Ny publikation hvor ORCA præsenteres – et nyt værktøj til at identificere lægemidler med antikolinerg effekt.
Et nyt studie er blevet publiceret i Age and Ageing, hvor man ved en Delphi proces har udviklet et nyt værktøj til at identificere lægemidler med antikolinerg effekt. Værktøjet hedder ORCA der står for “Older adult Risk Classification for Anticholinergics”, og oplister 211 lægemidler efter lav, medium og høj antikolinerg effekt.
Værktøjet er udviklet af 14 klinikere fra 9 forskellige europæiske lande i en Delphi proces, hvor man i en styret proces opnår konsensus blandt eksperter om bestemte ting. I dette tilfælde de enkelte lægemidlers antikolinerge belastning. I alt 233 lægemidler blev vurderet, hvoraf de 211 blev klassificeret som havende en antikolinerg effekt.
I nedenstående tabel ses de 211 lægemidler klassificeret efter antikolinerg byrde.
| Lav antikolinerg byrde | Moderat antikolinerg byrde | Høj antikolinerg byrde |
|---|---|---|
| Almotriptan | Amantadine | Acepromazine |
| Alprazolam | Baclofen | Amitriptyline |
| Ampicillin | Carbamazepine | Amoxapine |
| Aripiprazole | Cetirizine | Atropine |
| Asenapine | Cimetidine | Belladonna (and derivates) |
| Atenolol | Clidinium | Benzatropine (Benztropine) |
| Azathioprine | Cloperastine | Biperiden |
| Betaxolol | Cyclobenzaprine | Brompheniramine |
| Bromocriptine | Dextropropoxyphene (Propoxyphene chloride) | Carbinoxamine |
| Bromperidol | Disopyramide | Carisoprodol |
| Bupropion | Dosulepin | Chlorphenamine (chlorpheniramine) |
| Captopril | Fexofenadine | Chlorpromazine |
| Carbidopa (decarboxylase) | Fluphenazine | Chlorprothixene |
| Cefamandole | Loxapine | Cimetropium bromide |
| Cefalotin (cephalotin) | Methadone | Clemastine |
| Cefoxitin | Molindone | Clomipramine |
| Celecoxib | Nefopam | Clozapine |
| Chlordiazepoxide | Olanzapine | Cyproheptadine |
| Chlortalidone | Oxcarbazepine | Darifenacin |
| Ciclosporin | Paroxetine | Desipramine |
| Cinnarizine | Perphenazine | Dexbrompheniramine |
| Citalopram | Pethidine (Meperidine) | Dexchlorpheniramine |
| Clindamycin | Pimozide | Dicycloverine (Dicyclomine) |
| Clonazepam | Prochlorperazine | Difemerine |
| Clorazepate (potassium) | Promazine | Dimenhydrinate |
| Codeine | Pseudoephedrine | Diphenhydramine (Dimenhydrinate) |
| Colchicine | Quetiapine | Doxepin |
| Cortisone | Theophylline | Doxylamine |
| Cycloserine | Tramadol | Emepronium |
| Desloratadine | Zotepine | Fesoterodine |
| Desvenlafaxine | Zuclopenthixol | Flavoxate |
| Dexamethasone | Homatropine | |
| Dextromethorphan | Hydroxyzine | |
| Diazepam | Hyoscyamine | |
| Digitoxin | Imipramine | |
| Digoxin | Levomepromazine | |
| Diltiazem | Maprotiline | |
| Dipyridamole | Meclozine (Meclizine) | |
| Divalproex sodium (Valproate semisodium) | Mepyramine (Pyrilamine) | |
| Domperidone | Mequitazine | |
| Entacapone | Nortriptyline | |
| Escitalopram | Opipramol | |
| Eslicarbazepine | Orphenadrine (chloride/citrate) | |
| Estazolam | Otilonium bromide | |
| Famotidine | Oxybutynin | |
| Fentanyl | Pheniramine | |
| Flunitrazepam | Procyclidine | |
| Fluoxetine | Promethazine | |
| Flupentixol | Propantheline | |
| Flurazepam | Propiverine | |
| Fluvoxamine | Protriptyline | |
| Furosemide | Scopolamine (Hyoscine) | |
| Gentamicin | Solifenacin | |
| Glycopyrronium | Thioridazine | |
| Guaifenesin | Tiemonium iodide | |
| Haloperidol | Timepidium bromide | |
| Hydralazine | Tizanidine | |
| Hydrocodone | Tolterodine | |
| Hydrocortisone | Trifluoperazine | |
| Iloperidone | Trihexyphenidyl | |
| Ipratropium bromide | Trimipramine | |
| Isosorbide (mononitrate/dinitrate) | Triprolidine | |
| Ketotifen | Tropatepine | |
| Levocetirizine | Trospium | |
| Lithium | Valethamate | |
| Loperamide | ||
| Loratadine | ||
