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Anticholinergic

Agents Anticholinergic


Presentation

  • The patient presented with acute delirium and was successfully treated with physostigmine.[ncbi.nlm.nih.gov]
Fever
  • The quantity of saliva prodiced during surgery and incidence of fever were recorded.[ncbi.nlm.nih.gov]
  • Image copyright (C) British Broadcasting Corporation A study has linked commonly used medicines, including over-the-counter treatments for conditions such as insomnia and hay-fever, to dementia.[bbc.com]
  • Mild Anticholinergic Toxicity Moderate Anticholinergic Toxicity Severe Anticholinergic Toxicity Tachycardia Flushed face Mydriasis and blurred vision Dry mouth and skin Fever Agitated delirium Urinary retention Hypertension Hyperthermia CNS depression[rch.org.au]
  • Anticholinergic effect is enhanced by: Antidepressants, including amitriptyline, nortriptyline, paroxetine, fluoxetine and monoamine oxidase inhibitors (MAOI) Antihistamines used to treat asthma, hay fever and urticaria Tiotropium, ipratropium bromide[dermnetnz.org]
Rigor
  • […] home residents. 8, 9 We conclude that there is some reason to be concerned that long-term anticholinergic drug use might increase the subsequent risk of dementia, even though this conclusion needs to be confirmed by longer and more methodologically rigorous[ti.ubc.ca]
  • […] cognitive decline, suggesting causality. 8 But a single blind RCT in Norway found no improvements in cognitive function eight weeks after reducing anticholinergic drugs in patients at nursing homes. 9 And a systematic review has concluded that “very little rigorous[bmj.com]
  • Until these new alternatives undergo rigorous comparative trials, oxybutynin will remain first-line in pharmacotherapy in Australia.[nps.org.au]
Galactorrhea
  • With oral domperidone, side effects occur in fewer than 7% of patients and include headaches, dry mouth, diarrhea, anxiety, and prolactin-related findings, eg, breast tenderness and enlargement, galactorrhea (uncommon), and menstrual irregularities.[ncbi.nlm.nih.gov]
Constipation
  • This commonly leads to constipation and potentially to more severe complications such as bowel obstruction and ischemia.[ncbi.nlm.nih.gov]
Decreased Bowel Sounds
  • Peripheral inhibition is variable - but the symptoms may include: hot, dry skin, flushed appearance, mydriasis, tachycardia, decreased bowel sounds and urinary retention.[rch.org.au]
  • This may involve peripheral receptors (eg, in the heart, salivary glands, sweat glands, gastrointestinal tract, and genitourinary tract) with resulting tachycardia, hyperthermia, dry skin and mucous membranes, mydriasis, decreased bowel sounds and urinary[ncbi.nlm.nih.gov]
Xerostomia
  • […] and xerostomia. 2017 John Wiley & Sons A/S and The Gerodontology Association.[ncbi.nlm.nih.gov]
  • ‘The administration of antihypertensive and anticholinergic medications also impairs salivary functions and promotes xerostomia.’[en.oxforddictionaries.com]
Tachycardia
  • All five patients presented with classic signs and symptoms of anticholinergic toxicity, which included tachycardia, hot, dry and flushed skin, markedly dilated and fixed pupils, and pronounced delirium.[ncbi.nlm.nih.gov]
Hypertension
  • We suggest that adding dexmedetomidine as an adjunctive agent in the therapy of anticholinergic toxidrome may relieve the symptoms of agitation, psychosis, tachycardia, and hypertension, without the attendant risk of respiratory depression associated[ncbi.nlm.nih.gov]
  • They are sold over the counter and by prescription as sleep aids and for chronic diseases including hypertension, cardiovascular disease and chronic obstructive pulmonary disease (COPD).[web.archive.org]
Orthostatic Hypotension
  • […] an·ti·cho·lin·er·gic \ -ˌkō-lə-ˈnər-jik \ Definition of anticholinergic : opposing or blocking the physiologic action of acetylcholine The more sedating tricyclic antidepressant drugs … are more likely to produce orthostatic hypotension and such adverse[merriam-webster.com]
  • Factors significantly associated with a risk of a fall were: a prior history of a fall in the previous 12 months (adjusted odds ratio [aOR] 7.24, 4.06-12.89), orthostatic hypotension ([aOR] 2.84; 1.39-5.79), or prescription of antidepressants ([aOR] 2.12[ncbi.nlm.nih.gov]
  • hypotension (severe drop in systolic blood pressure when standing up suddenly) and significantly increased risk of falls in the elderly population.Older patients are at a higher risk of experiencing CNS sideffects due to lower acetylcholine production[en.wikipedia.org]
  • hypotension Constipation Dysphagia Excessive sweating Heat intolerance Urinary Sexual dysfunction.[www2.kumc.edu]
  • hypotension (especially 1st dose); dry mouth, constipation, diarrhea, syncope, tinnitus, tachycardia, rash, dyspepsia, sexual dysfunction tamsulosin Flomax Alpha-adrenergic antagonist 0.4 – 0.8 mg/day for BPH Low SE profile Weakness, dizziness, insomnia[web.archive.org]
Flushing
  • All five patients presented with classic signs and symptoms of anticholinergic toxicity, which included tachycardia, hot, dry and flushed skin, markedly dilated and fixed pupils, and pronounced delirium.[ncbi.nlm.nih.gov]
Decreased Sweating
  • Decreased sweating can put you at risk of heat stroke . Overdose and alcohol Using too much of an anticholinergic drug can result in unconsciousness or even death. These effects can also happen if you take anticholinergics with alcohol.[healthline.com]
