Evidence-Based Reviews

Do no harm: Benztropine revisited

Current Psychiatry. 2022 April;21(4):20-27 | doi: 10.12788/cp.0229

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First do no harm

Psychiatrists commonly prescribe benztropine to prevent EPS and TD, but available literature does not support the efficacy of benztropine for mitigating drug-induced parkinsonism, and studies report benztropine may significantly worsen cognitive processes and exacerbate TD.¹⁶ In addition, benztropine misuse has been correlated with euphoria and psychosis.¹⁶More than 3 decades ago, the World Health Organization Heads of Centres Collaborating in WHO-Coordinated Studies on Biological Aspects of Mental Illness issued a consensus statement²⁴ discouraging the prophylactic use of anticholinergics for patients receiving antipsychotics, yet we still see patients on an indefinite regimen of benztropine.

As clinicians, our goals should be to optimize a patient’s functioning and quality of life, and to use the lowest dose of medication along with the fewest medications necessary to avoid adverse effects such as EPS. Benztropine is recommended as a first-line agent for the management of acute dystonia, but its continued or indefinite use to prevent antipsychotic-induced adverse effects is not recommended. While all pharmacologic interventions carry a risk of adverse effects, weighing the risk of those effects against the clinical benefits is the prerogative of a skilled clinician. Benztropine and other anticholinergics prescribed for prophylactic purposes have numerous adverse effects, limited clinical utility, and a deleterious effect on quality of life. Furthermore, benztropine prophylaxis of drug-induced parkinsonism does not seem to be warranted, and the risks do not seem to outweigh the harm benztropine may cause, with the possible exception of “prophylactic” treatment of dystonia that is discontinued in a few days, as some researchers have suggested.^6-8 The preventive value of benztropine has not been demonstrated. It is time we took inventory of medications that might cause more harm than good, rely on current treatment guidelines instead of habit, and use these agents judiciously while considering replacement with novel, safer medications whenever possible.

CASE CONTINUED

The clinical team considers benztropine’s ability to cause cognitive effects, and decides to taper and discontinue it over 1 month. Ms. P is seen in an outpatient clinic within 1 month of discontinuing benztropine. She reports that her difficulty remembering words and details has improved. She also says that she is now able to concentrate on writing and reading. The consulting neurologist also notes improvement. Ms. P continues to report improvement in symptoms over the next 2 months of follow-up, and says that her mood improved and she has less apathy.

Bottom Line

Benztropine is a first-line medication for acute dystonia, but its continued or indefinite use for preventing antipsychotic-induced adverse effects is not recommended. Given the multitude of adverse effects and cognitive impairment noted with anticholinergics, tapering should be considered for patients receiving an anticholinergic medication such as benztropine.