Anticholinergics (or antimuscarinics) are most often used to help control some of the common side-effects which can occur with some antipsychotics (neuroleptics or major tranquillisers) e.g. tremor or shaking, stiffness or movement problems. The side effects of e.g. tremor or shaking, stiffness or movement problems are known as the "Extra-pyramidal side effects" or "Parkinsonian" side effects. The anticholinergic drugs are very effective for this but as these side effects tend to wear off, you may not need to take an anticholinergic drug all the time. These drugs are also used to control the symptoms of Parkinson's Disease itself.

Antipsychotics are mainly used to help treat some of the symptoms of:

• Psychiatric emergency
• ADHD (Attention Deficit Hyperactivity Disorder)
• Bipolar maintenance
• Dementia
• Depression
• Mania
• OCD (Obsessive Compulsive Disorder)
• Psychosis
• PTSD (Post-Traumatic Stress Disorder
• Schizophrenia

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Many of the symptoms of "psychosis" are caused by an over-activity of dopamine in the brain. Dopamine is a naturally occurring chemical messenger ("neurotransmitter") in the brain. Antipsychotic drugs block the action of this dopamine in the brain. However, dopamine is also important in controlling muscle tone or tension. Unfortunately, the antipsychotic drugs also block these muscular actions of dopamine and the tremor, stiffness or movement problems mentioned above then occur due to this imbalance of dopamine in the brain. In people who get these side-effects, the effects of the transmitter 'acetylcholine' are greater than normal. Acetylcholine causes the muscles to become stiffer. Antimuscarinic or anticholinergic drugs block or reduce some of the action of acetylcholine in the brain and so reduces these side-effects. For a more detailed explanation, click here. Some antipsychotics (especially the phenothiazines) also block acetylcholine receptors, which is partly useful in minimising this problem. It is not, however, usually enough to counteract the effects of the antipsychotic on dopamine.

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Tablets:

The tablets should be swallowed with at least half a glass of water whilst sitting or standing. This is to make sure that they reach the stomach and do not stick in your throat.

Liquids:

Your pharmacist should give you a medicine spoon or oral syringe. Use it carefully to make sure you measure the correct amount. Ask your pharmacist for a medicine spoon if you do not have one.

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Take your anticholinergic as directed on the medicine label. These medicines can give you a dry mouth. This can be helped by taking your medicine before food. They may also cause you to feel a bit sick or give you an upset stomach. If this happens it is best to take it after food as this will help. If you have a dry mouth, try taking your medicine after food and then sucking a peppermint, chewing gum or drinking water to help your thirst and stop your mouth getting dry.

Benztropine ("Cogentin") and Biperidin ("Akineton") can both cause you to feel sleepy so if the instructions say to take them once a day this is usually best at bedtime. They are not sleeping tablets. Benzhexol/trihexyphenidyl ("Artane"), orphenadrine ("Disipal") and procyclidine ("Kemadrin") can have the opposite effect. You should avoid taking these at night if possible as they may stop you getting off to sleep easily

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They start to work with an hour or so and the effect lasts for about 8 to 12 hours.

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This should be discussed with your doctor as people respond differently. Once the doses of your other drugs have settled down you may not need to take them regularly, only when you need them. If you are having a "depot" injection you may only need these tablets for a few days after your injection.

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Anticholinergics are not addictive as such. There have been some rare reports of people "abusing" them but this is uncommon, as they don't really have any stimulant or similar effects.

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If you are taking them regularly it is best not to stop them suddenly as you symptoms may then get worse. It is best to stop them gradually and you should discuss this with your doctor. If you are only taking them "when required" there is no problem.

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Start again as soon as you remember unless it is almost time for your next dose, then go on as before. Do not try to catch up by taking two or more doses at once as you may get more side-effects. You should tell your doctor about this next time you meet. If you forget some doses and do not notice any difference you may well not need to take them at the moment. Talk about this with your doctor.

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Use the information in the table below to find out about side effects associated with specific anticholinergenic medication.

Table adapted from UK Psychiatric Pharmacy Group leaflets, with kind permission www.ukppg.org.uk

Do not be worried by this list of side effects. You may get none at all. There are other rare side-effects. If you develop any unusual symptoms ask your doctor about them next time you meet.

