Management of dystonia in patients with hypersensitivity to anticholinergics

Abstract Background: Anticholinergics are one of the first-line treatment for patients with dystonia. However, there are few practical guidelines for patients with dystonia who have developed hypersensitivity to anticholinergics. Methods and Findings: This update was developed to provide clinicians with specific alternatives if patients are hypersensitive to anticholinergics but require management of dystonia. Recommendations were based upon literature review and expert opinion. We addressed several topics, including 1) the prevalence of hypersensitivity to anticholinergics, 2) anticholinergics and age-associated changes, 3) the Anticholinergic Cognitive Behavioral Scale, 4) the Anticholinergic Drug Scale,5) over the counter supplement use with anticholinergics, hypersensitivity to antihistamines, and management of dystonia. However, currently there is limited evidence supporting pharmacotherapy and non-pharmacologic treatments in patients with hypersensitivity to anticholinergics. Conclusions: We provide the guidance on patients with dystonia who are hypersensitive to anticholinergics, based on the literature and our clinical experience. We propose personalized dystonia treatment approaches when anticholinergic hypersensitivity arises. Gaps in the existing literature and future directions in the treatment of anticholinergic hypersensitive patients being treated for dystonia are also highlighted.