{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,4,8]],"date-time":"2026-04-08T12:40:13Z","timestamp":1775652013605,"version":"3.50.1"},"reference-count":49,"publisher":"MDPI AG","issue":"1","license":[{"start":{"date-parts":[[2023,1,10]],"date-time":"2023-01-10T00:00:00Z","timestamp":1673308800000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"funder":[{"name":"FCT\u2014Funda\u00e7\u00e3o para a Ci\u00eancia e a Tecnologia","award":["SFRH\/BD\/123678\/2016"],"award-info":[{"award-number":["SFRH\/BD\/123678\/2016"]}]}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["Pharmaceutics"],"abstract":"<jats:p>Anticholinergic burden tools have relevant pharmacological gaps that may explain their limited predictive ability for clinical outcomes. The aim of this study was to provide a universal pharmacological-based list of drugs with their documented affinity for muscarinic receptors. A comprehensive literature review was performed to identify the anticholinergic burden tools. Drugs included in these instruments were searched in four pharmacological databases, and the investigation was supplemented with PubMed. The evidence regarding the potential antagonism of the five muscarinic receptors of each drug was assessed. The proportion of drugs included in the tools with an affinity for muscarinic receptors was evaluated. A universal list of drugs with anticholinergic activity was developed based on their documented affinity for the different subtypes of muscarinic receptors and their ability to cross the blood-brain barrier. A total of 23 tools were identified, including 304 different drugs. Only 48.68%, 47.70%, 48.03%, 43.75%, and 42.76% of the drugs had an affinity to the M1, M2, M3, M4, and M5 receptor, respectively, reported in any pharmacological database. The proportion of drugs with confirmed antagonism varied among the tools (36.8% to 100%). A universal pharmacological-based list of 133 drugs is presented. It should be further validated in different clinical settings.<\/jats:p>","DOI":"10.3390\/pharmaceutics15010230","type":"journal-article","created":{"date-parts":[[2023,1,10]],"date-time":"2023-01-10T01:30:47Z","timestamp":1673314247000},"page":"230","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":10,"title":["A Universal Pharmacological-Based List of Drugs with Anticholinergic Activity"],"prefix":"10.3390","volume":"15","author":[{"given":"Marta","family":"Lavrador","sequence":"first","affiliation":[{"name":"Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal"},{"name":"Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal"}]},{"given":"Ana C.","family":"Cabral","sequence":"additional","affiliation":[{"name":"Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal"},{"name":"Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-2793-2129","authenticated-orcid":false,"given":"Manuel T.","family":"Ver\u00edssimo","sequence":"additional","affiliation":[{"name":"Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal"},{"name":"Faculty of Medicine, University of Coimbra, 3000-548 Coimbra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-8529-9595","authenticated-orcid":false,"given":"Fernando","family":"Fernandez-Llimos","sequence":"additional","affiliation":[{"name":"Laboratory of Pharmacology, Department of Drug Sciences, Faculty of Pharmacy, University of Porto, 4050-313 Porto, Portugal"},{"name":"Center for Health Technology and Services Research (CINTESIS), University of Porto, 4200-450 Porto, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-0127-4575","authenticated-orcid":false,"given":"Isabel V.","family":"Figueiredo","sequence":"additional","affiliation":[{"name":"Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal"},{"name":"Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6533-9932","authenticated-orcid":false,"given":"M. Margarida","family":"Castel-Branco","sequence":"additional","affiliation":[{"name":"Pharmacology and Pharmaceutical Care Laboratory, Faculty of Pharmacy, University of Coimbra, 3000-548 Coimbra, Portugal"},{"name":"Coimbra Institute for Clinical and Biomedical Research (iCBR), 3000-548 Coimbra, Portugal"}]}],"member":"1968","published-online":{"date-parts":[[2023,1,10]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"55","DOI":"10.1016\/j.archger.2016.09.003","article-title":"Inappropriate prescribing in older persons: A systematic review of medications available in different criteria","volume":"68","author":"Lucchetti","year":"2017","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"679","DOI":"10.1007\/s00228-018-2446-0","article-title":"Potentially inappropriate medication in the elderly: A systematic review of validated explicit criteria","volume":"74","author":"Motter","year":"2018","journal-title":"Eur. J. Clin. Pharmacol."