The Weekly Mind Reader: Overprescribing Benztropine

A recent study published in The Primary Care Companion for CNS Disorders investigated the real-world usage patterns of the drug benztropine in patients with movement disorders. 

Problematic Prescribing Patterns

Benztropine is an anticholinergic medication sometimes prescribed short-term for drug-induced movement disorders like acute dystonia or drug-induced parkinsonism. However, evidence shows it can worsen symptoms of tardive dyskinesia, another persistent movement disorder caused by antipsychotic medications.

To examine concerns about overprescribing of the drug, researchers analyzed a large US medical claims database, identifying more than 100,000 patients who began benztropine treatment between 2017-2020. They also surveyed 350 healthcare providers across both primary care and psychiatry specialties about their benztropine prescribing habits.

The results were concerning. More than half of the patients received benztropine for longer than the recommended three months. Many were taking the drug for more than a year. According to study authors, such long-term use raises safety issues, particularly for older adults who are vulnerable to anticholinergic side effects.

Also at issue–providers often reported prescribing benztropine for questionable reasons like preventing or treating tardive dyskinesia, against guideline recommendations from groups like the American Academy of Neurology. Primary care physicians were more likely than psychiatrists to continue benztropine long-term and use it inappropriately. Few worked in settings with clear protocols for discontinuing it.

Long-term use of the anticholinergic medication benztropine has been associated with multiple concerning side effects, particularly in elderly patients. Besides a higher risk of tardive, overuse is associated with cognitive impairment, severe constipation, blurred vision, dry mouth, urinary retention, and heart rhythm disturbances. By blocking the action of the neurotransmitter acetylcholine throughout the body, benztropine can negatively impact many organ systems as well. 

The study’s most important takeaway? Benztropine is being overprescribed despite documented risks. This indicates that many healthcare providers lack awareness of its appropriate usage and current guidelines. The authors called for more education on best practices for managing movement disorders.

And, as the authors make clear, judicious prescribing of anticholinergic medications like benztropine is increasingly important to avoid medication side effects and polypharmacy in an older population. Streamlining benztropine use per evidence-based recommendations could improve outcomes for vulnerable patients.

In Other Psychiatry and Neurology News

• Adjunctive brexpiprazole had a limited impact on the metabolic profile of patients with major depressive disorder, including weight gain. This is true regardless of diabetes status, including prediabetes/non-diabetes.
• A meta-analysis of more than 20 studies found no benefit for omega-3 PUFAs on ADHD core symptoms. However, the authors didn’t rule out improvement with long term supplementation. 
• In this episode of 5 Minute Pearls, Christina Cusin, MD discusses ketamine: when to recommend it, where to get it, other medication considerations, and treatment duration.
• Medicare has begun its new price negotiations, starting with 10 of the priciest drugs on the market. But why are neurology and psychiatry drugs missing from the list?
• The case of a woman with a live, 3-inch parasite lodged in her brain may make you squirm. 
• If you haven’t already, follow us on YouTube for insightful commentary, like this video on lumateperone for the treatment of schizophrenia, featuring Leslie Citrome, MD. 

NEW AT CME INSTITUTE

Click to earn free accredited CME credit.

Cognitive Impairment in Huntington Disease

Comparing LAI and Oral Antipsychotic Options: Expert Discussions with Schizophrenia Case Reports