Glycopyrrolate for drooling in children with medical complexity under three years of age

Background The aim of the study is to determine that Glycopirrolate is safe and effective in decreasing drooling in children with medical complexity under 3 years of age. Medical treatment is based on anticholinergic drugs as transdermal scopolamine, benzotropine and GLY. GLY (Glycopyrronium bromide) is a synthetic quaternary ammonium anticholinergic agent with poor blood–brain barrier penetration and consequently has limited central effects. Actually, the oral GLY formulation was approved by the United States Food and Drug Administration (FDA) to treat drooling in children aged 3–16 years. Five studies reported on GLY use for the treatment of drooling in children with cerebral palsy and other conditions with neurological impairment; four are prospective studies while one a retrospective review. Methods this is a case report of eighteen children (sex ratio 11/8, median age 17 months, range 2–36 months) under three years of age, followed by a multidisciplinary team at the Bambino Gesù Children Hospital. The median follow-up was of 31.5 months (range 1–69 months). Response to treatment was assessed according to the Drooling Impact Scale administered at time 0 and after 1 month. All patients have an important neurological impairment: nine patients have a cerebral palsy (Gross Motor Function Classification System class V) and nine a genetic/malformative syndrome. Twelve patients have a tracheostomy and two need mechanical ventilation. Gastrostomy is present in 16 out of 18 patients. All patients received Glycopirrolate. The median starting daily dose was 0.065 mg/kg/die (range 0.02–0.21 mg/kg/die) three times a day. The drooling impact scale was administered at time O and after 1 month. Results Four out 18 patients stopped treatment for adverse event, lack of efficacy or parental decision. The mean Drooling Impact Scale at time 0 was 89 (range 81–100) and after 1 month 61(range 43–78); the difference was statistically significant (P < 0.001). The overall response to treatment was 94%. Conclusions This is the first study to determine the safety and effectiveness of Glycopyrrolate in decreasing drooling in a specific subset of patients. No major side effects were observed. Further comparative studies are needed to confirm our results.

Influence of Drugs on Mild Cognitive Impairment in Parkinson’s Disease: Evidence from the PACOS Study

Background: Polytherapy and the anticholinergic activity of several drugs negatively influence cognition in the elderly. However, little is known on the effect on Mild Cognitive Impairment (MCI) in Parkinson’s Disease (PD). Methods: Patients with PD belonging to the baseline PACOS cohort with full pharmacological data, have been included in this study. MCI diagnosis was made according to the MDS level II criteria. Polytherapy was defined as patients assuming ≥6 drugs. Anticholinergic burden has been calculated using the Anticholinergic Drug Scale (ADS). Molecules have been classified according to the ATC classification. Association with MCI has been assessed with a multivariate logistic regression analysis with MCI as the dependent variable. Results: Pharmacological data was available for 238 patients (mean age 64.7±9.7). One hundred (42.0%) were diagnosed as MCI. In the full multivariate model (correcting for age, sex, disease duration, education, UPDRS-ME, LEDD-DAs) no association was found with either polytherapy or the ADS. Concerning drug classes, anti-hypertensive medications increased the risk of PD-MCI (OR 2.02;95%CI 1.04-3.89; p=0.035) while gastroprotective agents had a protective effect (OR 0.51; 95%CI 0.27-0.99; p=0.047). Conclusion: The magnitude of polytherapy and anticholinergic drugs burden does not appear to modulate MCI risk in PD, probably due to cautious prescription patterns. The effect of anti-hypertensive and gastroprotective agents on PD-MCI risk, while needing further confirmations, could be relevant for clinical practice.

