Avoiding anticholinergic burden in neuropsychiatric treatments comorbid with alcohol use disorder

ABSTRACT Alcohol use disorder (AUD) frequently co-occurs with neuropsychiatric conditions such as insomnia, anxiety, depression, and psychosis. The management of these comorbidities requires careful pharmacological consideration, particularly the avoidance of drugs that either interact adversely with alcohol or possess a high potential for misuse. After these considerations, many of the medications left available for AUD—such as tricyclic antidepressants and certain first-generation antipsychotics—are associated with anticholinergic burden (ACB), a cumulative side effect linked to an elevated risk of dementia. Given that AUD is itself an independent risk factor for cognitive decline and dementia, the use of ACB-contributing medications in this population may further potentiate neurocognitive deterioration through the compounding of risk factors. While ACB-sparing pharmacotherapeutic approaches have been developed for cognitively vulnerable populations such as the elderly and patients with dementia, similar clinical decision-making tools are not available for AUD care. This review highlights the evidence on the cognitive effects of AUD and ACB independently, to justify that this combination of risk factors should be avoided. Furthermore, it delineates pharmacological agents that should be either avoided or preferentially considered, forming the basis for an ACB-sparing approach in the treatment of four common neuropsychiatric comorbidities in AUD: insomnia, anxiety, depression, and psychosis.