04).

CONCLUSION

These results showed that even though this population was healthier than the general Japanese elderly population, the drug burden of polypharmacy and high dosages of anticholinergic/sedative drugs exerted significant negative effects on frailty and the quality of life. Additional research should be conducted to investigate the long-term effects of polypharmacy and anticholinergic/sedative drugs on elderly people.

Convergence excess consecutive esotropia associated with 0.01% atropine eye drops usage in patients operated for intermittent exotropia

To report convergence excess esotropia (CEET) following 0.01% atropine eye drops (Low dose atropine [LDA]). Children who developed CEET that resolved promptly after discontinuation of LDA are described. Three myopes aged 5.3 ± 1.2 years and mean sphere -4.5D were included. All were operated for intermittent exotropia earlier. Mean esotropia was +28.3PD for near and 10.6PD for distance. LDA induced high AC/A ratio and fusion normalized in 3 weeks after discontinuation of LDA. LDA should be used with caution in patients with esophoria or previously operated for intermittent exotropia. Any evidence of the emergence of a CEET should warrant discontinuation of LDA.

Design for a multicenter, randomized, sham-controlled study to evaluate safety and efficacy after treatment with the Nuvaira® lung denervation system in subjects with chronic obstructive pulmonary disease (AIRFLOW-3)

Background

Targeted lung denervation (TLD) is a bronchoscopically delivered ablation therapy that selectively interrupts pulmonary parasympathetic nerve signaling. The procedure has the potential to alter airway smooth muscle tone and reactivity, decrease mucous secretion, and reduce airway inflammation and reflex airway hyperresponsiveness. Secondary outcome analysis of a previous randomized, sham-controlled trial showed a reduction in moderate-to-severe exacerbations in patients with COPD after TLD treatment. A pivotal trial, AIRFLOW-3 has been designed to evaluate the safety and efficacy of TLD combined with optimal medical therapy to reduce moderate or severe exacerbations throughout 1 year, compared with optimal medical therapy alone.

Methods

The study design is a multicenter, randomized, full sham bronchoscopy controlled, double-blind trial that will enroll 400 patients (1:1 randomization). Key inclusion criteria are FEV₁/FVC < 0.7, FEV₁ 30 to 60% of predicted, post-bronchodilator, ≥ 2 moderate or 1 severe COPD exacerbations in the prior year, and COPD assessment test (CAT) ≥ 10. Primary objective will be the comparison of moderate or severe COPD exacerbations through 12 months of TLD therapy with optimal medical therapy versus optimal medical therapy alone. The sham group will be allowed to cross over at 1 year. Patients will be followed for up to 5 years.

Discussion

The multicenter, randomized, full sham bronchoscopy controlled, double-blind AIRFLOW-3 trial will evaluate the efficacy of TLD to reduce moderate or severe COPD exacerbations beyond optimal medical therapy alone. The target population are patients with COPD, who suffer persistent symptoms and exacerbations despite optimal treatment, defining an unmet medical need requiring novel therapeutic solutions. This trial is registered at clinicaltrials.gov: NCT03639051.

Prehospital Anticholinergic Burden Is Associated With Delirium but Not With Mortality in a Population of Acutely Ill Medical Patients

OBJECTIVES

Anticholinergic drugs have several side effects, and they have been associated with adverse outcomes, particularly in older patients. The aim of this study was to analyze anticholinergic burden and its relationship to delirium and mortality in older acutely ill medical patients.

DESIGN

Cohort study.

SETTING AND PARTICIPANTS

Patients 65 years of age and older who were admitted to an Internal Medicine ward between August 1 and December 31, 2016.

METHODS

Anticholinergic drug use, outpatient and inpatient, was assessed using the Anticholinergic Cognitive Burden Scale (ACB). Prevalent delirium was diagnosed by the Short Confusion Assessment Method (Short-CAM).

RESULTS

Of the 198 patients, 28.3% developed delirium. Mortality rate was 13.6% in-hospital and 45.6% at 12 months. In multivariate analysis, outpatient ACB was associated with delirium, with an odds ratio (OR) of 1.65 [95% confidence interval (CI) 1.09-2.51]. Those with delirium had longer hospital stays (median 13 vs 8 days; P = .01), received more drugs (median 18 vs 15; P = .02), and presented a higher inpatient ACB (mean 3.9 vs 3.1; P = .034). No increased risk was found for in-hospital or 12-month mortality with drug use, ACB, or delirium.

DISCUSSION

In the population studied, we found an association between anticholinergic burden as measured by the ACB and the presence of delirium, but not with mortality at 12 months. A very high 12-month mortality rate might have been an obstacle for association recognition.

CONCLUSIONS AND IMPLICATIONS

Clinician awareness of possible drug side effects, especially in older populations, is crucial. As part of medication reconciliation at the time of hospitalization, ACB of prehospitalization medications should be routinely calculated by inpatient pharmacy services and made available to medical teams.

Gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic drugs for overactive bladder treatment

Introduction: Overactive bladder (OAB) has a heterogeneous presentation that varies between individuals and by gender. Treatment with antimuscarinic medications is standard first line pharmacotherapy for most patients with OAB. However, gender specific differences in the pharmacokinetics and pharmacodynamics of antimuscarinic therapy are often overlooked and not discussed.Areas covered: This review will explore differences by gender between the presentation and treatment of OAB. We will discuss the differences between sexes in terms of lower urinary tract anatomy, muscarinic receptors, and hormone variation. The effect of antimuscarinics on males and females as well as adherence and persistence patterns will be reviewed in order to fully review all available literature on the gender specific pharmacokinetic and pharmacodynamic considerations for antimuscarinic use in the treatment of OAB.Expert opinion: Despite extensive research into various antimuscarinic formulations and therapeutic regimens for the treatment of OAB, identification of gender specific pharmacokinetic and pharmacodynamics considerations remains scant. As our knowledge and understanding of OAB, muscarinic receptors, and antimuscarinic medications evolve, we will hopefully be better able to understand and implement gender-specific and genomic-sprecific treatment regimens and considerations for improved clinical outcomes.