Drugs with high and low central anticholinergic activity
| Drug class | High central anticholinergic burden | Alternatives with low/no central anticholinergic burden |
| Antidepressants* | Tricyclic antidepressants | SSRIs (except paroxetine) Mirtazapine Venlafaxine Agomelatine Moclobemide Duloxetine Vortioxetine Tranylcypromine |
| Antihistamines | Chlorphenamine Promethazine Hydroxyzine Cyproheptadine Cyclizine (and other first generation antihistamines) | Cetirizine Loratadine Fexofenadine (and other second generation antihistamines) |
| Antipsychotics* | Clozapine Olanzapine Quetiapine Zotepine Chlorpromazine | Aripiprazole Amisulpride Risperidone Lurasidone Cariprazine |
| Antispasmodics | Atropine sulfate Dicycloverine | Alverine Mebeverine Peppermint oil Hyoscine butylbromide (Buscopan) Propantheline bromide |
| Hypersalivation | Hyoscine hydrobromide (Kwells)‡ | Pirenzepine† Atropine eye drops‡ (sublingually) |
| Drugs for Parkinson’s disease* | Trihexyphenidyl (benzhexol) Benzatropine† Amantadine Orphenadrine | Co-beneldopa Co-careldopa Entacapone Rasagiline Ropinirole Selegiline Tolcapone |
| Drugs for urinary symptoms | Oxybutynin Tolterodine | Darifenacin Trospium Solifenacin Fesoterodine |
*With regard to antidepressants, antipsychotic drugs and drugs used for Parkinson’s disease, it is not always possible to switch to an alternative agent with lower central anticholinergic activity. If a patient has been stable on a psychotropic drug for many years and is tolerating it well, it may not be appropriate to switch to an alternative drug simply based on its anticholinergic activity. Many other factors should inform this decision including a discussion with the patient and carers.
†Unlicensed.
‡Off-label.
SSRI, selective serotonin re-uptake inhibitors;