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. 2025 Oct;47(5):1532-1536.
doi: 10.1007/s11096-025-01965-5. Epub 2025 Aug 13.

Anticholinergic medicines - medication management, prescribing cascades, and deprescribing

Ivana Tadic  1 , Anita Elaine Weidmann  2
Affiliations

Anticholinergic medicines - medication management, prescribing cascades, and deprescribing

Ivana Tadic et al. Int J Clin Pharm. 2025 Oct.

Abstract

This comment aims to raise awareness of the problems encountered when using anticholinergic burden (ACB) tools for the assessment of inappropriate medications (PIM), concerns related to prescribing cascades, and the process of deprescribing in patients older than 65 years. The first published tool, BEERS criteria from 1991, interpreted the ACB as the single biggest iatrogenic problem in treating older patients. Numerous subsequent publications repeated this interpretation rather than using real-world data. By comparing three internationally validated PIM tools (AGS BEERs criteria; EU(7)-PIM; PIM), this comment highlights how their anticholinergic (ACh) medicines lists differ, lack specific details on the strength of the ACh effect while also not providing suitable alternative pharmacological approaches. In addition, this comment considers the recognized contribution of ACh medicines in prescribing cascades and resultant inappropriate polypharmacy concerns while also considering barriers to deprescribing in the face of lacking detailed clinical guidance.

Keywords: Cascades; Cholinergic antagonists; Deprescriptions; Inappropriate prescribing; Patient safety.

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Conflict of interest statement

Declarations. Competing interest: A.E.W., is an Associate Editor of the International Journal of Clinical Pharmacy. She had no role in handling the manuscript, neither in the processes of editorial review and peer review nor in relation to decision making. The authors have no relevant financial or non-financial interests to disclose. Ethics approval: No ethics approval was needed for this comment.

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