Anticholinergics: Protecting patients

Last updated: May 13, 2022

The main strategy in managing patients taking anticholinergic medicines is to regularly review them and then remember the four As:

1.  Awareness. Know the pattern of potential anticholinergic side effects, and be able to identify patients experiencing them or at risk from them.
2.  Alternatives. Consider other options to anticholinergics where possible, including non-drug treatments.
3.  Additive effects. Avoid co-prescribing medicines that have anticholinergic side effects.
4.  Amounts. Restrict exposure by keeping doses low, especially in older people who may be more sensitive.

Alternatives to anticholinergics

When possible, it makes sense to avoid anticholinergics especially in older people. The table below suggests some example choices you may be able to consider instead of anticholinergics, including non-drug options. Stopping an existing anticholinergic medicine is not without risk in certain patients, and in some circumstances you may want to take specialist clinical advice before initiating a change. For example, stopping a tricyclic antidepressant abruptly or a medicine used in mental health may destabilise a chronic condition or cause withdrawal effects in some people.

Some of these options will be inappropriate for an individual patient. You will obviously need to check whether they are safe and appropriate for your patient's medical condition before prescribing them.

It's worth noting that there are two different forms of hysocine available. Hyoscine butylbromide ('Buscopan') is licensed for gut, gastrointestinal and biliary indications but does not enter the brain so doesn't cause CNS side effects. The other form is hyoscine hydrobromide and this does enter the CNS where it can cause anticholinergic effects, so it's best avoided in older people if possible. This hydrobromide form is used in some over-the-counter travel sickness medicines such as Kwells.

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