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These drugs may make you feel a little drowsy. You should not drive (see below) or operate machinery until you know how they affect you. You should be careful as they may affect your reaction times. Benztropine ("Cogentin") and Biperidin ("Akineton") can both cause you to feel sleepy so if the instructions say to take them once a day this is usually best at bedtime. They are not sleeping tablets. Benzhexol ("Artane"), orphenadrine ("Disipal") and procyclidine ("Kemadrin") can have the opposite effect. You should avoid taking these at night if possible as they may stop you getting off to sleep easily.

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It is not thought that any of the anticholinergics cause any changes in weight. If you do start to have problems with your weight, however, tell your doctor next time you meet as he or she can arrange for you to see a dietician for advice.

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Drugs can affect desire (libido), arousal (erection) and orgasmic ability. The anticholinergic drugs have not been reported to have a major adverse effect on these three stages. However, if this does happen, you should discuss this with your doctor, as a change in dose may help minimise the problem.

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If you are taking an anticholinergic, you should avoid alcohol as it may make you feel more sleepy. If this happens, you must take extra care if you need to drive or operate machinery. You must seek advice on this. 

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You should have no problem with any foods or drinks, other than alcohol (see separate question).

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The anticholinergics have a few interactions with other medicines:

• The effects of anticholinergics can sometimes be increased by SSRIs (e.g. citalopram, fluoxetine, paroxetine, sertraline), some older antipsychotics, tricyclics (e.g. dosulepin, imipramine, lofepramine) or memantine
• Anticholinesterases (because anticholinergics decrease the effect of acetylcholine in the brain or anticholinesterases [e.g. donepezil, rivastigmine and galantamine] increase the effect of acetylcholine)
• Anticholinergics can slightly sometimes decrease the effect of cimetidine

This does not necessarily mean that this will happen in everyone or that some of these medicines can not be used together. It just that you may need to follow your doctor's instructions very carefully. There are many other possible drug interactions.

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You should have no problems with "The Pill" and any of the anticholinergics.

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It is important to consider that there will be a risk to you and your child from taking a medicine during pregnancy but also a possible risk from stopping the medicine e.g. getting ill again. Unfortunately, no decision is risk-free. It will be for you to decide which is the least risk. All we can do here is to help you understand some of the issues, so you can make an informed decision. For your information, major malformations occur "spontaneously" in about 2-4% of all pregnancies, even if no drugs are taken. The main problem with medicines is termed "teratogenicity" i.e. a medicine causing a malformation in the unborn child. A medicine causing teratogenicity is called a "teratogen". Since a baby has completed it's main development between days 17 and 60 of the pregnancy (the so-called "first trimester") these first 2-16 weeks are the main concern. After that, there may be other problems e.g. some medicines may cause slower growth. The infant may also be affected after birth e.g. withdrawal effects are possible with some drugs.

If possible, the best option is to plan in advance. If you think you could become pregnant, discuss this with your doctor and it may be possible to switch to medicines thought to carry least risk, and take other risk-reducing steps e.g. adjusting doses, taking vitamin supplements etc. If you have just discovered you are pregnant, don't panic, but seek advice from your GP within the next few days if possible. He or she may also want to refer you on to someone with more specialist knowledge of your medicine.

Very few medicines have been shown to be completely safe in pregnancy and so no manufacturer or advisor can ever say any medicine is safe. They will usually advise not to take a medicine during pregnancy, unless the benefit is much greater than the risk. In the UK, there is the NTIS (National Teratology Information Service) who offer individual risk assessments. However, their advice should always be used to help you and your doctor decide what is the risk to you and your baby. There is a risk from taking the medicine and a risk should you stop a medicine e.g. you might become ill again and need to go back on the medication again. The advice offered here is just that i.e. advice, but may give you some idea about the possible risks and what (at the time of writing) is known through the medical press.

