[Anticholinergic scales: Use in psychiatry and update of the anticholinergic impregnation scale]. / Les échelles anticholinergiques : usage en psychiatrie et mise à jour de l'échelle d'imprégnation anticholinergique.

Anticholinergic properties are well known to prescribers, notably in mental health, as a therapeutic strategy for i.e. extrapyramidal syndrome but also as a source of numerous adverse side effects. Herein, we propose a narrative literature review describing: (i) cholinergic pharmacology and anticholinergic properties; (ii) the importance of anticholinergic therapeutic properties in psychiatry; (iii) the existing anticholinergic drug scales and their usage limitations in Psychiatry and; last (iv) an update to the anticholinergic drug impregnation scale, designed for the French psychiatry practice. The anticholinergic side effects can appear both in the peripheral level (dry mouth, constipation, etc.) and in the central level (especially as cognitive deficits). Many of the so called « anticholinergic ¼ drugs are in fact entirely or mostly antimuscarinic and act essentially as parasympathetic system antagonists. Overall, anticholinergic/antimuscarinic side effects are usually attributed to psychotropic medications: to certain antipsychotics, notably classical neuroleptics such as phenothiazine and also to tricyclic antidepressants. In practice, the impact of anticholinergic toxicity treatments is often highlighted due to their excessively prolonged use in patients on antipsychotics. Interestingly, these antipsychotic treatments are better known for their anticholinergic side effects, especially cognitive ones, with an early onset specially in elder patients and/or in the case of polymedication. In order to evaluate anticholinergic side effects, metrics known as anticholinergic burden scales were created in the last few decades. Nowadays, 13 different scales are documented and accepted by the international academic community, but only three of them are commonly used: the Anticholinergic Drug Scale (ADS), the Anticholinergic Risk Scale (ARS) and the Anticholinergic Burden Scale (ACB). All of them are based on a similar principle, consisting of grading treatments individually, and they are normally scored from 0 - no presence of side effects - to 3 - anticholinergic effects considered to be strong or very strong. Using these scales enables the calculation of the so-called "anticholinergic burden", which corresponds to the cumulative effect of using multiple medications with anticholinergic properties simultaneously. The application of anticholinergic scales to patients with psychiatric disorders has revealed that schizophrenic patients seem to be especially sensitive to anticholinergic cognitive side effects, while elder and depressed patients were more likely to show symptoms of dementia when exposed to higher anticholinergic burden. Unfortunately, these tools appear to have a low parallel reliability, and so they might induce large differences when assessing side effects predictability. In addition, the capacity of these scales to predict central adverse effects is limited due to the fact they poorly or do not differentiate, the ability of treatments to cross the blood-brain barrier. Finally, one last limitation on the validity of these scales is prescription posology is not accounted for side effects considered to be dose dependent. Recently, the MARANTE (Muscarinic Acetylcholine Receptor ANTagonist Exposure) scale has incorporated an anticholinergic burden weighting by posology. Nevertheless, this new model can be criticized, due to the limited number of medications included and due to testing a limited number of potency ranges and dosages for each treatment. Herein, we propose an update to the Anticholinergic Impregnation Scale, developed specifically for the French Psychiatry practice. The scale validation was based on an evaluation of the prescriptions correcting anticholinergic peripheral side effects (constipation, xerostomia and xeropthalmia). This indirect evaluation allowed us to show patients with an anticholinergic impregnation score higher than 5 received significantly more treatments for constipation and xerostomia. This strategy bypasses the bias of a cognitive evaluation in patients with severe mental health disorders. Moreover, the relevance of a tool developed specifically for French psychiatry is justified by the fact that some highly prescribed treatments for mental illness in France (cyamemazine and tropatemine) are strong anticholinergics, and also by the fact they are rarely included in the existing anticholinergic scales. This update of the original scale, published in 2017, includes information whether prescribed drugs cross the blood-brain barrier and thus makes possible a more accurate assessment when evaluating anticholinergic central side effects. Finally, the anticholinergic impregnation scale will soon be integrated into a prescription help software, which is currently being developed to take into consideration dose dependent adverse effects.

[Pharmaco-therapeutic evaluation of medical treatments of adult autistics and multi-handicapped patients in a public mental health unit]. / Les traitements psychotropes prescrits dans un établissement public de santé mentale accueillant des personnes atteintes d'autisme et des polyhandicapés.

