Identification of anticholinergic activity rating scales

A literature review was conducted on PubMed/MEDLINE^® comprising the period between January 2006 and July 2017, using the Medical Subject Headings (MeSH) terms “cholinergic antagonists”, “anticholinergic”, “anticholinergic agents” and keywords “nicotinic antagonists”, “muscarinic antagonists”, “atropinic”, “scale”, “load”, “burden”, “risk”, “exposure” and “medication”. The search strategy used boolean operators AND and OR . The search was limited to articles in English and had the purpose of identifying anticholinergic activity rating scales.

The articles were selected by title and abstract, by two investigators. The eligible studies were subjected to a complete text analysis. The inclusion criterion was studies that featured an instrument to rate the anticholinergic burden of drugs.

A total of 11 anticholinergic scales with activity grading were identified and selected for data extraction and development of our scale: Anticholinergic Drug Scale (ADS),⁽ 5 ⁾ Anticholinergic Burden Classification (ABC),⁽ 9 ⁾ Clinician-Rated Anticholinergic Score (CrAS^),( 10 ⁾ Anticholinergic Risk Scale (ARS),⁽ 11 ⁾ Serum Anticholinergic Activity (SAA),⁽ 12 ⁾ Anticholinergic Cognitive Burden Scale (ACB),⁽ 13 ⁾ Anticholinergic Activity Scale (AAS),⁽ 14 ⁾ Anticholinergic Load Scale (ACL),⁽ 15 ⁾ Anticholinergic Effect on Cognition (AEC),⁽ 16 ⁾ Muscarinic Acetylcholine Receptor ANTagonist Exposure (MARANTE)⁽ 4 ⁾ and Anticholinergic Impregnation Scale (AIS).⁽ 3 ⁾

Until July 2017, three systematic reviews had been published aiming to identify anticholinergic activity rating scales, but only one of them described the scales and the associations between calculated anticholinergic burdens and clinical outcomes.⁽ 17 ⁾ The other two reviews provided tables with the name of the drugs with anticholinergic activity listed in the scales.⁽ 1 ^, 8 ⁾ Some investigations use the name Duran Scale, or Duran List, to refer to the table of 100 drugs rated as high or low activity, contained in the ADS,⁽ 5 ⁾ ABC,⁽ 9 ⁾ SAA,⁽ 12 ⁾ ARS,⁽ 11 ⁾ CrAS,⁽ 10 ⁾ AAS⁽ 14 ⁾ and ACL scales,⁽ 15 ⁾ developed by the authors of the systematic review, and based on said scales. It was supplemented by a search on Martindale: the complete drug reference,⁽ 18 ⁾ to clarify any discrepancies between scale scores.⁽ 1 ^, 17 ^, 19 ⁾ A table of 195 drugs was developed based on a systematic review, which also covered the ADS,⁽ 5 ⁾ ABC,⁽ 9 ⁾ SAA,⁽ 12 ⁾ ARS,⁽ 11 ⁾ CrAS,⁽ 10 ⁾ AAS⁽ 14 ⁾ and ACL scales,⁽ 15 ⁾ however rating them into high, medium and low anticholinergic activity. This table points out the discrepant scores found in the different scales.⁽ 8 ⁾

A table of drugs with definite, probable and possible anticholinergic effects was published during the study period, but it presented no activity grading.⁽ 20 ⁾ The Summated Anticholinergic Medications Scale (SAMS) includes only the anticholinergic drugs with high anticholinergic activity, listed in the 2012 American Geriatrics Society Beers Criteria⁽ 21 ⁾ and previous studies, and the only difference is that it states the minimum effective daily dose to calculate the anticholinergic burden.⁽ 22 ⁾ The Drug Burden index is a composite index measuring the anticholinergic and sedative burden considering the daily dose used, but with no specific list of anticholinergic drugs or activity grading.⁽ 23 ⁾