It may be helpful to know that in the USA, the FDA (Food and Drug Administration) classifies medicines in pregnancy in five groups:
# A = Studies show no risk, so harm to the unborn child appears only a remote possibility
B = Animal and human studies indicate a lack of risk but are not fully conclusive
C = Animal studies indicate a risk but there is no safety data in humans
D = a definite risk exists but the benefit may outweigh the risk in some people
X = the risk outweighs any possible benefit

The anticholinergics are all classified as "C". There is no firm evidence of a teratogenic effect, but some problems have been reported and so you should seek personal advice from your GP, who may then if necessary seek further specialist advice.

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The anticholinergics can affect your driving in two ways. Firstly, you may feel drowsy and/or suffer from blurred vision at first when taking any of these drugs. Secondly, the drugs can slow down your reactions or reflexes. This is especially true if you also have a dry mouth, blurred vision, constipation etc. (the so-called "anticholinergic side effects"). Until these wear off, or you know how your medicine affects you, do not drive or operate machinery. You should be careful as they may affect your reaction times or reflexes even though you feel well.

Under Section 4 of the Road Traffic Act 1988 anyone driving while unfit to drive, due to illness (e.g. schizophrenia, mania) or any drug, can be prosecuted. Under UK law it does not matter if the drug is a prescribed medicine or an illegal drug. It’s the effect on your driving that is the main thing. If your ability to drive might be reduced due to illness or medicines, under UK law you must let your insurance company know. If you don’t, the insurance might say this is as 'withholding a material fact' (ie not telling them something they ought to know) and might mean that if you have an accident they might not pay up. Your doctor will be able to advise you.

Medical rules for all drivers:
For the full story click here (opens in new window) and go to "Medical standards". Here there is a pdf document (regularly updated) called "At a glance guide to the current medical standards of fitness to drive" that can be downloaded. It is aimed at medical practitioners (GPs).
For the "Customers guide" (ie a guide for the general public) click here (opens in new window) and download the 'Customer service guide for drivers with medical conditions'.

How to tell the UK DVLA:
If you need to tell the DVLA and you already have a license, you need to download the medical questionnaire from the DVLA website. Or you can call the DVLA to ask them to send it to you. You also need to fill out a form to give your consent for doctors from the DVLA doctors to contact your doctor or a specialist. You can either post, fax or email these forms back to:
Drivers Medical Group, DVLA, Swansea, SA99 1TU
Tel: 0870 600 0301
Fax: 0845 850 0095
Email: eftd@dvla.gsi.gov.uk
Web www.direct.gov.uk/motoring (opens in new window)
You should always allow DVLA to contact your doctor, as what your doctor says will help the DVLA decide if you can keep your license. Rarely, the DVLA may ask you to have a (free) medical examination, which will be free. This is called a medical enquiry.

What happens next
If you give the DVLA all the information they need, they can usually sort things out within 15 days. If they need more information from you, your doctor or other sources, they will try to sort it out within 90 days. What they decide will also depend on what you’re doing e.g. driving a bus is different to driving down to the shops. What can happen includes:

• You may be able to keep your license or be issued with a new one.
• If the DVLA’s doctor thinks your fitness to drive needs to be reviewed again, you may be given a license valid for 1, 2 or 3 years.
• Your license may be taken from you (revoked) or your application refused. This will only happen if you do not meet the standards of fitness to drive at the moment. If this happens, you would be told the reasons for the decision. You would also be told when you can apply again.

Driving safely
If you want to carry on driving, you must take sensible steps to reduce any risk:

• Avoid driving when you are tired or ill
• Do not drive after having any alcohol as this can make an drowsiness worse (a third of all fatal road traffic incidents involve alcohol-dependent drivers)
• Avoid driving at night, dusk or in bad weather
• Avoid motorways, dual carriageways and the rush hour
• Give yourself plenty of time. Don’t rush
• Be extra careful if you have not slept well the previous night

As some medicines can affect your driving, be extra careful:

• If starting a new medicine
• After a change in dose (especially an increase)
• If you are on a high dose or seem very sensitive to side effects
• If you are taking any medicines for other symptoms e.g. antihistamines for hay fever or allergies
• If your medicine causes you blurred vision, drowsiness, poor co-ordination, poor attention

If you are driving less than 2000 miles a year, once you consider insurance, tax, MoT, repairs, maintenance and petrol, you may actually find it is cheaper to get taxis and busses, and walk the short journeys.

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