What are the contraindications and precautions for using Buscopan (hyoscine butylbromide)?

Contraindications and Precautions for Buscopan (Hyoscine Butylbromide)

Buscopan should not be used in patients with ileus, tachycardia, angina, cardiac failure, or prostatic hypertrophy with urinary retention, while the traditional teaching to withhold it in patients with a history of glaucoma is outdated and should be abandoned. 1, 2

Absolute Contraindications

Gastrointestinal Conditions

• Ileus or impaction colics: Buscopan is contraindicated when intestinal obstruction is present 1

Cardiovascular Conditions

• Tachycardia: Contraindicated due to anticholinergic effects that elevate heart rate 2
• Angina pectoris: Contraindicated as per product monograph 2
• Cardiac failure: Absolute contraindication requiring avoidance 2
• Important caveat: Administration of Buscopan results in heart rate elevation, making heart rate an invalid indicator of pain severity for 30 minutes post-injection 1

Urological Conditions

• Prostatic hypertrophy with urinary retention: Contraindicated due to anticholinergic effects that can worsen urinary retention 2

The Glaucoma Misconception

The widespread practice of withholding Buscopan based on any history of glaucoma is incorrect and should be discontinued. 2, 3, 4

Why Traditional Teaching Is Wrong

• Only patients with undiagnosed and untreated angle-closure glaucoma are at risk 3
• Patients who give a positive history of glaucoma are already diagnosed and treated (typically with definitive laser treatment), and therefore are not at risk 2, 4
• Open-angle glaucoma (the most common form) is not affected by hyoscine 4
• Despite 81.6% of UK radiologists withholding Buscopan for glaucoma history, only 0.8% have ever seen an attack of glaucoma attributed to the drug 3

Correct Approach to Glaucoma

• Do not routinely ask about glaucoma history before administering Buscopan 3, 5
• Instead, counsel patients post-procedurally to seek urgent medical attention if they develop eye pain, redness, decreased vision, nausea, vomiting, or headache 2
• Minor visual accommodation impairment may occur in patients ≤50 years old within 12-21 minutes of administration, but this does not impair driving ability 5

Precautions and Monitoring

Pregnancy and Lactation

• Not recommended in pregnant or lactating patients, as safety has not been established 1

Drug Interactions

• Effects may be potentiated by concomitant anticholinergic drugs 1
• Drug compatibility should be monitored closely in patients requiring adjunctive therapy 1

Route of Administration

• Safety has not been established for intramuscular (IM) administration 1
• For gastrointestinal spasms, intramuscular preparations may be more effective than oral forms due to poor oral absorption (<1% bioavailability) 6, 7

Cardiac Monitoring

• Patients with cardiac comorbidities require careful cardiac monitoring in an environment with resuscitation equipment and trained staff 2
• Use only when potential benefits outweigh risks in patients with tachycardia, angina, or cardiac failure 2
• Cardiac complications appear more clinically significant than ophthalmic ones (1.9% vs 0.8% reported complications) 3

Clinical Context

When to Use Buscopan

• Abdominal pain associated with gastrointestinal cramping and spasms 6
• Intestinal dysmotility 6
• Irritable bowel syndrome with abdominal cramping 6
• Suggested use before or during ERCP 2
• Severe or refractory abdominal pain (intramuscular route) 8

When NOT to Use Buscopan

• Recommended against before or during colonoscopy (strong recommendation) 2
• Suggested against before or during gastroscopy 2

Common Pitfall to Avoid

The most common error is withholding Buscopan from patients who report a history of glaucoma. This practice is based on outdated teaching and misunderstands the actual risk profile. The patient who gives a positive glaucoma history is already treated and not at risk; the theoretical patient at risk has undiagnosed angle-closure glaucoma and will not give a positive history. 2, 3, 4