Practical Strategies for Anticholinergic Deprescribing

Transcript:

Desiree Matthews: Welcome, everyone. Today, we're going to be discussing anticholinergic burden and practical strategies for deprescribing. My name is Desiree Matthews. I'm a board-certified psychiatric nurse practitioner, and today, we have two of my lovely colleagues, Dr Jonathan Meyer and Dr Leslie Citrome, with us here today.

Dr Jonathan Meyer: Hi, my name is Jonathan Meyer. I'm a voluntary clinical professor of psychiatry at the University of California in San Diego.

Dr Leslie Citrome: I'm Dr Citrome. I'm a clinical professor of psychiatry and behavioral sciences at New York Medical College in Valhalla, New York.

Desiree Matthews: Thank you. Today, we're going to be having a wonderful discussion about understanding anticholinergic medications and how they act both centrally and peripherally. We also want to discuss how that may lead to unintended drug side effects. We're also going to learn how to use available tools on how to calculate anticholinergic burden as well as discuss practical strategies today to help guide patients and care partners through that deprescribing process, including methods to avoid cholinergic rebound.

Alright, so we talked about medications that may be implicated in anticholinergic burden and what that means for our patients in terms of unintended side effects. But how do we go about if we identify a patient with cognitive impairment? Maybe they're having blurred vision and urinary retention, and we need to help deprescribe and get these individuals off of anticholinergics. Where would we start? How can we help our patients and their family members go through this process?

Dr Citrome: I think we need to remember this is not able to be done in a day. We have to be prepared for the rather lengthy process and take as much time as is necessary for the patient to be comfortable with the deprescribing process. Otherwise, they'll interrupt it. They'll resume taking the anticholinergic medicine whether you want them to or not. This is a big, big problem, but if you prepare the patient ahead of time and have a schedule over the course of a month, or two, or three—depending on how complex the situation is—it is possible. But all too often, this is not fully appreciated, and it's much too bad.

Dr Meyer: I think that's really the biggest point. You're playing the long game here. I don't care how long it takes you to get the patient off the anticholinergic, within reason, as long as you do it. There are studies out there where sometimes they took literally months to get somebody off an anticholinergic, but in the end, the patient benefits, and, primarily, what is seen is improvements in cognition. Don't be in a hurry.                                                                                                                                                          

As Dr Citrome alluded to, if you're in a hurry, people will get withdrawal syndromes. Primarily manifested as sleep disturbance early on. They won't feel well, and they'll say, ‘Hey, I told you, Desiree. I needed that benztropine.’ No, they didn't need it. They just needed someone to be more patient in getting rid of. But if you don't have buy-in, that's what would be the biggest pattern. I think reassurance that you know how to do this and, perhaps, unlike other providers who are too quick on the draw, we're going to do this slowly, so you're not uncomfortable.

Dr Citrome: You know, a good parallel to this is getting someone off a benztropine or a Z-drug they've been taking for a very long time; you never do that overnight. We kind of know that, and patients don't, though. If you start switching medicines, then you go to another class of medicines to help them sleep—for example—they might stop abruptly. Experience withdrawal and say, ‘You know this new medicine isn’t working,’ but it's really the withdrawal of the old medicine. I mentioned this as a parallel idea because most of us have had patients on Benzos and Z-drugs, and the goal was to take them off that, and we have a long schedule to help them get off it. It doesn't happen overnight.

Desiree Matthews: Exactly.

Dr  Meyer: There's no one standard off titration, but all of us have been really involved in panels where there's often the consensus—and I'm also just a number, and maybe we'll all give our input— if you're using benztropine no faster than perhaps a half milligram every 2 weeks, and sometimes even more slowly, I know there's always the urge to get rid of it sooner. But sooner sometimes doesn't always lead to a good outcome. What do you think?

Dr Citrome: I think you're absolutely right. However, patients may have a different idea. So, whenever you propose a taper to a patient, sometimes they want to get it over with quickly. They don't know that they would be potentially very uncomfortable. I think it's very important to be very clear to the patients about why you're going so slowly.

Desiree Matthews: We really want to avoid that cholinergic rebound because, as you said, if we don't spend the time with the education, really help them understand why we are going slowly, we'll still get there, right? We don't want them to end up coming back to us and saying, ‘Hey, I really do need this,’ and then we're starting back from square 1, re-tapering.

When we consider this, so we have many medications, both in psychiatry and in the medical world, that have anticholinergic activity, as we learned. We talked about the anticholinergic burden and how potentially we can calculate it. We are talking about how to slowly deprescribe these agents, and I think we're really hearing that education is key. Not just for us as clinicians but for the patients. For the families to make this comfortable and to help them be successful. Now, with that, are there any last words of advice, tidbits, or pearls that you want to offer us about anticholinergics and how we can help out?

Dr Citrome: Yes, so one thing that sometimes surprises people is that medicines that are relatively newish, like olanzapine, have quite powerful anticholinergic properties. And the product label for olanzapine actually says don't combine it with another anticholinergic medication; that's not always completely appreciated. So even some of the newer medicines that are—it's not like a tricyclic antidepressant; it's not like an old low potency first-generation antipsychotic—it's something relatively new. I would urge everyone to be familiar with this. Your pharmacy is also your friend here, and they will often bring up potential drug-drug interactions. I would listen to them.

Dr Meyer: I think a lot of us would say, globally, that anticholinergics really now drugs in the past. If I had to give you a call to action, It would be, please do not initiate them if your patient has drug-induced parkinsonism. You cannot reduce the dose with a D2 blocker. We have another way to treat that problem; it's called amantadine, which does not cause cognitive impairment. Anticholinergic don't work for akathisia. As we discussed, they make tardive dyskinesia worse. They certainly don't prevent the onset of tardive dyskinesia.  

Once you can avoid starting them, then you can become an expert in deprescribing them, and for all the reasons we ventured—removal of cognitive side effects, removal of peripheral side effects. Also, there are new medicines being developed that may want to stimulate those muscarinic receptors in the brain. If you have people on these centrally acting agents, you won't be able to use that. We have a lot of folks talking in the same manner. I think whether it's from the movement disorder or the cognition perspective, using new medicines to stop prescribing centrally acting anticholinergics and learn how to get people off of them.

Dr Citrome: But before throwing the baby out with the bathwater completely, sometimes we encounter patients who have an acute dystonic reaction. What do we do then? Well, an intramuscular administration of an anticholinergic is what is necessary, but that is not a winning strategy to continue doing. I would avoid the offending agent in the future for that individual person. That's the treatment for it over the long haul. So, benztropine can be helpful, but not as a permanent solution to the problem.

Desiree Matthews: Exactly. Time-limited with a plan to stop. Absolutely.

Dr Meyer: Or manage the Parkinsonism if you can't remove the offending agent. Let's say long-acting injectable with the alternative, which is much less problematic, which isn't amantadine.

Desiree Matthews: Very true. Well, I think that's all we have time for now, but as always, It was wonderful to have this discussion with you guys today. Thank you, everyone, for joining us on this topic about anticholinergics with good colleagues of mine. If you want to learn more about this topic or other mental health topics, please visit Psych Congress Network to learn more.