An anticholinergic agent is a substance that blocks the neurotransmitter acetylcholine in the central and the peripheral nervous system. Anticholinergics inhibit parasympathetic nerve impulses by selectively blocking the binding of the neurotransmitter acetylcholine to its receptor in nerve cells. The nerve fibers of the parasympathetic system are responsible for the involuntary movement of smooth muscles present in the gastrointestinal tract, urinary tract, lungs, and many other parts of the body. Anticholinergics are divided into three categories in accordance with their specific targets in the central and/or peripheral nervous system: antimuscarinic agents, ganglionic blockers, and neuromuscular blockers.
Anticholinergic drugs are used to treat a variety of conditions:
- Gastrointestinal disorders (e.g., gastritis, diarrhea, pylorospasm, diverticulitis, ulcerative colitis, nausea, and vomiting)
- Genitourinary disorders (e.g., cystitis, urethritis, and prostatitis)
- Respiratory disorders (e.g., asthma, chronic bronchitis, and chronic obstructive pulmonary disease [COPD])
- Sinus bradycardia due to a hypersensitive vagus nerve.
- Insomnia, although usually only on a short-term basis.
- Dizziness (including vertigo and motion sickness-related symptoms)
When a significant amount of an anticholinergic is taken into the body, a toxic reaction known as acute anticholinergic syndrome may result. This may happen accidentally or intentionally as a consequence of recreational drug use. Anticholinergic drugs are usually considered the least enjoyable by many recreational drug users, possibly due to the lack of euphoria caused by them. There have been reported cases of users experiencing what they attribute to "euphoria" from the use of this substance. In terms of recreational use, these drugs are commonly referred to as deliriants. The risk of addiction is low in the anticholinergic class. The effects are usually more pronounced in the elderly, due to natural reduction of acetylcholine production associated with its use.
Long term use increases the risk of both mental and physical decline. It is unclear if they affect the risk of death generally. However, in older adults they do appear to increase the risk of death. Possible effects of anticholinergics include:
- Poor coordination
- Decreased mucus production in the nose and throat; consequent dry, sore throat
- Dry-mouth with possible acceleration of dental caries
- Stopping of sweating; consequent decreased epidermal thermal dissipation leading to warm, blotchy, or red skin
- Increased body temperature
- Pupil dilation; consequent sensitivity to bright light (photophobia)
- Loss of accommodation (loss of focusing ability, blurred vision – cycloplegia)
- Increased heart rate
- Tendency to be easily startled
- Urinary retention
- Diminished bowel movement, sometimes ileus (decreases motility via the vagus nerve)
- Increased intraocular pressure; dangerous for people with narrow-angle glaucoma.
- Euphoria or dysphoria
- Respiratory depression
- Memory problems
- Inability to concentrate
- Wandering thoughts; inability to sustain a train of thought
- Incoherent speech
- Mental confusion (brain fog)
- Wakeful myoclonic jerking
- Unusual sensitivity to sudden sounds
- Illogical thinking
- Visual disturbances
- Periodic flashes of light
- Periodic changes in visual field
- Visual snow
- Restricted or "tunnel vision"
- Visual, auditory, or other sensory hallucinations
- Warping or waving of surfaces and edges
- Textured surfaces
- "Dancing" lines; "spiders", insects; form constants
- Lifelike objects indistinguishable from reality
- Phantom smoking
- Hallucinated presence of people not actually there
- Rarely: seizures, coma, and death
- Orthostatic hypotension (severe drop in systolic
blood pressure when standing up suddenly) and significantly increased risk of falls in the elderly population.
A common mnemonic for the main features of anticholinergic syndrome is the following:
- Blind as a bat (dilated pupils)
- Red as a beet (vasodilation/flushing)
- Hot as a hare (hyperthermia)
- Dry as a bone (dry skin)
- Mad as a hatter (hallucinations/agitation)
- Bloated as a toad (ileus, urinary retention)
- And the heart runs alone (tachycardia)
Acute anticholinergic syndrome is reversible and subsides once all of the causative agent has been excreted. Reversible Acetylcholinesterase inhibitor agents such as physostigmine can be used in life-threatening cases. Wider use is discouraged due to the significant side effects related to cholinergic excess including: seizures, muscle weakness, bradycardia, bronchoconstriction, lacrimation, salivation, bronchorrhea, vomiting, and diarrhea. Even in documented cases of anticholinergic toxicity, seizures have been reported after the rapid administration of physostigmine. Asystole has occurred after physostigmine administration for tricyclic antidepressant overdose, so a conduction delay (QRS > 0.10 second) or suggestion of tricyclic antidepressant ingestion is generally considered a contraindication to physostigmine administration.
Anticholinergics are classified according to the receptors that are affected:
- Antimuscarinic agents operate on the muscarinic acetylcholine receptors. The majority of anticholinergic drugs are antimuscarinics.
- Antinicotinic agents operate on the nicotinic acetylcholine receptors. The majority of these are non-depolarising skeletal muscle relaxants for surgical use that are structurally related to curare. Several are depolarizing agents.
Examples of common anticholinergics:
- Antimuscarinic agents
- Benzatropine (Cogentin)
- Chlorpheniramine (Chlor-Trimeton)
- Dicyclomine (Dicycloverine)
- Dimenhydrinate (Dramamine)
- Diphenhydramine (Benadryl, Sominex, Advil PM, Unisom, etc.)
- Doxepin (Sinequan, Deptran)
- Doxylamine (Restavit)
- Glycopyrrolate (Robinul)
- Hydroxyzine (Atarax, Vistaril)
- Ipratropium (Atrovent)
- Orphenadrine (Norflex)
- Oxitropium (Oxivent)
- Oxybutynin (Ditropan, Driptane, Lyrinel XL)
- Tolterodine (Detrol, Detrusitol)
- Tiotropium (Spiriva)
- Tricyclic antidepressants (28 compounds with numerous trade names)
- Trihexyphenidyl (Artane)
- Antinicotinic agents
- Bupropion (Zyban, Wellbutrin) - Ganglion blocker
- Dextromethorphan - Cough suppressant and ganglion blocker
- Doxacurium - Nondepolarizing skeletal muscular relaxant
- Hexamethonium - Ganglion blocker
- Mecamylamine - Ganglion blocker and occasional smoking cessation aid
- Tubocurarine - Nondepolarizing skeletal muscular relaxant
Physostigmine is one of only a few drugs that can be used as an antidote for anticholinergic poisoning. Nicotine also counteracts anticholinergics by activating nicotinic acetylcholine receptors. Caffeine (although an adenosine receptor antagonist) is able to counteract the anticholinergic symptoms by reducing sedation and increasing acetylcholine activity, thereby causing alertness and arousal.
- Atropa belladonna (deadly nightshade)
- Brugmansia species
- Datura species
- Garrya species
- Hyoscyamus niger (henbane)
- Mandragora officinarum (mandrake)
Use as a deterrent
Several narcotic and opiate-containing drug preparations, such as those containing hydrocodone and codeine are combined with an anticholinergic agent to deter intentional misuse. Examples include Hydromet/Hycodan (hydrocodone/homatropine), Lomotil (diphenoxylate/atropine) and Tussionex (hydrocodone polistirex/chlorpheniramine). However, it is noted that opioid/antihistamine combinations are used clinically for their synergistic effect in the management of pain and maintenance of dissociative anesthesia (sedation) in such preparations as Meprozine (meperidine/promethazine) and Diconal (dipipanone/cyclizine), which act as strong anticholinergic agents.
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