INTRODUCTION: This paper presents a survey conducted on a population of multi-handicapped patients and autistic adults hospitalised long term in the Paul Guiraud mental health Hospital in Villejuif France. OBJECTIVE: The aim of the survey is to deepen the knowledge of the treatments for this specific population. METHODS: A preliminary medical investigation was conducted on the population in order to target different groups of patients. Once patients had listed and defined their medical needs, prescriptions were analysed to assess whether clinical characteristics had an impact. Thus, the analysis of treatments was carried out for the 57 patients (14% of the hospital population) and compared to other investigations conducted on the population commonly hospitalised in Psychiatry. The evaluation of the treatments was obtained through a questionnaire which enabled us to target the therapeutical goals and to obtain additional clinical information. The drugs with a high rate of prescription were compared between the autistic group and the multi-handicapped group. The important comorbidity and the multi-symptomatology of autism often involves the polymedication of these patients (8+/-0.8 drugs per patient). RESULTS: Fifty per cent of the treatments are referred to as somatic treatments. The average length of stay (22.3 years) and the high average age are aggravating factors for polymedication. The average number of psychotropic molecules also appears higher than in the populations studied in the literature. The heterogeneity of clinical forms of autism and polyhandicap encourages prescribers to multidrug therapy. The prescriptions usually remain stable (17.5% of psychiatric treatment is adapted and only 7% of somatic treatment). Epilepsy and constipation are the main treated somatic disorders. In psychiatry, the oral route is the privileged route of administration (81% of treatments) with, more specifically, the use of drinkable solutions for the psychiatric treatment. Neuroleptic drugs are the basic treatment of these patients (82% of prescriptions). The aim of the prescription of neuroleptics is essentially to obtain behavioural or antipsychotic sedation. Cyamemazin is the most prescribed drug (46% of neuroleptic prescriptions), mainly for its anxiolytic effects. Co-prescription is frequent (55.3%) and corresponds to 53% of co-prescriptions of an association of phenothiazine and butyrophenone. Doses are high, which implies the prescription of treatments against the neuroleptics side-effects (86% of patients have such a prescription). The rate of prescriptions of the other psychotropic drugs (hypnotics, anxiolytics, etc.) is approximately equivalent between our population and the "classical" hospitalised psychiatric population, except for antidepressants (7% of prescriptions) because the differential diagnosis is difficult in these patients. Nearly 60% of patients have prescriptions of hypnotic drugs. However, this figure is tempered by prescriptions of drugs "if necessary" in two-thirds of the cases. Finally, only 30% of patients have systematic hypnotic prescriptions. CONCLUSION: Although autistics are clinically different from multi-handicapped patients, no statistically significant difference was demonstrated in their prescriptions, which implies a similar pharmacological management. It is difficult to clearly distinguish these two populations only according to the type of drugs used and the doses prescribed.

[Acute postpartum anaemia. Clinical practice and interest of intravenous iron]. / Anémies sévères du post-partum immédiat. Pratique clinique et intérêt du fer par voie intraveineuse.

OBJECTIVES: Postpartum anaemia is a very frequent pathology concerning from 4% to 27% of patients. The purpose of this study was to estimate clinical practice in front of acute postpartum anaemia and to value a new treatment: intravenous iron. PATIENTS AND METHODS: Retrospective study over a period of 2 years (April 2001-March 2003) realised in the Department of Gynaecology and Obstetrics of Belfort Regional Hospital. Two hundred and seventeen patients were included (5% of deliveries in the same period) with immediate postpartum period haemoglobin <8 g/dl. Two groups were individualised according to the availability or not of an intravenous iron therapy. Clinical and biologic elements concerning deliveries were analysed. RESULTS: Average haemoglobin values, from delivery to 48 h after it, were 5.81 g/dl for blood-transfused patients, 6.88 g/dl for intravenous iron treated patients and 7.43 g/dl for oral iron treated patients. Fifteen patients were transfused during the year before the launch of intravenous iron as a possible therapy and only five patients the next year. The benefit of haemoglobin values with an intravenous iron therapy was 1.9 g/dl on 7 days and 3.1 g/dl on 14 days. DISCUSSION AND CONCLUSION: These results suggest a real efficiency of intravenous iron therapy for acute postpartum anaemia (haemoglobin values <8 g/dl) with a good tolerance. Patients with haemoglobin values <7 g/dl treated by intravenous iron tend to show that some blood transfusions would be thereby avoided even though blood transfusion remains the urgency treatment.

[Value of trimeprazine among hypnotics in a psychiatric facility]. / Place de l'alimémazine parmi les hypnotiques dans un établissement de soins psychiatriques.

Trimeprazine (TPZ) has been marketed in France since 1959, as tablets and solution containing respectively 5 mg and 40 mg/ml. TPZ is a phenothiazine derivative with known antihistaminic and sedative effects. The first approved indication for TPZ is in the treatment of allergy. However, its frequent sedative effects are undesirable in this indication. The second approved indication is in the treatment of insomnia (5-20 mg/day) and TPZ is an alternative to conventional hypnotics as diazepam, flunitrazepam, zolpidem, butobarbital... Due to the prescription frequency of this medicine in our hospital, we analyzed the naturalistic prescriptions mode and the clinical end point in patients hospitalized for mental illness. On the one hand, using the hospital prescription software, we analyzed: prescriptions frequency, dose regimen and drug associations with hypnotics, anxiolytics and sedative antipsychotics. On the other hand, we came into contact with physicians in order to know their opinion on TPZ and the whole point of that indication. The results showed a very high prescription frequency (139/400 patients; 35%), a marked increase in dose compared to those approved by the French Drug Administration (5-20 mg/day: 5%; 20-200 mg/day: 95%) and main drug association with hypnotics, tranquilizers or antipsychotics, respectively 38%, 65% and 91%. Clinical end points are: non addictive properties and an easily adequation of posology for the drinkable drop form in contrast with tablets. Thus, TPZ appears as a first-line hypnotic in spite of its adverse effects common to phenothiazine (atropinic and antidopaminergic effects) and is a usefull medicine for the treatment of insomnia in psychotic patients.