Reducing ACB Risk

If you are concerned that you have scored highly, please talk to your doctor. Do not abruptly stop your medications without discussion first - it can make you unwell.

If you are concerned that your patient has scored highly, please do have a discussion with them about the implications of a high anticholinergic burden and consider de-prescribing. Anticholinergic scores do not take into account dosage of medications, but higher doses do carry more risk. Therefore if complete cessation of the drug isn't possible, consider a dose reduction. Every drug has a cumulative effect, and so any small strides towards reducing polypharmacy will be beneficial. As a collective, we can promote a cultural shift away from prescribing and towards lifestyle/behaviour changes.

Primum non nocere (First do no harm).

Some options for reducing the score:
Chlorphenamine Nasal sprays, Loratidine, Fexofenadine
Oxybutynin Non-pharmacological alternatives (eg pelvic floor exercises), Mirabegron
Remember - Oxybutynin is a small structure that easily crosses the Blood-brain barrier.
Solifenacin, Trospium, and Tolteradine do not cross so easily.
Amitriptyline (for depression) Lifestyle options, SSRIs (citalopram, sertraline) or SNRIs (Duloxetine, Venlafaxine)
Amitriptyline (for pain) Conservative options such as stretching, hot water bottles, Gabapentin, Duloxetine
Codeine, Tramadol Physiotherapy, massage, stretching, heat/ice, Paracetamol

The following table has been adapted from Scottish Intercollegiate Guidelines Network (SIGN) Polypharmacy Guidance, March 2015, and shows for each group of medications, which are considered to have a lower or higher risk of Anticholinergic Burden.

When consulting the literature, there are discrepancies between the numerical anticholinergic burden assigned to different medications. In the interest of patient safety, we have opted for the higher burden scores in these instances.

Please consider recommendations from your local health economy formulary when making prescribing decisions.

Medicine Group Anticholinergic Burden
Minimal Mild Moderate Severe
  • Buproprion
  • Duloxetine
  • Mirtazepine
  • Sertraline
  • Venlafaxine
  • Amitriptyline
  • Imipramine
  • Nortriptyline
  • Paroxetine
  • Urinary Incontinence
  • Mirabegron
  • Darafenacin
  • Fesoteradine
  • Oxybutynin
  • Solifenacin
  • Tolterodine
  • Trospium
  • Nausea and Vomiting
  • Cyclizine
  • Prochlorperazine
  • Domperidone
  • Metoclopramide
  • Levomepromazine
  • Antihistamines
  • Cetirizine
  • Desloratidine
  • Fexofenadine
  • Loratidine
  • Chlorphenamine
  • Clemastine
  • Reflux medications
  • Omeprazole
  • Lansoprazole
  • Cimetidine
  • Ranitidine
  • Adapted from Scottish Intercollegiate Guidelines Network (SIGN) Polypharmacy Guidance, March 2015