  • sweating/dry skin Bladder Difficulty starting urination/impaired bladder emptying Urinary retention/overflow incontinence Subtle and not-so-subtle toxicity Students often learn the adverse effects of anticholinergics from a mnemonic, e.g.: “Blind as[ti.ubc.ca]
  • Peripheral effects include drying of the mouth and eyes, decreasing sweating, constipation and tachycardia. Central effects may include drowsiness, memory impairment, hallucinations, delirium, excitement and/or restlessness.[cpsa.ca]
  • The features of toxicity at peripheral and central receptors can be remembered using the following mnemonic "Hot as a hare": Fever "Red as a beet:" Flushed skin "Blind as a bat": Mydriasis "Dry as a bone": Dry mouth, dry eyes and decreased sweating "Mad[rch.org.au]
  • Blurred vision Dry mouth Dry eyes Decreased urine production Decreased sweat production Constipation Memory impairment Delirium Confusion When possible, the use of anticholinergics should be avoided in the elderly because anticholinergic side effects[medicinenet.com]
Axillary Sweating
  • Methantheline bromide therapy was associated with a 41% reduction in axillary sweating, 16.4% reduction in palmar sweating, 25% decrease in HDSS score and 40.9% increase in DLQI score.[ncbi.nlm.nih.gov]
Persecutory Delusion
  • Two weeks later patient suddenly developed delirium, characterized by nocturnal agitation, severe insomnia, daytime sedation, confusion, hallucinations and persecutory delusions.[ncbi.nlm.nih.gov]
Chronic Anxiety
  • A 9-year-old girl with chronic anxiety and gastrointestinal problems was prescribed oral sertraline 6.25 mg daily, as well as hyoscyamine, ondansetron, montelukast, and a course of nitazoxanide.[ncbi.nlm.nih.gov]
Urinary Retention
  • When drugs with anticholinergic effects are given to immobilized patients such as those with severe depression, close observation including monitoring of urine volume is needed to prevent IVCS caused by drug-induced urinary retention, and subsequent PE[ncbi.nlm.nih.gov]
  • The number of such drugs is larger than most clinicians realize. 3 Lists vary, 4 and may not include drugs whose active metabolites are potently antimuscarinic, 5 or which often cause typical AC adverse effects such as dry mouth or urinary retention.[ti.ubc.ca]
  • Potential adverse effects include blurred vision, dry mouth, constipation and urinary retention A lack of ability to urinate. .[parkinson.org]
  • Peripheral inhibition is variable - but the symptoms may include: hot, dry skin, flushed appearance, mydriasis, tachycardia, decreased bowel sounds and urinary retention.[rch.org.au]
Confusion
  • A 33-year-old man with a history of recreational benztropine abuse presented to the emergency department with confusion, abdominal pain, and distention. An abdominal radiograph revealed gross fecal loading.[ncbi.nlm.nih.gov]
  • Older individuals are susceptible to confusion and hallucinations on anticholinergics, so these agents should be avoided in people older than 70.[parkinson.org]
Agitation
  • The agitation worsened and did not respond to benzodiazepines. The patient was then given a dose of 0.6 mg physostigmine (0.02 mg/kg) intravenously with reversal of the agitation.[ncbi.nlm.nih.gov]
Seizure
  • Half an hour after routine fundoscopy, a 62-year-old man experienced two generalized seizures with respiratory arrest and required intubation and mechanical ventilation. The patient was treated with physostigmine and made a full recovery.[ncbi.nlm.nih.gov]
  • Treat seizures with benzodiazepines Treat hypoglycaemia Treat hyperthermia with cooling measures. Antipyretics are unhelpful. Reassurance and management in a quiet area may be sufficient for those with mild signs/symptoms.[rch.org.au]
  • January 13, 2013 AGENTS anti-histamines anti-parkinsonians atropine anti-spasmodics mydriatics skeletal muscle relaxants plants CLINICAL FEATURES delirium tachycardia dry and flushed skin dilated pupils myclonus hyperthermia urinary retention bowel sounds seizures[lifeinthefastlane.com]
  • Even in documented cases of anticholinergic toxicity, seizures have been reported after the rapid administration of physostigmine.[en.wikipedia.org]
Stupor
  • The varied presentation of the syndrome ranging from somnolence, confusion, amnesia, delayed recovery, stupor, coma to agitation, hallucinations, dysarthria, ataxia, delirium makes it difficult to diagnose accurately - hence a diagnosis of exclusion.[academic.oup.com]
  • Signs And Symptoms : Serious overdose with hydrocodone is characterized by respiratory depression (a decrease in respiratory rate and/or tidal volume, Cheyne-Stokes respiration, cyanosis), extreme somnolence progressing to stupor or coma, skeletal muscle[web.archive.org]
  • […] switching from subject to subject OR Altered level of consciousness (any of the following count as altered level of consciousness) Vigilant Hyperalert Overly sensitive to environmental stimuli Startled very easily Lethargic Drowsy but easily aroused Stupor[www2.kumc.edu]
Agitated Delirium
  • The characteristic feature of toxicity at central receptors is agitated delirium.[rch.org.au]
  • The onset of symptoms is dose-dependent and includes ataxia, disorientation, short-term memory loss, confusion, hallucinations, psychosis, agitated delirium, seizures, coma, respiratory failure and cardiovascular collapse.[ 13 ] Furthermore, clinical[ncbi.nlm.nih.gov]
  • The onset of symptoms is dose-dependent and includes ataxia, disorientation, short-term memory loss, confusion, hallucinations, psychosis, agitated delirium, seizures, coma, respiratory failure and cardiovascular collapse. [13] Furthermore, clinical signs[dx.doi.org]