| Lorazepam | ||
| Lumiracoxib | ||
| Methocarbamol | ||
| Methylprednisolone | ||
| Metoclopramide | ||
| Metoprolol | ||
| Midazolam | ||
| Mirtazapine | ||
| Morphine | ||
| Naratriptan | ||
| Nefazodone | ||
| Nifedipine | ||
| Nizatidine | ||
| Oxazepam | ||
| Oxycodone | ||
| Paliperidone | ||
| Pancuronium | ||
| Phenelzine | ||
| Phenobarbital | ||
| Piperacillin | ||
| Pramipexole | ||
| Prednisolone | ||
| Prednisone | ||
| Pregabalin | ||
| Primaquine | ||
| Quinidine | ||
| Ranitidine | ||
| Risperidone | ||
| Rotigotine | ||
| Selegiline | ||
| Sertraline | ||
| Sumatriptan | ||
| Temazepam | ||
| Tiotixene | ||
| Tiotropium bromide | ||
| Trandolapril | ||
| Trazodone | ||
| Triamcinolone | ||
| Triamterene | ||
| Triazolam | ||
| Trimebutine | ||
| Valproic acid (Valproate) | ||
| Vancomycin | ||
| Venlafaxine | ||
| Warfarin | ||
| Ziprasidone | ||
| Zolmitriptan | ||
| Zonisamide |
Følgende lægemidler vurderede man ikke havde nogen klinisk betydende antikolinerg byrde: Amiodarone, Benazepril, Bisacodyl, Capecitabine, Chloroquine, Chlorzoxazone, Fluticasone, Isoniazid, Hyperici herba/Hypericum perforatum/St John’s wort, Lansoprazole, Mebeverine, Mefloquine, Memantine, Metformin, Methotrexate, Naltrexone, Secobarbital.
ORCA værktøjet supplerer den eksisterende liste for antikolinerg belastning der blev udgivet af IRF i 2017. Her opdeles lægemidler ligeledes i tre kategorier efter lille, stærk og meget stærk antikolinerg belastning, som det ses i nedenstående tabel.
| Kategori 3: meget stærk effekt | Kategori 2: stærk effekt | Kategori 1: lille-moderat effekt | Alternativer | |
| Antidepressiva | Amitriptylin | Dosulepin | Mirtazapin | Duloxetin og venla-faxin har lav elleringen systemisk antikolinerg effekt |
| Clomipraminb | Paroxetin | |||
| Doxepinb | Reboxetin | |||
| Imipramin | ||||
| Nortriptylinb | ||||
| Antihistaminer | Cinnarizinc | Desloratadinc | Ranitidin | Fexofenadin eller cetirizin kan være et alternativ ved behov for nonsederende antihistamin.En PPI fx omeprazol kan være et alternativ til ranitidin |
| Clemastin | Loratadin | |||
| Cyclizinc | ||||
| Diphenhydramina | ||||
| Hydroxyzin | ||||
| Meclozina | ||||
| Promethazin | ||||
| Antiparkinsonmidler | Biperidenc | – | Entacapon | Carbidopa/levodopa har lav eller ingen systemisk antikolinerg effekt |
| Orphenadrin | Pramipexol | |||
| Procyclidin | Selegilin | |||
| Antipsykotika | Clozapinb | Loxapina | Haloperidol | Blandt atypiske antipsykotika er aripiprazol og ziprasidon de mindst antikolinerge |
| Perphenazin | Olanzapin | Risperidon | ||
| Periciazin | Quetiapin | |||
| Pimozida | ||||
| Prochlorperazin | ||||
| Gastrointestinalespasmolytika | Hyoscinbutylc | – | – | Mebeverin kan være et alternativ |
| Hyoscyamin | ||||
| Propanthelina | ||||
| Korttidsvirkendeantikolinergika | – | Ipratropiumc | – | Korttidsvirkende β2-agonister fx salbutamol kan være et alternativ |
| Langtidsvirkendeantikolinergika | – | Aclidiniumc | – | Langtidsvirkende β2-agonister fx formoterol kan være et alternativ |
| Glycopyrroniumc | ||||
| Tiotropium | ||||
| Umeclidiniumc | ||||
| Urologiskespasmolytika | Darifenacinb | Fesoterodin | – | Mirabegron kan være et alternativ ved overaktiv blæresyndrom.En α1-receptorblokker fx doxazosin kan være et alternativ ved prostatahyperplasi |
| Oxybutynin | Solifenacin | |||
| Tolterodinb | Tolterodin | |||
| Trospium | ||||
| Øvrige | Atropin | Baclofen | Metoclopramid | Ondansetron kan være et alternativ til metoclopramid.Psylliumfrøskaller kan være et alternativ til loperamid |
| Hyoscinc | Carbamazepina | |||
| Tizanidin | Loperamid | |||
| Oxcarbazepina | ||||