Association between anticholinergic burden and dementia in UK Biobank

Previous studies on the association between the long-term use of anticholinergic drugs and dementia report heterogenous results. This variability could be due to, among other factors, different anticholinergic scales used, and differential effects of distinct classes of anticholinergic drugs. Here, we use 171,775 participants of UK Biobank with linked GP prescription records to calculate the cumulative annual anticholinergic burden (ACB) and ascertain dementia diagnoses through GP- and inpatient records. We then use Cox proportional hazards models to compare 13 anticholinergic scales and anticholinergic burden (ACB) due to different classes of drugs in their association with dementia. We find dementia to be more strongly predicted by ACB than by polypharmacy across most anticholinergic scales (standardised ORs range: 1.027-1.125). Furthermore, not only the baseline ACB, but the slope of the longitudinal trajectory of ACB (HR=1.094; 95% CI: 1.068-1.119) is predictive of dementia. However, the association between ACB and dementia holds only for some classes of drugs – especially antidepressants, antiepileptics, and high-ceiling antidiuretics. Moreover, we do not find a clear relationship between reported anticholinergic potency and dementia risk. The heterogeneity in findings on the association between ACB and dementia may in part be due to different effects for different classes of drugs. Future studies should establish such differences in more detail and further examine the practicality of using a general measure of anticholinergic potency as it relates to the risk of dementia.

Decreasing trends in potentially inappropriate medications in older people: a nationwide repeated cross-sectional study

Background Potentially Inappropriate Medications (PIMs) and polypharmacy are widely used indicators of suboptimal prescribing for older people. The aim of this study was to describe the changes in the prevalence of PIMs and polypharmacy among people aged 75 years and over between 2011 and 2019 in France. Methods PIMs and polypharmacy were assessed among people aged 75 years and over every two years between 2011 and 2019 using the French health insurance data system. Sixteen PIM criteria from the 2015 Beers and STOPP lists were assessed. Polypharmacy (5 to 9 drugs) and hyper-polypharmacy (≥10 drugs) were defined based on the average number of drugs dispensed per quarter. The Annual Percent Change (APC) and 95%CI were assessed using linear regression models after standardization of the prevalence on age and sex. Results The study population included 5,777,645 individuals over 75 years old in 2011 and 6,328,155 in 2019. The prevalence of PIMs decreased from 49.6 to 39.6% over the study period (APC: − 1.19% [− 1.35;-1.04]). Of the sixteen indicators assessed, the prevalence of thirteen decreased between 2011 and 2019. Benzodiazepines were the most frequent PIMs (34.7% in 2011 to 26.9% in 2019), followed by anticholinergic drugs (12.1% in 2011 to 8.3% in 2019), oral non-steroidal anti-inflammatory drugs (11.4 to 7.8%), and PIMs related to antihypertensive drugs (7.4 to 6.0%). Overall, women and individuals aged 85 years and older were more likely to receive PIMs. The prevalence of hyper-polypharmacy decreased from 30.5 to 25.9% over the study period. Conclusion This study, which is the first to assess the change in prevalence of PIMs and polypharmacy over time from comprehensive health data in France, highlights that PIMs and hyper-polypharmacy declined between 2011 and 2019. However, PIMs remains frequent for older people and often involves benzodiazepines.

On the effect of certain medications in violation of the chemistry and motility of the large intestine

As you know, functional disorders of the large intestine are common in many diseases. Practical doctors usually pay little attention to them and, in particular, to the effect of such frequently used drugs as antibiotics, sulfonamides, vitamins, and anticholinergic drugs. In this regard, we have made an attempt to find out the advisability of using some of them in the treatment of functional disorders of the intestine.

A qualitative study of the perception of nursing home practitioners about the implementation of quality indicators for drug consumption in nursing homes

Introduction Nursing homes (NHs) are an ideal environment in which to implement interventions aimed at reducing inappropriate prescriptions. Quality indicators (QIs) may be useful to standardize practices, but it is unclear how they mediate change. In the framework of a quantitative study aimed at reducing the prescription of anticholinergic drugs among NH residents using QIs, we performed a qualitative study to describe the investigators’ perception of the utility of QIs. Methods Qualitative study using focus group methodology. Focus groups were recorded and transcribed, and analyzed by thematic analysis. Participants were purposefully recruited from among the medical directors of the NHs in the quantitative study. Results Five medical directors participated in two focus group meetings. The main themes to emerge were: (1) communication is key to introducing new practices and achieving lasting uptake; (2) improved coordination and communication provided useful information to help interpret the quantitative results observed: e.g., participants reported that they were able to obtain contextual and patient-specific information that explained why some prescribers had consistently, but justifiably “poor” performance on the quantitative indicators; (3) negative aspects reported included reluctance to change among prescribers and the tendency to shirk responsibility. Conclusion From the point of view of medical directors of NHs participating in an interventional program to reduce inappropriate prescriptions of anticholinergic drugs, the main factor driving the success of the program was communication, which is key to achieving adherence. Improved communication provides useful insights into the reasons why no quantitative reduction is observed in objective quality indicators.

