An Evidence-Based Update on Anticholinergic Use for Drug-Induced Movement Disorders

Authors

Nora Vanegas-Arroyave, Department of Neurology, Baylor College of Medicine, 7200 Cambridge Street, Suite 9A, Houston, TX, 77030, USA. Nora.VanegasArroyave@bcm.edu.
Stanley N. Caroff, Corporal Michael J. Crescenz Veterans Affairs Medical Center, Philadelphia, PA, USA.
Leslie Citrome, New York Medical College, Valhalla, NY, USA.
Jovita Crasta, South Nassau Communities Hospital, Baldwin, NY, USA.
Roger S. McIntyre, Department of Psychiatry and Pharmacology, University of Toronto, Toronto, ON, Canada.
Jonathan M. Meyer, Department of Psychiatry, University of California San Diego, La Jolla, CA, USA.
Amita Patel, Dayton Psychiatric Associations, Dayton, OH, USA.
J Michael Smith, LifeSpring Behavioral Health, Spring, TX, USA.
Khody Farahmand, Neurocrine Biosciences, Inc, San Diego, CA, USA.
Rachel Manahan, Neurocrine Biosciences, Inc, San Diego, CA, USA.
Leslie Lundt, Neurocrine Biosciences, Inc, San Diego, CA, USA.
Samantha A. Cicero, Neurocrine Biosciences, Inc, San Diego, CA, USA.

Author Type(s)

Faculty

Journal Title

CNS Drugs

First Page

239

Last Page

254

Document Type

Article

Publication Date

4-1-2024

Department

Psychiatry and Behavioral Sciences

Abstract

Drug-induced movement disorders (DIMDs) are associated with use of dopamine receptor blocking agents (DRBAs), including antipsychotics. The most common forms are drug-induced parkinsonism (DIP), dystonia, akathisia, and tardive dyskinesia (TD). Although rare, neuroleptic malignant syndrome (NMS) is a potentially life-threatening consequence of DRBA exposure. Recommendations for anticholinergic use in patients with DIMDs were developed on the basis of a roundtable discussion with healthcare professionals with extensive expertise in DIMD management, along with a comprehensive literature review. The roundtable agreed that "extrapyramidal symptoms" is a non-specific term that encompasses a range of abnormal movements. As such, it contributes to a misconception that all DIMDs can be treated in the same way, potentially leading to the misuse and overprescribing of anticholinergics. DIMDs are neurobiologically and clinically distinct, with different treatment paradigms and varying levels of evidence for anticholinergic use. Whereas evidence indicates anticholinergics can be effective for DIP and dystonia, they are not recommended for TD, akathisia, or NMS; nor are they supported for preventing DIMDs except in individuals at high risk for acute dystonia. Anticholinergics may induce serious peripheral adverse effects (e.g., urinary retention) and central effects (e.g., impaired cognition), all of which can be highly concerning especially in older adults. Appropriate use of anticholinergics therefore requires careful consideration of the evidence for efficacy (e.g., supportive for DIP but not TD) and the risks for serious adverse events. If used, anticholinergic medications should be prescribed at the lowest effective dose and for limited periods of time. When discontinued, they should be tapered gradually.

Recommended Citation

Vanegas-Arroyave, N., Caroff, S. N., Citrome, L., Crasta, J., McIntyre, R. S., Meyer, J. M., Patel, A., Smith, J. M., Farahmand, K., Manahan, R., Lundt, L., & Cicero, S. A. (2024). An Evidence-Based Update on Anticholinergic Use for Drug-Induced Movement Disorders. CNS Drugs, 38 (4), 239-254. https://doi.org/10.1007/s40263-024-01078-z