| ACB = Anticholinergic Cognitive Burden Scale; ADS = Anticholinergic Drug Scale; mARS = modified Anticholinergic Risk Scale,PPI = protonpumpehæmmer.a)Lægemidler fra ACB-listen [6] med ACB-score på 2 eller 3.b)Lægemidler, hvor der er divergens mellem mARS- og ADS-listens kategorisering (2 eller 3) [5, 8].c)Yderligere udvalgte lægemidler, der baseret på forfattergruppens skøn har antikolinergt bivirkningspotentiale. | ||||
Older adult risk classification for anticholinergics (ORCA): a Delphi panel-validated scale
Abstract
BACKGROUND: Drugs with anticholinergic properties (DAP) are widely prescribed in older adults for various medical conditions. However, their cumulative anticholinergic burden is associated with adverse outcomes, including cognitive decline, falls and hospitalisations. Anticholinergic scales vary significantly, complicating their interpretation and application into clinical practice and research. Recent systematic reviews provide an overview of existing scales, however often lack the clinical perspective of healthcare professionals. To address this gap, we developed the older adult risk classification for anticholinergics (ORCA) scale, incorporating both evidence and expert clinical judgement.
METHODS: A preliminary drug list was derived from the most comprehensive systematic review. A two-round Delphi process was conducted with 14 clinicians from nine European countries with substantial expertise in geriatric medicines and clinical pharmacology. Each round consisted of two phases in which experts rated the anticholinergic burden of drugs using a four-point Likert scale. Additional drugs and anticholinergic burden scales could be proposed at any point. Consensus was defined using the Lynn method.
RESULTS: A total of 233 drugs were assessed. Experts classified 17 drugs as having no anticholinergic properties, 115 as low, 31 as moderate and 65 as high burden. The majority of included DAP were central nervous system drugs, particularly antipsychotics and antidepressants. Five drugs did not reach consensus.
CONCLUSION: The ORCA scale is a clinically informed, evidence-based classification of DAP tailored for older adults. It offers a standardised tool to support clinicians, pharmacists and researchers in assessing anticholinergic burden, enhancing prescribing safety and guiding therapeutic decision-making in this vulnerable population.
METHODS: A preliminary drug list was derived from the most comprehensive systematic review. A two-round Delphi process was conducted with 14 clinicians from nine European countries with substantial expertise in geriatric medicines and clinical pharmacology. Each round consisted of two phases in which experts rated the anticholinergic burden of drugs using a four-point Likert scale. Additional drugs and anticholinergic burden scales could be proposed at any point. Consensus was defined using the Lynn method.
RESULTS: A total of 233 drugs were assessed. Experts classified 17 drugs as having no anticholinergic properties, 115 as low, 31 as moderate and 65 as high burden. The majority of included DAP were central nervous system drugs, particularly antipsychotics and antidepressants. Five drugs did not reach consensus.
CONCLUSION: The ORCA scale is a clinically informed, evidence-based classification of DAP tailored for older adults. It offers a standardised tool to support clinicians, pharmacists and researchers in assessing anticholinergic burden, enhancing prescribing safety and guiding therapeutic decision-making in this vulnerable population.
Redaktørens kommentar
Hos ældre er høj antikolinerg byrde fra lægemidler associeret med bl.a. kognitiv svækkelse, fald og indlæggelser, hvilket gør det vigtigt at vurdere den samlede antikolinerge belastning af lægemidler. ORCA værktøjet rummer en nem oversigt over lægemidlers antikolinerge belastning.
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