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Systematic review of anticholinergic risk scales in older adults

  • Pharmacoepidemiology and Prescription
  • Published:
European Journal of Clinical Pharmacology Aims and scope Submit manuscript

Abstract

Background

Anticholinergic drugs are often involved in explicit criteria for inappropriate prescribing in older adults. Several scales were developed for screening of anticholinergic drugs and estimation of the anticholinergic burden. However, variation exists in scale development, in the selection of anticholinergic drugs, and the evaluation of their anticholinergic load. This study aims to systematically review existing anticholinergic risk scales, and to develop a uniform list of anticholinergic drugs differentiating for anticholinergic potency.

Methods

We performed a systematic search in MEDLINE. Studies were included if provided (1) a finite list of anticholinergic drugs; (2) a grading score of anticholinergic potency and, (3) a validation in a clinical or experimental setting. We listed anticholinergic drugs for which there was agreement in the different scales. In case of discrepancies between scores we used a reputed reference source (Martindale: The Complete Drug Reference®) to take a final decision about the anticholinergic activity of the drug.

Results

We included seven risk scales, and evaluated 225 different drugs. Hundred drugs were listed as having clinically relevant anticholinergic properties (47 high potency and 53 low potency), to be included in screening software for anticholinergic burden.

Conclusion

Considerable variation exists among anticholinergic risk scales, in terms of selection of specific drugs, as well as of grading of anticholinergic potency. Our selection of 100 drugs with clinically relevant anticholinergic properties needs to be supplemented with validated information on dosing and route of administration for a full estimation of the anticholinergic burden in poly-medicated older adults.

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Acknowledgments

We thank Thierry Christiaens and Veronika Wirtz for assistance in developing the methodology for this project.

This study was funded by a grant from the Flemish Interuniversity Council, through the University Development Cooperation (VLIR-UOS), Belgium. The funding agency was in no way implicated in the study design, data collection, analysis and interpretation, nor was there any involvement in the decision to submit the paper for publication.

Conflict of interest

None to declare

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Robert H. Vander Stichele.

Annex

Annex

N

Drug name

ATC 5th level

Carnahan 2006 USA

Ancelin 2006 France

Chew 2008 USA

Rudolph 2008 USA

Han 2008 USA

Ehrt 2010 Norway

Sittironnarit 2011 Australia

• Sublist 1. Discrepancies in drugs that received low grades, not confirmed in Martindale® (improbable anticholinergic action)

1

Alverine

A03AX08

 

2

     

2

Amoxicillin

J01CA04

0

 

1

   

0

3

Ampicillin

J01CA01

1

      

4

Azathioprine

L04AX01

1

      

5

Benazepril

C09AA07

0

   

1

  

6

Betaxolol

C07AB05

    

1

  

7

Bisacodyl

A06AB02

0

 

0

   

1

8

Bupropion

N06AX12

0

 

0

 

1

  

9

Captopril

C09AA01

1

    

0

0

10

Carbidopa

N/A

0

 

0

1

1

 

1

11

Cefalexin

J01DB01

0

 

1

   

0

12

Cefamandole

J01DC03

1

      

13

Cefoxitin

J01DC01

1

      

14

Celecoxib

M01AH01

0

 

1

   

1

15

Cephalotin

J01DB03

1

      

16

Clindamycin

J01FF01

1

      

17

Cortisone

H02AB10

1

      

18

Cycloserine

J04AB01

1

      

19

Cyclosporine

L04AD01

1

      

20

Chlorthalidone

C03BA04

1

     

0

21

Dexamethasone

H02AB02

1

      

22

Dextromethorphan

R05DA09

    

1

  

23

Diltiazem

C08DB01

1

 

0

   

0

24

Diphenoxylate

A07DA01

0

 

1

   

0

25

Dipyridamole

B01AC07

1

 

0

  

0

 

26

Duloxetine

N06AX21

0

 

1

   

0

27

Escitalopram

N06AB10

0

 

1

   

1

28

Estazolam

N05CD04

1

      

29

Famotidine

A02BA03

1

 

0

   

0

30

Flunitrazepam

N05CD03

     

1

 

31

Flurazepam

N05CD01

1

      

32

Fluticasone-salmeterol

R03AK06

1

      

33

Gentamicin

J01GB03

1

      

34

Guaifenesin

R05CA03

0

   

1

  

35

Hydralazine

C02DB02

1

     

0

36

Hydrocortisone

H02AB09

1

      

37

Isosorbidedinitrate

C01DA08

1

    

0

0

38

Isosorbidemononitrate

C01DA14

1

    

0

0

39

Ketotifenophthalmic

S01GX08

1

      

40

Lansoprazole

A02BC03

0

 

1

  

1

0

41

Levofloxacin

J01MA12

0

 

1

    

