Why Not Rock the Boat? Deprescribing Anticholinergic Medications That Are No Longer Needed in Persons With Schizophrenia.

Anticholinergic medications (ACMs) prescribed for the treatment of antipsychotic-associated extrapyramidal symptoms (EPSs) are frequently prescribed for durations that exceed expert guidelines and are associated with significant side-effect burden. Evidence suggests that education with regard to the risks of long-term prescribing of ACMs for resolved EPSs may be lacking in the health care community, and no best practices exist for deprescribing ACMs. This review discusses EPSs and their treatment with two ACMs, benztropine and trihexyphenidyl, and it presents evidence of the risks of chronic ACM prescribing, including serious side effects such as cognitive impairment, dry mouth, blurred vision, and risk for delirium, as well as sequelae of severe constipation and urinary retention. It is pertinent to remember that many psychotropic agents, including several antipsychotics, as well as other commonly prescribed medications have moderate to strong anticholinergic properties. Each ACM, when prescribed with other medications concomitantly, compounds ACM burden and associated side effects. Informed by the authors' extensive experience with quality improvement projects on deprescribing ACMs, this review examines both the benefits and risks of ACM deprescribing, with an emphasis on choosing appropriate patients and engaging in shared decision making while utilizing patient-facing assessments and decision-support tools. ACM tapering schedules are suggested, along with recommendations for closer patient monitoring during the deprescription process. Barriers to deprescription at the patient, prescribing clinician, and system level are then reviewed, along with relevant ethical considerations inherent to any medication changes, including ACM deprescribing.