Is there an alternative to scopolamine (hyoscine) patches that can reduce secretions without causing significant sedation?

Glycopyrrolate Is the Preferred Alternative to Scopolamine for Reducing Secretions with Less Sedation

Glycopyrrolate is the preferred alternative to scopolamine patches for reducing secretions as it does not cross the blood-brain barrier and is therefore less likely to cause sedation or delirium. 1

Comparison of Anticholinergic Options

Glycopyrrolate

• Does not effectively cross the blood-brain barrier, making it less likely to cause sedation, drowsiness, or delirium compared to scopolamine 1
• Effective for reducing excessive secretions associated with dyspnea 1
• Can be administered intravenously or subcutaneously at a dose of 0.2-0.4 mg every 4 hours as needed 1
• May produce peripheral anticholinergic side effects (dry mouth, urinary retention) but with minimal central nervous system effects 1
• Shown to be effective in reducing secretions in clinical studies, with one randomized controlled trial demonstrating significant reduction in death rattle compared to scopolamine 2

Scopolamine

• Crosses the blood-brain barrier readily, causing significant central nervous system effects 1, 3
• Common adverse effects include drowsiness (in up to 20% of patients), disorientation, confusion, and potential delirium 4
• Can cause cognitive impairment, particularly in elderly patients who may be more sensitive to neurological effects 4
• Available in transdermal patch form (releases 0.5 mg over 3 days) but has a delayed onset of action (approximately 12 hours) 1, 3
• Can also be administered subcutaneously for more immediate effect 1

Other Options

• Atropine can be used as an alternative, administered as 1% ophthalmic solution, 1-2 drops sublingually every 4 hours as needed 1
• Hyoscyamine is another anticholinergic option but also crosses the blood-brain barrier and may cause sedation 1

Clinical Decision-Making Algorithm

1. First-line option: Glycopyrrolate 0.2-0.4 mg IV or subcutaneously every 4 hours as needed 1

   • Best for patients where sedation is a concern
   • Particularly beneficial for elderly patients who are more sensitive to CNS effects 4

2. Alternative options (if glycopyrrolate is unavailable or ineffective):

   • Atropine 1% ophthalmic solution, 1-2 drops sublingually every 4 hours as needed 1
   • Scopolamine subcutaneous injection (if immediate effect is needed) 1
   • Scopolamine transdermal patch (if longer-acting effect is desired, but be aware of 12-hour onset delay) 1, 5

Important Clinical Considerations

• When managing secretions in palliative care, the goal is to reduce distressing symptoms while minimizing adverse effects that could impact quality of life 1
• Anticholinergic medications should be used when secretions are causing distress, such as noisy breathing or dyspnea 1
• In a randomized controlled study comparing glycopyrrolate and scopolamine for death rattle, glycopyrrolate demonstrated significantly better reduction of secretions 2
• For patients requiring procedural sedation, glycopyrrolate has been shown to improve ease of procedures and reduce secretion-induced hypoxemia and cough 6

Common Pitfalls and Caveats

• Scopolamine patches have a delayed onset of approximately 12 hours, making them inappropriate for immediate management of secretions 1, 5
• All anticholinergics can cause peripheral side effects such as dry mouth, urinary retention, and decreased gastrointestinal motility 4
• Anticholinergics should be used with caution in patients with glaucoma, urinary retention, or intestinal obstruction 4
• Elderly patients are more sensitive to the neurological and psychiatric effects of anticholinergics, particularly those that cross the blood-brain barrier like scopolamine 4
• Monitoring for adverse effects is essential, especially when using medications with CNS effects 4

By selecting glycopyrrolate over scopolamine, clinicians can effectively manage excessive secretions while minimizing the risk of sedation and other central nervous system adverse effects that can significantly impact patient quality of life.