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Adding pre-emptive anticholinergics to antipsychotics: Is it justified?

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  • 1Department of Psychiatry, Armed Forces Medical College, Pune, Maharashtra, India.

Industrial Psychiatry Journal
|November 24, 2022
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Summary

Antipsychotics treat schizophrenia, but anticholinergics are often unnecessarily prescribed. Evidence does not support prophylactic anticholinergic use with antipsychotics, despite lower extrapyramidal side effects (EPS) with newer drugs.

Keywords:
Anticholinergicsantipsychoticsextrapyramidal symptomsprophylaxis

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Area of Science:

  • Psychiatry
  • Clinical Pharmacology

Background:

  • Antipsychotics are primary treatments for schizophrenia and psychotic disorders.
  • Anticholinergics were historically used to manage extrapyramidal side effects (EPS) of first-generation antipsychotics (FGAs).
  • Concurrent anticholinergic use remains high despite lower EPS rates with second-generation antipsychotics (SGAs).

Purpose of the Study:

  • To evaluate the evidence for prophylactic anticholinergic use in patients treated with antipsychotics.
  • To review the efficacy of anticholinergics for various EPS.
  • To summarize guidelines regarding anticholinergic use with antipsychotics.

Main Methods:

  • Literature review focusing on the association between SGAs and EPS.
  • Analysis of anticholinergic efficacy for different EPS.
  • Summary of national and international treatment guidelines.

Main Results:

  • Second-generation antipsychotics (SGAs) are associated with markedly lower rates of EPS compared to FGAs.
  • The prophylactic use of anticholinergics with antipsychotics is not supported by evidence.
  • Anticholinergic use may lead to long-term side effects, potential worsening of EPS, and poor treatment adherence.

Conclusions:

  • There is no evidence to support the routine or prophylactic use of anticholinergics with antipsychotics.
  • Clinicians should avoid the tendency towards excessive caution when prescribing antipsychotics and anticholinergics.
  • Discontinuation of unnecessary anticholinergic use may improve patient outcomes and reduce adverse effects.