Carga anticolinérgica en pacientes mayores de 65 años con tratamiento farmacológico ambulatorio en una población colombiana / Anticholinergic load in patients older 65 years with ambulatory pharmacological treatment in a Colombian population

RESUMEN Introducción: los fármacos con potencial efecto anticolinérgico son prescritos frecuentemente en la población mayor de 65 años. Existen varias escalas para calcular la carga anticolinérgica: Anticholinergic Drug Scale, Anticholinergic Risk Scale y Anticholinergic Cognitive Burden. Objetivo: caracterizar la carga anticolinérgica en pacientes mayores de 65 años con polifarmacia que son formulados ambulatoriamente. Métodos: estudio de corte transversal, retrospectivo con información de prescripción registrada desde abril hasta septiembre de 2016. Se utilizó la base de datos transaccional de prescripción de una EPS nacional registrada en la plataforma tecnológica de un PBM (Pharmacy Benefit Management). Se analizaron los medicamentos con propiedades anticolinérgicas y carga anticolinérgica. Resultados: fueron 115.713 los pacientes formulados, con una edad media de 74 años. Los grupos terapéuticos más asociados con carga anticolinérgica moderada fueron, en un 6,5 %, dimenhidrinato, amantadina, biperideno y quetiapina. Un 13,1 % con carga anticolinérgica alta donde se encuentran el butil bromuro de hioscina y la amitriptilina. Discusión: el manejo de las patologías en los pacientes adultos mayores es compleja y se llega hasta el punto de requerir prescripción de múltiples medicamentos; por lo cual, se hace fundamental evaluar la necesidad del uso de estos, además de verificar su pertinencia y las posibles interacciones farmacológicas de alta significancia clínica, para evitar la presencia de eventos adversos. Por esto se han desarrollado escalas que permiten mejorar el resultado terapéutico especialmente en fármacos con carga anticolinérgica.

SUMMARY Background: Drugs with potential anticholinergic effect are usually prescribed to the population over 65 years. There are several scales created to calculate anticholinergic burden: Anticholinergic Drug Scale, Anticholinergic Risk Scale, and Anticholinergic Cognitive Burden. Objective: To characterize the anticholinergic burden in patients older than 65 years with polypharmacy who are prescribed in ambulatory settings. Methods: Retrospective cross-sectional study with information registered from April to September 2016. The database of prescription records of a health management organization (HMO), with national registries in the Pharmacy Benefit Management (PBM) technology platform, was used. Medicines were analyzed by its anticholinergic properties and anticholinergic burden. Results: There were 115,713 patients with a median age of 74 years. The medicines with moderate anticholinergic burden were dimenhydrinate, amantadine, biperidene and quetiapine in 6.5 %, and with high anticholinergic burden hyoscine butylbromide and amitryptiline in 13.1 %. Discussion: The medical attention of diseases of the elderly is complex and requires the prescription of multiple medications. It is important to evaluate the medicines and verify their relevance and possible pharmacological interactions, to avoid the presence of adverse events. For this reason, scales have been developed, they allow improving therapeutic results, and especially in medicines with anticholinergic burden and systems of clinical alerts that promotes correct formulation.

Anticholinergic toxicity in a one-year-old male following ingestion of Lupinus mutabilis seeds: case report

ABSTRACT CONTEXT: The seeds from Lupinus mutabilis Sweet, also called "chocho", are an important part of the diet in several countries in South America. Prior to consumption, processing is required to remove toxic alkaloids. These alkaloids are known to have pharmacological properties as antiarrhythmics, antimuscarinics and hypoglycemics. CASE REPORT: We report a case in which a one-year-old male initially presented with altered mental status and respiratory distress and subsequently developed symptoms of anticholinergic toxicity, after ingesting a large amount of chocho seeds. CONCLUSION: In spite of going through a difficult clinical condition, the subject evolved favorably through receiving supportive treatment. The seeds from Lupinus mutabilis provide nutritional benefits when consumed, but people need to know their risks when these seeds are consumed without proper preparation.

