How to assess and reduce the anticholinergic burden
Polypharmacy guidance: Appropriate prescribing making medicines safe, effective and sustainable 2026-2029
A single medicine with anticholinergic properties may not put a person at risk of severe adverse effects, but when used in combination, effects may accumulate. Reducing the anticholinergic burden may result in improvements in short-term memory, confusion, behaviours and delirium.
A scale or table that assigns a cumulative anticholinergic score to a patient’s prescribed medication can be used to assess anticholinergic burden. A number of these scoring systems are available. While this approach is valid, the overall aim is to reduce total anticholinergic exposure as much as possible. The table below is intended to be a guide to which areas anticholinergic burden is likely to be the highest. This information has been drawn from the modified anticholinergic risk scale mARS, which updates the guidance in 2018.134 This is a developing area with disagreements between different sources. Some of this table is based on incomplete or poor evidence, or on expert opinion. The anticholinergic effects of medication may become better understood with time. Some of these therapeutic areas are highly specialised (for example Parkinson’s disease) and would require expert advice before considering a change. As noted here, less anticholinergic alternatives often have other concerns. If an anticholinergic agent must be used, consider reducing the dose. 123,125,126,127,130,145,146 or consider the cumulative effect of agents having anticholinergic effects.
Please note that the table below may need to be scrolled horizontally or vertically in order to view all information, depending on your device. Reducing anticholinergic burden87,134,130,147
| Medicine class or condition |
Avoid if possible Highly anticholinergic drugs mARs 3 and 2 |
Caution Drugs with some anticholinergic activity mARs 1 |
Alternatives and general notes |
| Antidepressants |
Tricyclic antidepressants |
SSRIs Trazodone Lofepramine Mirtazapine |
Venlafaxine and duloxetine have low anticholinergic activity |
| Antipsychotics |
Fluphenazine Chlorpromazine Clozapine Levomepromazine Olanzapine Thioridazine Perphenazine Promethazine Trifluorperazine Pericyazine |
Quetiapine Risperidone Haloperidol |
Aripiprazole and ziprasidone are the least anticholinergic Avoid phenothiazines |
| Nausea and vertigo |
Cyclizine |
- |
Metoclopramide has unknown activity (conflicting data). However, carries specific MHRA caution regarding parkinsonian and cognitive side effects Domperidone does not usually penetrate the CNS, but caution is required for QT prolongation Nausea treatments all cause potential problems. Keep courses as short as possible Cinnarizine has some anticholinergic activity |
| Urinary antispasmodics |
Oxybutynin Tolterodine Fesoterodine Flavoxate Darifenacin Solifenacin Propiverine Trospium |
- |
Mirabegron has no recorded anticholinergic activity and may be an option It is essential to ensure that medication is effective and stop if not effective Duloxetine is known to have low to nil systemic anticholinergic activity |
| Sedatives |
Clemastine Hydroxyzine Cyproheptadine Promethazine |
Diazepam Lorazepam Nitrazepam Temazepam |
Zolpidem and zopiclone no anticholinergic activity but have falls risk Medicines should be used in line with BZ and z-drug guidance Avoid sedative antihistamines Non-drug measures are preferred |
| Antihistamines |
Chlorphenamine Promethazine Hydroxyzine Clemastine Cyproheptadine Cetirizine Loratadine |
- |
If taken for seasonal conditions check this is happening. Desloratadine may be an alternative |
| H2-receptor antagonists | Cimetidine | Famotidine |
PPIs have no anticholinergic burden. Prescribe at the lowest dose to control symptoms. Caution with increased risk of Clostridioides difficile infection |
| Drugs used in Parkinson’s Disease and management of drug-induced extrapyramidal symptoms |
Procyclidine Trihexyphenidyl (benzhexol) Orphenadrine Benztropine Amantadine |
Bromocriptine Levodopa Carbidopa Selegiline Entacapone Pramipexole |
- |
| Spasticity |
Baclofen |
Diazepam Methocarbamol |
- |
| Analgesia |
Nefopam Tramadol Pethidine |
Morphine Oxycodone Fentanyl |
Gabapentin has minimal anticholinergic activity |
| Others |
Atropine Hyoscine Propantheline Dicycloverine Loperamide Pseudoephedrine Propiverine Carbamazepine |
Lithium Ipratropium Tiotropium Umeclidinium Glycopyrronium Aclidinium |
Furosemide and digoxin have unknown anticholinergic activity |
For an example of an NTI for ACB, see Data to drive change.