Low-dose anticholinergic therapy causes cognitive impairment in Parkinson's disease patients

Background: Before L-Dopa’s discovery, anticholinergic drugs were among the first treatments for Parkinson’s disease. Only now trihexyphenidyl (THP) is approved to treat unresponsive L-dopa tremors in young, cognitively unaffected Parkinson’s disease patients. However, there are no specific recommendations for disease duration, medication dose, or cognitive status. In low-income countries, THP is still frequently used in Parkinson’s disease patients with tremor. The objective of the current study was to evaluate cognitive performance in Parkinson’s disease patients receiving a low dose of THP. Material and methods: The study was performed on nineteen PD patients, nine of whom were on THP. All patients completed MoCA cognitive assessment. The patients were matched depending on their age, disease severity based on UPDRS III and duration of the disease. Results: The THP patients were taking an average dose of 3.3 mg of THP daily for an average of 1.8 years. There were no statistical differences between THP patients and non-THP patients in age (64.8± 4.8 vs 67.2±6.9, p=0.4), UPDRS III (32.1±8.9 vs 41.5±20.6, p=0.2) and disease duration (6.2±4.9 vs 7.0 ± 4.0, p=0.7). The THP patients had lower cognitive performance, with a total MoCA of 19.22 ± 3.3 vs. non-THP patients 24.2±3.0, p=0.003. Conclusions: In Parkinson’s disease patients, even a low dose of THP causes significant cognitive loss.

Potentially inappropriate prescriptions of antipsychotic and anticholinergic drugs in patients with Parkinson's disease

Aim: The objective was to determine the prevalence of the potentially inappropriate antipsychotics and anticholinergics used in patients with Parkinson's disease. Materials & methods: A cross-sectional study identified the prescription of antipsychotics, anticholinergics and drugs for the treatment of Parkinson's disease. The anticholinergic burden was evaluated, and quetiapine and clozapine were considered to be adequate antipsychotics. Results: 2965 patients with Parkinson's disease were identified. The presence of psychiatric disorders and other neurological pathologies was associated with a greater probability of receiving potentially inappropriate antipsychotic prescriptions. The presence of greater number of comorbidities was associated with a greater probability of receiving anticholinergics. Conclusion: Older age and associated comorbidities, especially psychiatric and neurological comorbidities, increase the likelihood of patients with Parkinson's disease being prescribed antipsychotics and anticholinergics.

Treatment-resistant Abuse of Oxybutynin With Psychotic Symptoms: A Case Report and Literature Review

BackroundAnticholinergic drugs are the most commonly used addictive drugs among non-prescription drugs. Oxybutynin is one of the anticholinergic drugs widely used for overactive bladder and nocturnal enuresis treatment for both adults and children. Here is a new case of oxybutynin use with high dose and long-term use despite recurrent treatment applications. Case PresentationA 25 years old, unemployed man that was graduated from primary school applied to the inpatient clinic. He reported that he has been using oxybutynin for 8 years. He was taking 500 mg/day of oxybutynin (100 pills in a day), approximately. He stated that he had taken 250-300 pills in some days (1000-1500 mg/day). He described agitation, irritability, anxiety, visual and auditory hallucinations, reference thoughts, and persecution delusions. The patient was diagnosed with Other Substance Use Disorders according to the Diagnostic and Statistical Manual of Mental Disorders-5 (DSM-5) criteria. Carbamazepine 400 mg/day, olanzapine 10 mg/day, and lorazepam 2.5 mg/day treatments were started. At the end of the five weeks, both symptoms improved completely. In the follow-up, he had no psychiatric symptoms two months after the discharge. He was not using any substance or addictive drugs; working regularly in his father’s family business. ConclusionsOxybutynin is one of the non-controlled drugs, so can be obtained easily from pharmacies without a prescription in Turkey. Interestingly, case reports about oxybutynin use are all from Turkey. Oxybutynin should be considered for the potential for addiction due to its anticholinergic properties, easily accessible, and cumulative cases. Psychiatrists and non-psychiatric physicians, especially urologists should be aware of the addiction potential of the drug because of anticholinergic effects, especially between substance users, and oxybutynin may cause some psychotic effects.