Intended for healthcare professionals

Practice Sustainable Practice

Reducing patient and planetary harms from high anticholinergic burden medication

BMJ 2024; 384 doi: (Published 15 January 2024) Cite this as: BMJ 2024;384:e075708

Linked Editorial

Sustainable practice: what can I do?

  1. Honey Smith, salaried GP, clinical net zero lead, co-chair123,
  2. Hannah Fligelstone, FY2 doctor4
  1. 1Richmond Medical Centre, Sheffield, UK
  2. 2South Yorkshire Integrated Care Board
  3. 3Greener Practice Community Interest Company, Sheffield
  4. 4Mid-Yorkshire Hospitals NHS Trust, Wakefield
  1. Correspondence to H Smith honey.smith1{at}

What you need to know

  • Prescribing medicines with high anticholinergic burden carries significant risk of adverse clinical outcomes for patients

  • Anticholinergic burden scores can be a useful way of assessing anticholinergic burden

  • Consider tapering when stopping anticholinergic medications to avoid withdrawal effects, which may include nausea and sweating

Overprescribing and polypharmacy have been identified as a risk to patients and the planet.1 Prescribing medications with a high anticholinergic burden carries significant risk for patients, particularly older people. The adverse outcomes that result from this also incur substantial carbon and planetary burdens which might be mitigated by deprescribing anticholinergic drugs where appropriate.

Why change is needed

Polypharmacy (the concurrent use of multiple medication items by one individual)2 in older people are becoming increasingly common.34 One common aspect of polypharmacy is high anticholinergic burden.56 When one or more drugs with anticholinergic properties are prescribed, the risk of adverse events combines and accumulates. Examples of medications with an anticholinergic burden (ACB) are shown in table 1.

View this table:
Table 1

Commonly prescribed drugs with anticholinergic burden (ACB)

Clinical implications

Drugs have different levels of anticholinergic effect. The extent of an individual’s ACB can be summarised through their ACB score, for which there are several validated ACB score calculators.7 The risks of anticholinergics increase with each additional point scored, with an increase in mortality associated with the number and ACB potency …

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