},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"104283","DOI":"10.1016\/j.archger.2020.104283","article-title":"Drug interactions for elderly people with mental and behavioral disorders: A systematic scoping review","volume":"93","author":"Forgerini","year":"2021","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_4","doi-asserted-by":"crossref","first-page":"753","DOI":"10.1517\/14740338.2016.1165664","article-title":"Anticholinergics: Theoretical and clinical overview","volume":"15","author":"Nishtala","year":"2016","journal-title":"Expert Opin. Drug Saf."},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"1477","DOI":"10.1111\/j.1532-5415.2011.03491.x","article-title":"Anticholinergic medication use and cognitive impairment in the older population: The medical research council cognitive function and ageing study","volume":"59","author":"Fox","year":"2011","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"25","DOI":"10.1007\/s40520-015-0359-7","article-title":"Anticholinergic drugs and negative outcomes in the older population: From biological plausibility to clinical evidence","volume":"28","author":"Collamati","year":"2016","journal-title":"Aging Clin. Exp. Res."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"1485","DOI":"10.1007\/s00228-013-1499-3","article-title":"Systematic review of anticholinergic risk scales in older adults","volume":"69","author":"Duran","year":"2013","journal-title":"Eur. J. Clin. Pharmacol."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"1299","DOI":"10.1007\/s00228-015-1932-x","article-title":"Different methods, different results\u2014How do available methods link a patient\u2019s anticholinergic load with adverse outcomes?","volume":"71","author":"Mayer","year":"2015","journal-title":"Eur. J. Clin. Pharmacol."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"209","DOI":"10.1111\/bcp.12617","article-title":"Drugs with anticholinergic effects and cognitive impairment, falls and all-cause mortality in older adults: A systematic review and meta-analysis","volume":"80","author":"Ruxton","year":"2015","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"835","DOI":"10.1007\/s40266-015-0310-9","article-title":"The Association between Anticholinergic Medication Burden and Health Related Outcomes in the \u2018Oldest Old\u2019: A Systematic Review of the Literature","volume":"32","author":"Cardwell","year":"2015","journal-title":"Drugs Aging"},{"key":"ref_11","doi-asserted-by":"crossref","unstructured":"Salahudeen, M.S., Duffull, S.B., and Nishtala, P.S. (2015). Anticholinergic burden quantified by anticholinergic risk scales and adverse outcomes in older people: A systematic review. BMC Geriatr., 15.","DOI":"10.1186\/s12877-015-0029-9"},{"key":"ref_12","doi-asserted-by":"crossref","unstructured":"Salahudeen, M.S., Chyou, T.Y., and Nishtala, P.S. (2016). Serum Anticholinergic Activity and Cognitive and Functional Adverse Outcomes in Older People: A Systematic Review and Meta-Analysis of the Literature. PLoS ONE, 11.","DOI":"10.1371\/journal.pone.0151084"},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"1","DOI":"10.1016\/j.archger.2015.10.002","article-title":"Systematic review on the use of anticholinergic scales in poly pathological patients","volume":"62","year":"2016","journal-title":"Arch. Gerontol. Geriatr."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1007\/s40266-018-0549-z","article-title":"Anticholinergic Drug Burden Tools\/Scales and Adverse Outcomes in Different Clinical Settings: A Systematic Review of Reviews","volume":"35","author":"Welsh","year":"2018","journal-title":"Drugs Aging"},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"147","DOI":"10.1007\/s00228-020-02994-x","article-title":"Quality of anticholinergic burden scales and their impact on clinical outcomes: A systematic review","volume":"77","author":"Lisibach","year":"2021","journal-title":"Eur. J. Clin. Pharmacol."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"635","DOI":"10.2174\/138920011796504518","article-title":"Paying attention to pharmacokinetic and pharmacodynamic mechanisms to progress in the area of anticholinergic use in geriatric patients","volume":"12","year":"2011","journal-title":"Curr. Drug Metab."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"441","DOI":"10.1586\/ecp.10.34","article-title":"Association between prescribing of antimuscarinic drugs and antimuscarinic adverse effects in older people","volume":"3","author":"Bostock","year":"2010","journal-title":"Expert Rev. Clin. Pharmacol."},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"105306","DOI":"10.1016\/j.phrs.2020.105306","article-title":"Association between anticholinergic burden and anticholinergic adverse outcomes in the elderly: Pharmacological basis of their predictive value for adverse outcomes","volume":"163","author":"Lavrador","year":"2021","journal-title":"Pharmacol. Res."