Anticholinergic burden (AB) or anticholinergic load (AL) refers to the cumulative effect of taking multiple medications with anticholinergic actions, which can lead to adverse effects, particularly in older adults, including cognitive impairment, falls, constipation and urinary retention. Two recent studies^1,2 explored the problems associated with anticholinergic burden and the impact of pharmaceutical interventions.

Mariam Hijazi and colleagues (University Hospital Getafe, Madrid, Spain) investigated the relationship between anticholinergic burden (AB) and the degree of chronic functional constipation (CFC) in patients admitted to the emergency department with at least one chronic medication.  They reported that one-third of the 65 patients included in the study met the criteria for CFC. The mean age of participants was 76 years and a large proportion (67.7%) had medication with a medium-high AB. Multivariate analysis revealed that AB was significantly associated with a higher probability of CFC diagnosis [OR=19.0 (95% CI,2.2–162.9) p=0.007], along with female sex [OR=4.1(95% CI,1.2–13.9) p=0.023]. Although more than a quarter of participants usually used laxatives, half of them still met the criteria for constipation, suggesting that laxatives may be ineffective in the presence of significant anticholinergic burden.

Bernikier and colleagues (Rochefort Hospital, France) focused on analysing the anticholinergic load (AL) of prescriptions in hospitalised patients aged 75 and older and the impact of pharmaceutical interventions (PI). AL was calculated at admission using a scoring system where each molecule received a score from 0 to 3 based on its anticholinergic effects. A prescription was considered to have a “high” AL if it contained at least one drug with a score ≥ 2 and/or if the overall AL exceeded predefined thresholds.

The study found that almost 40% (23 out of 60) of patients had a high AL at admission requiring a PI. Following PIs, which often involved switching to drugs with lower scores or discontinuing unnecessary treatments, a reduction in the discharge AL score was observed in 56% of patients. There was also a notable decrease in the number of patients taking drugs with the highest anticholinergic score (3) and a reduction in the number of patients exceeding the theoretical AL thresholds.  The authors concluded that the calculation for AL should be integrated into hospital reports and the information be passed to referring doctors.

These studies underline the role of pharmacists in identifying and managing anticholinergic burden in elderly patients. In the hospital setting, proactive pharmaceutical interventions can significantly reduce anticholinergic load at discharge, potentially improving patient outcomes. This can involve suggesting dose adjustments, medication switches, or discontinuation of non-essential anticholinergic medications.

References

1. Hijaz Vega M, Alonso-Zazo J, Cosin-Munilla L et al relationship between anticholinergic burden associated with medications and functional chronic constipation in patients admitted to emergency departments. (Poster) EAHP Congress 2025

2. Bernikier E, Giraudeau C, Arcizet J et al. Anticholinergic load: a better score for a gold prescription? (Poster) EAHP Congress 2025

Prescribing by hospital pharmacists is now well-established in a number of countries and there is evidence that stakeholders take a positive view of this development on hospital workflows and patient safety. A national expert taskforce in Ireland has recommended that hospital pharmacist prescribing (HPP) be initiated in Ireland in 2027. In preparation for this, the views of existing Irish prescribers (doctors, nurses, and midwives) need to be understood. Marie Richardson (University College Cork and Our Lady of Lourdes Hospital, Drogheda, Ireland) undertook a survey of doctors, nurses and midwives working in Irish hospitals to investigate their perspectives about HPP and its potential impact on healthcare delivery.

In total, 238 Irish prescribers responded to an anonymous online survey. The findings revealed overall support for HPP among the surveyed groups, who anticipated benefits such as reduced prescribing errors and improved workflows. However, the study also indicated varied levels of support for pharmacists prescribing independently in different clinical scenarios. For example, about 20% of respondents felt that a prescribing pharmacist should not prescribe a new medicine at all. Overall, the findings suggested a positive reception towards HPP among Irish prescribers, with an expectation of enhanced patient safety and efficiency.

References

1. Expert Taskforce. Expert Taskforce to Support the Expansion of the Role of Pharmacy Final Report [Internet]. Dept of Health; 2024. https://www.gov.ie/en/publication/f3b42-expert-taskforce-to-support-the-expansion-of-the-role-of-pharmacy-final-report/
2. Richardson M, Dalton K, Spooner M, Murphy K. Doctors’, Nurses’, and Midwives’ views of Hospital Pharmacist Prescribing: a Cross-Sectional Survey Study (Poster) EAHP Congress 2025

Biopharmaceuticals are complex biological molecules that require careful storage and handling to ensure medication integrity. They are especially sensitive to mechanical stress and shaking, temperature excursions and light exposure.¹ A major concern is that conditions during transport of compounded drugs could lead to aggregation of proteins and consequent changes in immunogenicity. Thus, a high-quality, compounded product could be prepared in a centralised pharmacy facility but could then be altered during transport to wards or clinics. As some hospitals use pneumatic tube delivery systems for rapid transport of medicines and other items between wards and departments, this is an issue of concern.

Kjellstrom and colleagues² described a project to explore the impact of hospital transport systems, including pneumatic tubes, on protein stability in iv bags and syringes. They noted that the use of pneumatic tubes is prohibited in many hospitals after studies demonstrated increased numbers of subvisible particles from protein aggregates.

This study examined the impact of pneumatic tube systems and electric platform trucks on protein stability in IV bags and ready-to-use syringes. Smartlabels (CPI, UK) were used for shock and vibration monitoring. Flow imaging microscopy, size exclusion chromatography and visual inspection measurements were performed.

The results showed that transport via pneumatic tubes was associated with:

• increased levels of spherical particles in syringes – thought to be most likely silicone oil
• increased numbers of sub-visible particles in IV bags with headspace (with and without added drugs)

Furthermore, the addition of polysorbate 20 prevented particles over 10 micrometers, but increased total numbers of particles.

The authors concluded that high shock levels during transport using pneumatic tubes appeared to release particles from the material of both syringes and IV bags. They recommended removing headspace during transport of IV bags, especially if using pneumatic tube systems.

References

1. Sabaté-Martínez C, Paulsson M, González-Suárez S, Elofsson U, Fureby AM, Wahlgren M, López-Cabezas C. How are we handling protein drugs in hospitals? A human factors and systems engineering approach to compare two hospitals and suggest a best practice. Int J Qual Health Care. 2024 Mar 18;36(1):mzae020. doi: 10.1093/intqhc/mzae020. PMID: 38462489; PMCID: PMC11002458.
2. Kjellström A, Cederwall I, Sabaté Martinez C, Elofsson U, Wahlgren M, Paulsson M. Impact of hospital transport systems including pneumatic tubes, on protein stability in iv bags and syringes. (Poster) EAHP Congress 2025

2SPD-009-PTS-poster