42

Lorazepam

N05BA06

1

 

0

    

43

Lumiracoxib

M01AH06

      

1

44

Metformin

A10BA02

0

 

1

   

1

45

Methotrexate

L04AX03

0

     

1

46

Methylprednisolone

H02AB04

1

      

47

Midazolam

N05CD08

1

      

48

Naratriptan

N02CC02

      

1

49

Nizatidine

A02BA04

1

     

0

50

Oxazepam

N05BA04

1

 

0

  

0

1

51

Pancuronium

M03AC01

1

      

52

Phenobarbital

N03AA02

0

   

1

1

 

53

Phenytoin

N03AB02

0

 

1

    

54

Piperacillin

J01CA12

1

      

55

Pramipexol

N04BC05

0

  

1

 

0

 

56

Prednisolone

H02AB06

1

    

0

 

57

Pseudoephedrine

R01BA02

0

     

2

58

Selegiline

N04BD01

0

  

1

 

0

 

59

Sumatriptan

N02CC01

      

1

60

Topiramate

N03AX11

0

 

1

    

61

Trandolapril

C09AA10

0

   

1

  

62

Triamcinolone

H02AB08

1

      

63

Triamterene

C03DB02

1

     

0

64

Valproatesodium

N03AG01

1

      

65

Valproicacid

N03AG01

1

 

0

   

0

66

Vancomycin

J01XA01

1

      

67

Ziprasidone

N05AE04

  

0

1

   

68

Zolmitriptan

N02CC03

      

1

• Sublist 2. Drugs that received an explicit 0 in 3 out of 4 scales

1

Acetylsalicylicacid

N02BA01

0

 

0

  

0

0

2

Allopurinol

M04AA01

0

    

0

0

3

Amlodipine

C08CA01

0

 

0

  

0

0

4

Atenolol

C07AB03

0

 

0

  

0

0

5

Atorvastatin

C10AA05

0

 

0

  

0

0

6

Carbamazepine

N03AF01

  

0

  

0

0

7

Clopidogrel

B01AC04

0

 

0

   

0

8

Donepezil

N06DA02

0

    

0

0

9

Enalapril

C09AA02

0

 

0

  

0

0

10

Galantamine

N06DA04

0

 

0

  

0

0

11

Gemfibrozil

C10AB04

0

     

0

12

Glipizide

A10BB07

0

 

0

  

0

0

13

Haloperidol

N05AD01

0

 

0

  

0

 

14

Hydrochlorothiazide

C03AA03

0

 

0

  

0

0

15

Ibuprofen

M01AE01

0

 

0

  

0

0

16

Insulin

A10A

0

    

0

0

17

Ketoprofen

M01AE03

0

    

0

0

18

Levodopa

N04BA01

0

 

0

  

0

0

19

Lisinopril

C09AA03

0

 

0

  

0

0

20

Losartan

C09CA01

0

 

0

  

0

 

21

Metoprolol

C07AB02

0

 

0

  

0

0

22

Nifedipine

C08CA05

  

0

  

0

0

23

Nitroglycerin

C01DA02

0

 

0

  

0

0

24

Omeprazole

A02BC01

0

 

0

  

0

 

25

Pantoprazole

A02BC02

0

 

0

   

0

26

Paracetamol

N02BE01

0

 

0

  

0

0

27

Pioglitazone

A10BG03

0

 

0

   

0

28

Piroxicam

M01AC01

0

    

0

0

29

Propranolol

C07AA05

0

 

0

   

0

30

Rabeprazol

A02BC04

0

 

0

   

0

31

Ropinirole

N04BC04

0

    

0

0

32

Rosiglitazone

A10BG02

0

 

0

   

0

33

Senna

A06AB06

0

    

0

0

34

Sertralin

N06AB06

  

0

  

0

0

35

Simvastatin

C10AA01

0

 

0

  

0

0

36

Spironolactone

C03DA01

0

    

0

0

37

Terbutaline

R03AC03

0

    

0

0

38

Timolol

C07AA06

0

    

0

0

39

Tamoxifen

L02BA01

0

    

0

0

40

Trimethoprim

J01EA01

0

 

0

   

0

41

Venlafaxine

N06AX16

0

 

0

  

0

 

42

Verapamil

C08DA01

0

    

0

0

43

Warfarin

B01AA03

  

0

  

0

0

44

Zolpidem

N05CF02

0

 

0

   

0

45

Zopiclone

N05CF01

0

    

0

0

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Durán, C.E., Azermai, M. & Vander Stichele, R.H. Systematic review of anticholinergic risk scales in older adults. Eur J Clin Pharmacol 69, 1485–1496 (2013). https://doi.org/10.1007/s00228-013-1499-3

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  • DOI: https://doi.org/10.1007/s00228-013-1499-3

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