Intoxicación por Datura stramonium: serie de tres casos / Datura stramonium poisoning: series of three cases

Se presenta una serie de tres casos de pacientes menores de edad con intoxicación por ingesta de semillas de Datura stramonium, ocurridos durante el mes de mayo en la provincia de Mendoza. Pacientes de sexo masculino, ente 15 y 3 años de edad. Uno de ellos asociado con ingesta intencional de semillas y otros dos por intoxicación accidental al ingerir las semillas jugando con el fruto de la planta. La recolección de semillas se realizó en zona rural periurbana, y todos los casos fueron llevados a la consulta por familiares directos, ante la presencia de desorientación, ataxia y disartria. Los tres pacientes desarrollaron síndrome anticolinérgico, con delirio y alucinaciones, requiriendo internación y tratamiento sintomático, con buena evolución y recuperación completa entre las 24 y 72 horas. Se resalta el riesgo que representa la presencia de este vegetal tóxico, no sólo por su fácil disponibilidad, sino por las bajas dosis letales de sus alcaloides y la falta de diagnóstico etiológico por parte de los servicios de urgencia.

A series of three cases of pediatric patients with poisoning by ingestion of seeds of Datura stramonium, which occurred during the month of May in the province of Mendoza is presented. Male patients, among 15 and 3 years old. One associated with intentional ingestion of seeds and other two by accidentally ingesting seeds while playing with the fruit of the poisonous plant. Seed collection was conducted in rural and peri-urban areas, and all patients were brought to the office by relatives, due to the presence of dysarthria disorientation and ataxia. The three patients developed anticholinergic syndrome with delirium and hallucinations, requiring hospitalization and symptomatic treatment. All cases had favorable outcome and complete recovery within 24 to 72 hours. It is highlighted the risk posed by the presence of this toxic plant, not only for its easy availability, but low lethal doses of its alkaloids and lack of etiological diagnosis by emergency services.

Postcardiotomy Central Anticholinergic Syndrome: Report of A Case / 대한흉부외과학회지

Central anticholinergic syndrome is defined as an absolute or relative reduction in cholinergic activity in the central nervous system and has a wide variety of manifestations. It is associated with almost any drug given during anesthesia, except neuromuscular relaxants, and treated with the cholinesterase inhibitor physostigmine. The diagnosis of central anticholinergic syndrome is often made when symptoms resolve promptly after the administration of physostigmine. We present a case of a central anticholinergic syndrome diagnosed by treatment with physostigmine, in a patient who received closure of patent foramen ovale associated with stroke.

Central Anticholinergic Syndrome Confirmed with Physostigmine after Open Heart Surgery / 대한마취과학회지

Central anticholinergic syndrome (CAS) can be caused by many anesthetic drugs. Early diagnosis and treatment are very important because untreated CAS may result in a life-threatening condition. Physostigmine, though not available in Korea, is the only drug which can confirm and treat CAS. A forty five year old patient underwent open heart surgery due to patent foramen ovale. Anesthetic agents which were used for anesthetic induction and maintenance were midazolam, fentanyl and isoflurane. Following anesthesia, he showed irritated and excited behavior and delayed recovery from anesthesia more than 3 h after operation in the ICU, even though flumazenil and naloxone were given to rule out the residual anesthetic effect. After physostigmine 4 mg was administered intravenously, he calmed down and became more coherent. There was no evidence of neurologic deficit in the following brain MRI and neurologic examination. We report the first case of CAS confirmed with physostigmine in Korea.

A Suspected Case of Central Anticholinergic Syndrome after N2O-O2-Propofol Anesthesia / 대한마취과학회지

Central anticholinergic syndrome (CAS) is the clinical picture of the central cholinergic blockade. Many drugs used in anesthesia may cause blockade of central cholinergic neurotransmission. Early diagnosis of CAS is very important clinically, CAS's effects are broad and life-threatening. However, it is difficult to find physostigmine in Korea, which is essential to confirm a diagnosis for CAS. An 18-year-old female who was diagnosed with hyperhydrosis underwent a thoracoscopic sympathicotomy. She received N2O-O2-Propofol anesthesia. The anesthesia was unevenful, but postoperatively, she suffered from drowsiness, fever, mydriasis, stiffness of the left upper and lower extremities, and seizures. All tests to seek the cause of CAS such as blood chemistry, brain CT, brain MRI, and CSF test, were normal. She completely recovered without any sequelae after 3 days in ICU. Though it was not confirmed with physostigmine, we report the case to be suspected CAS by all other indications.