Treatment

  • No untoward effects occurred as a result of treatment with physostigmine.[ncbi.nlm.nih.gov]

Etiology

  • In 6/30 the population comprised SCI patients with neurogenic bladder alone; the remainder included mixed neurogenic etiologies.[ncbi.nlm.nih.gov]
  • Etiology Drugs and medications with anticholinergic effects include the following: Anticholinergics: Atropine, scopolamine, benztropine, glycopyrrolate, ipratropium Antihistamines: Diphenhydramine, promethazine, doxylamine Antipsychotics: Chlorpromazine[unboundmedicine.com]
  • ‘In each of these cases, once the iatrogenic etiology of this syndrome was recognized, the patients' symptoms improved rapidly and dramatically with administration of anticholinergic medication.’[en.oxforddictionaries.com]
  • Causes include: Obstruction – prostate hypertrophy, urethral stricture, cystocele, pelvic mass Hypocontractility – associated with both muscular and neurologic etiologies.[web.archive.org]

Epidemiology

  • METHODS: This retrospective cohort database study used the Hispanic Established Populations for the Epidemiologic Study of the Elderly cohort.[ncbi.nlm.nih.gov]
  • Epidemiology Anticholinergic poisoning occurs either from intentional ingestion of certain plants or over-the-counter medications (e.g., Jimson weed, diphenhydramine) (Can J Emerg Med 2007;9(6):467) or from accidental overdosing (e.g., medical noncompliance[unboundmedicine.com]
  • He has since completed further training in emergency medicine, clinical toxicology, clinical epidemiology and health professional education.[lifeinthefastlane.com]
  • Next, we included the Center for Epidemiologic Studies Depression Scale score category at each visit in the model rather than a history of depressive symptoms.[doi.org]
  • Content Outline: Introduction Types of Urinary Incontinence Epidemiology Pathophysiology Evaluation Management Prevention E. Readings: Recommended Readings: DeMaagd, G., & Geibing, J. D. (2006).[web.archive.org]
Sex distribution
Age distribution

Pathophysiology

  • Antidepressants: Amitriptyline, nortriptyline, imipramine, desipramine Antiparkinson drugs: Benztropine, trihexyphenidyl Mydriatics: Cyclopentolate, homatropine, tropicamide Muscle relaxants: Cyclobenzaprine Plants: Belladonna, Jimson weed, Amanita mushrooms Pathophysiology[unboundmedicine.com]
  • Elderly patients can be particularly sensitive to the anticholinergic action of drugs because of physiological and pathophysiological changes that often accompany the aging process.[ncbi.nlm.nih.gov]
  • PATHOPHYSIOLOGY Normal micturition (urination) depends on several factors working synchronously. Many pathological processes and age-related changes can result in UI.[web.archive.org]
  • This last point is important because the pathophysiological changes in the brains of patients with AD require several years to occur. 16 Finally, these studies did not take into account that certain anticholinergics are used to manage insomnia and depression[doi.org]

Prevention

  • Controller Medications Prevent asthma symptoms from occurring Can reduce and/or prevent: Inflammation and scarring in the airways Tightening of the muscle bands around the airways (bronchospasm) Do not show immediate results, but work slowly over time[pamf.org]
  • When drugs with anticholinergic effects are given to immobilized patients such as those with severe depression, close observation including monitoring of urine volume is needed to prevent IVCS caused by drug-induced urinary retention, and subsequent PE[ncbi.nlm.nih.gov]
  • Others are used to prevent nausea, vomiting, and motion sickness. Anticholinergics and antispasmodics are also used in certain surgical and emergency procedures.[mayoclinic.org]

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