What is a suitable patch for managing excess secretions, particularly in hyperhidrosis?

Glycopyrrolate Patch for Managing Excess Secretions

For patients with excess secretions, particularly in hyperhidrosis, a transdermal scopolamine patch is the recommended treatment option, though it takes approximately 12 hours to become effective and is therefore not appropriate for immediate symptom control. 1

Pharmacological Options for Controlling Excess Secretions

First-line Options:

• Scopolamine

  • Available as transdermal patch (1.5 mg patches, 1-6 patches q3d) 1
  • Takes approximately 12 hours to reach therapeutic effect 1
  • Can be administered subcutaneously (0.4 mg SC q4h PRN) for faster onset 1
  • Good for planned management of secretions

• Glycopyrrolate

  • Dosing: 0.2-0.4 mg IV or SQ q4h PRN 1, 2
  • Advantage: Does not cross blood-brain barrier effectively, reducing risk of delirium 1
  • Particularly useful for terminal secretions/death rattle 2
  • FDA-approved for management of excessive drooling (sialorrhea) 3

• Atropine

  • Can be administered as 1% ophthalmic solution, 1-2 drops SL q4h PRN 1
  • Alternative when other options unavailable

For Hyperhidrosis Specifically:

For hyperhidrosis, treatment options should be selected based on the affected area:

1. Topical treatments:

   • Aluminum chloride solutions (first-line for axillary hyperhidrosis) 4
   • Glycopyrronium tosylate cloth (2.4% solution) - FDA approved for axillary hyperhidrosis 5

2. Iontophoresis:

   • First-line for palmoplantar hyperhidrosis 4
   • Can be enhanced with anticholinergic substances 6

3. Systemic anticholinergics:

   • Including oral glycopyrrolate
   • Limited by side effect profile 4, 7

4. Botulinum toxin injections:

   • Effective for 3-9 months 4
   • Alternative when other treatments fail

Clinical Considerations

Patient Selection

• Assess the underlying cause of excess secretions:
  • Palliative care/end-of-life secretions
  • Hyperhidrosis (primary vs. secondary)
  • Sialorrhea associated with neurological conditions

Monitoring and Adverse Effects

• Common side effects:

  • Dry mouth
  • Constipation
  • Urinary retention
  • Blurred vision
  • Flushing 3

• Special precautions:

  • Avoid in patients with glaucoma
  • Use with caution in patients with prostatic hypertrophy
  • Monitor for signs of urinary retention 3

Important Caveats

• Transdermal scopolamine patches take approximately 12 hours to become effective - not appropriate for immediate symptom control 1
• For urgent control of secretions, subcutaneous administration of scopolamine or glycopyrrolate is preferred 1
• Glycopyrrolate is less likely to cause delirium compared to other anticholinergics due to limited blood-brain barrier penetration 1
• For hyperhidrosis, treatment should be tailored to the affected area (axillary, palmar, plantar, or craniofacial) 7

Treatment Algorithm

1. Identify the type and location of excess secretions

2. For end-of-life secretions:

   • Start with glycopyrrolate 0.2-0.4 mg IV/SQ q4h PRN 1
   • Alternative: scopolamine patch (1-6 patches q3d) with subcutaneous injection for immediate effect 1

3. For hyperhidrosis:

   • Axillary: Aluminum chloride or glycopyrronium tosylate cloth 4, 5
   • Palmar/plantar: Tap water iontophoresis 4
   • If unsuccessful, consider systemic anticholinergics or botulinum toxin 4

By following this approach, most patients with excess secretions can achieve significant symptom relief with appropriate medication selection.