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"781","DOI":"10.1001\/archinte.167.8.781","article-title":"A drug burden index to define the functional burden of medications in older people","volume":"167","author":"Hilmer","year":"2007","journal-title":"Arch. Intern. Med."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"1227","DOI":"10.1111\/jgs.12343","article-title":"A standard international version of the Drug Burden Index for cross-national comparison of the functional burden of medications in older people","volume":"61","author":"Faure","year":"2013","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"530","DOI":"10.1159\/000441718","article-title":"The Influence of Patient Characteristics on Anticholinergic Events in Older People","volume":"5","author":"Salahudeen","year":"2015","journal-title":"Dement. Geriatr. Cogn. Disord. Extra"},{"key":"ref_22","doi-asserted-by":"crossref","first-page":"D1074","DOI":"10.1093\/nar\/gkx1037","article-title":"DrugBank 5.0: A major update to the DrugBank database for 2018","volume":"46","author":"Wishart","year":"2018","journal-title":"Nucleic Acids Res."},{"key":"ref_23","first-page":"D1006","article-title":"The IUPHAR\/BPS Guide to PHARMACOLOGY in 2020: Extending immunopharmacology content and introducing the IUPHAR\/MMV Guide to MALARIA PHARMACOLOGY","volume":"48","author":"Armstrong","year":"2020","journal-title":"Nucleic Acids Res."},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"650","DOI":"10.1002\/gps.4507","article-title":"Anticholinergic effect on cognition (AEC) of drugs commonly used in older people","volume":"32","author":"Bishara","year":"2017","journal-title":"Int. J. Geriatr. Psychiatry"},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1481","DOI":"10.1177\/0091270006292126","article-title":"The Anticholinergic Drug Scale as a measure of drug-related anticholinergic burden: Associations with serum anticholinergic activity","volume":"46","author":"Carnahan","year":"2006","journal-title":"J. Clin. Pharmacol."},{"key":"ref_26","doi-asserted-by":"crossref","first-page":"508","DOI":"10.1001\/archinternmed.2007.106","article-title":"The anticholinergic risk scale and anticholinergic adverse effects in older persons","volume":"168","author":"Rudolph","year":"2008","journal-title":"Arch. Intern. Med."},{"key":"ref_27","doi-asserted-by":"crossref","unstructured":"Boustani, M.C.N., Munger, S., Maidment, I., and Fox, C. (2008). Impact of anticholinergics on the aging brain: A review and practical application. Ageing Health, 4.","DOI":"10.2217\/1745509X.4.3.311"},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"160","DOI":"10.1136\/jnnp.2009.186239","article-title":"Use of drugs with anticholinergic effect and impact on cognition in Parkinson\u2019s disease: A cohort study","volume":"81","author":"Ehrt","year":"2010","journal-title":"J. Neurol. Neurosurg. Psychiatry"},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"455","DOI":"10.1136\/bmj.38740.439664.DE","article-title":"Non-degenerative mild cognitive impairment in elderly people and use of anticholinergic drugs: Longitudinal cohort study","volume":"332","author":"Ancelin","year":"2006","journal-title":"BMJ"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"173","DOI":"10.1159\/000325171","article-title":"Effects of anticholinergic drugs on cognitive function in older Australians: Results from the AIBL study","volume":"31","author":"Sittironnarit","year":"2011","journal-title":"Dement. Geriatr. Cogn. Disord."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"654","DOI":"10.1097\/JCP.0b013e31818ce849","article-title":"Drugs with anticholinergic properties as a risk factor for cognitive impairment in elderly people: A population-based study","volume":"28","author":"Cancelli","year":"2008","journal-title":"J. Clin. Psychopharmacol."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"1333","DOI":"10.1111\/j.1532-5415.2008.01737.x","article-title":"Anticholinergic activity of 107 medications commonly used by older adults","volume":"56","author":"Chew","year":"2008","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"116","DOI":"10.1176\/appi.ajp.161.1.116","article-title":"Association of anticholinergic load with impairment of complex attention and memory in schizophrenia","volume":"161","author":"Minzenberg","year":"2004","journal-title":"Am. J. Psychiatry"},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"2203","DOI":"10.1111\/j.1532-5415.2008.02009.x","article-title":"Cumulative anticholinergic exposure is associated with poor memory and executive function in older men","volume":"56","author":"Han","year":"2008","journal-title":"J. Am. Geriatr. Soc."},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"1511","DOI":"10.1016\/0024-3205(78)90006-1","article-title":"A clinical method of estimating risk of drug induced delirium","volume":"22","author":"Summers","year":"1978","journal-title":"Life Sci."