Cogentin, Benadryl, Artane.....

[psych]

Hello all,

To those who have experience seeing a large # of severely mentally ill (or more simply patients heavily medicated with antipsychotics) I have a question: are anticholinergics something you prescribe indefinitely?
In training it was emphasized these may be needed when a drug is first started and titrated up, but also important to taper off after a couple weeks/months once the dose of antipsychotic that was needed, was clarified. It was also implied the patient would adapt and not need an anticholinergic. Problem is, in training, we saw people on the inpatient unit, or briefly outpatient, and didn't actually follow them for months post starting an anticholinergic.
Well now, post residency, I'm facing inheriting so many patients on an antipsychotic + anticholinergic combo which they've been on for a long time (if not months, years). I wonder if I can taper the people I inherit off of cogentin/benadryl/artane? Is this reasonable? I would discuss w/patient beforehand of course, but I'd like to get an idea from others if they've been successful.
My stereotypical patient is someone who was hospitalized, ultimately transitioned to haldol decanoate, or Prolixin or Consta or Sustenna or Maintenna or high dose oral ect..( + an anticholinergic). In my mind, if there is absolutely no signs or symptoms of EPS, I could and should, taper the anticholinergic. Does anyone have input on this topic. Successes or failures?

Appreciate any feedback!

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[psych]

Also I see people on an anticholinergic + another medication that has anticholinergic properties (olanzapine, seroquel, clozaril) and therefore extremely ridicule the need for an EPS med.

On a related note, I'd like to bring up Thorazine. In my experience, there can be pretty dramatic EPS rxns, while other providers might lump it as having the same properties as low potency atypicals like seroquel. I'm a skeptic in thinking, an anticholinergic isn't needed, and feel more inclined to leave it on board. If this is completely whacky sounding, please correct me.

Again thanks for reading.

 

[wolfvgang22]

Yes, taper and monitor the Artane and cogentin. I do it all the time. These medications are often unecessary, as you say. And taper whatever else you can whenever you see a lot of polypharmacy that is of questionable utility. Just review the chart carefully, and talk to your patients and their caregivers first in case there is a good reason for the odd medication he or she is taking. Don't change any medications without seeing the patient first. Follow up.

 

[HarryMTieboutMD]

Though Chlorpromazine is a low potency first generation antipsychotic with an anticholinergic burden, its EPS burden is definitely higher than any of the SGAs. As for discontinuation, I think the evidence is variable and limited by small sample sizes, etc. Here's a recent, prospective study showing no significant worsening of movement problems: http://www.ncbi.nlm.nih.gov/pubmed/25489477.

A lot of this comes down to the insight of the patient, what the patient wants/does, and clinical judgment. For example, I have a schizophrenic patient on Haldol 10mg BID (anything less leads to really distressing psychosis), yet he experiences significant EPS at this dose. Cogentin 2mg BID helps, but he gets eye crusting and xerostomia, but he likes to exercise so he continues to take the cogentin. He had high premorbid functioning and actually has minimal negative symptoms, but I think the heavy D2 blockade is causing inattention and problems with working memory, so I am trying to convince him to agree to switch to Seroquel.

I have another schizophrenic patient on Haldol 9mg (previous resident convinced him to lower dose 1mg) who has EPS so obvious that even a medical student could recognize it, but it is not bothersome to him as long as he takes 25mg Benadryl. While I would like to decrease the Haldol and get rid of the anticholinergic, the patient is old and does not want to change his regimen, and he has full capacity and understanding.

I have another patient stable (from a psychosis standpoint, limited in functioning by negative symptoms) on Invega Sustenna 234 who previously required additional PO paliperidone because of breakthrough psychosis and cogentin for EPS. He has since discontinued both oral meds with resultant control of psychosis and no motor side effects.

I think with each patient it's a risk/benefit situation (ie, is she/she old and having side effects, do they need it PRN, etc) and informed discussion with patient and guardian.

 

[smalltownpsych]

Just wanted to add a related question about akathisia. It has been my understanding in the past that anticholinergics are of little benefit for this since it is not really an EPS, but I have seen it prescribed for that specific reason numerous times.

 

[HarryMTieboutMD]

Just wanted to add a related question about akathisia. It has been my understanding in the past that anticholinergics are of little benefit for this since it is not really an EPS, but I have seen it prescribed for that specific reason numerous times.

1. Strictly speaking, the pathophysiology of akathisia is localizable to the Extrapyramidal system and is caused by downstream consequences of D2 blockade, so yes, I would consider it to be an Extrapyramidal Side Effect.

2. The evidence for anticholinergics in akathisia is limited based on lack of well designed studies. The general approach is if the only side effect is akathisia is to 1) Lower the dose of antipsychotic (people get drug happy and don't think about this one), 2a) try propranolol, 2b)try a benzo (depends on preference of Dr). I have seen some people use B6 and some of the newer, fringe type drugs, but for practical purposes you are shooting in the dark. Anecdotally cogentin will help some people, and you might try it if they have Parkinsonism/dystonia along with akathisia.

 

[PistolPete]

I've been told that Cogentin and the like loses its efficacy for EPS prevention after about 3 or so months, but I don't have a reference for you. And I agree, taper them off of it and monitor!

 

[Blitz2006]

Great thread,

not to thread jack, but any preference with benadryl vs. cogentin vs. artane? I believe artane is the "strongest" right?

 

[splik]

Great thread,

not to thread jack, but any preference with benadryl vs. cogentin vs. artane? I believe artane is the "strongest" right?

It doesn't matter which you use. the anticholinergics are pretty much the same, though technically benadryl is an antihistamine that also happens to have some antimuscarinic action so that would be less anticholinergic than the others. as such I wouldn't use it other than acutely (e.g. for acute dystonia). artane is the least sedating, and also has the least peripheral effects. cogentin is somewhere in the middle. artane has the greatest abuse potential, or at least has been the most commonly abused. This might have something to do with its faster onset of action of euphoriant/deliriogenic effects. i never seen artane used around here.

 

[Shikima]

So, curiously; how much anticholinergic activity do I get from Paxil to ward off EPS?

 

[splik]

So, curiously; how much anticholinergic activity do I get from Paxil to ward off EPS?

not enough it's weakly anticholinergic. main significance is withdrawal syndrome. that said there is no evidence from placebo controlled studies that anticholinergics even prevent EPS in the first place

 

[wolfvgang22]

I never prescribe an anticholinergic unless the patient has symptoms.
I was amused as a resident rotating in the ER, watching ER attendings prescribe Cogentin every single time they prescribed promethazine to a patient because one person had EPS the year before. They then lectured me at length about avoiding polypharmacy.