},{"key":"ref_36","doi-asserted-by":"crossref","first-page":"582","DOI":"10.1111\/bcpt.12699","article-title":"A Novel Scale Linking Potency and Dosage to Estimate Anticholinergic Exposure in Older Adults: The Muscarinic Acetylcholinergic Receptor ANTagonist Exposure Scale","volume":"120","author":"Klamer","year":"2017","journal-title":"Basic Clin. Pharmacol. Toxicol."},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Kiesel, E.K., Hopf, Y.M., and Drey, M. (2018). An anticholinergic burden score for German prescribers: Score development. BMC Geriatr., 18.","DOI":"10.1186\/s12877-018-0929-6"},{"key":"ref_38","doi-asserted-by":"crossref","first-page":"628","DOI":"10.1111\/ggi.13680","article-title":"Development of an Anticholinergic Burden Scale specific for Korean older adults","volume":"19","author":"Jun","year":"2019","journal-title":"Geriatr. Gerontol. Int."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"427","DOI":"10.1016\/j.therap.2016.12.010","article-title":"The anticholinergic impregnation scale: Towards the elaboration of a scale adapted to prescriptions in French psychiatric settings","volume":"72","author":"Briet","year":"2017","journal-title":"Therapie"},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"eAO4435","DOI":"10.31744\/einstein_journal\/2019AO4435","article-title":"Development of a Brazilian anticholinergic activity drug scale","volume":"17","author":"Nery","year":"2019","journal-title":"Einstein"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"422","DOI":"10.1038\/sj.clpt.6100303","article-title":"Physical and cognitive performance and burden of anticholinergics, sedatives, and ACE inhibitors in older women","volume":"83","author":"Cao","year":"2008","journal-title":"Clin. Pharmacol. Ther."},{"key":"ref_42","first-page":"232","article-title":"Drug Delirium Scale (DDS): A tool to evaluate drugs as a risk factor for Delirium","volume":"1","author":"Nguyen","year":"2016","journal-title":"Int. J. Innov. Res. Med. Sci."},{"key":"ref_43","first-page":"003","article-title":"Rating the delirogenic potential of drugs for prediction of side effects in elderly psychiatric inpatients","volume":"1","author":"Hefner","year":"2015","journal-title":"J. Pharma. Pharmacovigil."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"361","DOI":"10.1177\/2042098617725267","article-title":"Assessing and predicting drug-induced anticholinergic risks: An integrated computational approach","volume":"8","author":"Xu","year":"2017","journal-title":"Ther. Adv. Drug Saf."},{"key":"ref_45","unstructured":"Lavrador, M. (2022). Quantifying Anticholinergic Burden as a Predictor of Negative Clinical Outcomes in Elderly\u2014A Contribution to Clinical Practice. [Ph.D. Dissertation, Faculty of Pharmacy, University of Coimbra]."},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"130","DOI":"10.1016\/j.pharmthera.2018.04.010","article-title":"Basic and clinical aspects of antimuscarinic agents used to treat overactive bladder","volume":"189","author":"Yamada","year":"2018","journal-title":"Pharmacol. Ther."},{"key":"ref_47","doi-asserted-by":"crossref","first-page":"235","DOI":"10.1111\/j.1365-2125.2011.03961.x","article-title":"A comprehensive non-clinical evaluation of the CNS penetration potential of antimuscarinic agents for the treatment of overactive bladder","volume":"72","author":"Callegari","year":"2011","journal-title":"Br. J. Clin. Pharmacol."},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"1182","DOI":"10.1016\/j.jagp.2016.07.024","article-title":"Limitations of the Anticholinergic Activity Assay and Assay-Based Anticholinergic Drug Scales","volume":"24","author":"Mayer","year":"2016","journal-title":"Am. J. Geriatr. Psychiatry Off. J. Am. Assoc. Geriatr. Psychiatry"},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"128","DOI":"10.1007\/s11096-020-01117-x","article-title":"Size of the associations between anticholinergic burden tool scores and adverse outcomes in older patients","volume":"43","author":"Lavrador","year":"2021","journal-title":"Int. J. Clin. Pharm."}],"container-title":["Pharmaceutics"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/1999-4923\/15\/1\/230\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2025,10,10]],"date-time":"2025-10-10T18:05:09Z","timestamp":1760119509000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/1999-4923\/15\/1\/230"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2023,1,10]]},"references-count":49,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2023,1]]}},"alternative-id":["pharmaceutics15010230"],"URL":"https:\/\/doi.org\/10.3390\/pharmaceutics15010230","relation":{},"ISSN":["1999-4923"],"issn-type":[{"value":"1999-4923","type":"electronic"}],"subject":[],"published":{"date-parts":[[2023,1,10]]}}}