Scopolamine Transdermal Patch: Indications, Application, and Safety
Indications
The scopolamine transdermal patch is FDA-approved for prevention of motion sickness and postoperative nausea and vomiting (PONV) in adults. 1
Primary Approved Uses:
- Motion sickness prevention in adults requiring antiemetic effect for journeys lasting 6-12 hours or longer 1, 2
- PONV prevention associated with recovery from anesthesia and/or opiate analgesia and surgery 1, 3
Off-Label Uses in Palliative Care:
- Breakthrough chemotherapy-induced nausea/vomiting when other antiemetics fail, dosed as 1.5 mg transdermal patch changed every 72 hours 4
- Excessive secretion management in palliative care patients with life expectancy of weeks to days (but NOT hours/imminently dying) 5
- Acute vertigo suppression during Ménière's disease attacks, though limited course only due to significant side effect profile 4
Application Instructions
Dosing and Placement:
- Each patch delivers 1 mg of scopolamine over 3 days (despite containing 1.5 mg total, with 140 mcg priming dose) 1
- Apply to hairless area behind one ear at least 4-8 hours before antiemetic effect is required 1, 2
- For faster protection: Apply patch 1 hour before journey combined with oral scopolamine 0.3-0.6 mg 2
Specific Timing by Indication:
- Motion sickness: Apply at least 4 hours before departure; protective plasma concentration (50 pg/mL) achieved after 6 hours, steady state (100 pg/mL) at 8-12 hours 1, 2
- PONV (non-cesarean surgery): Apply the evening before surgery, remove 24 hours post-surgery 1
- Palliative secretion management: When applying patch, simultaneously administer subcutaneous scopolamine 0.4 mg every 4 hours PRN to provide immediate effect during the 12-hour onset period 5
Application Technique:
- Wear only ONE patch at a time; do not cut the patch 1
- Wash hands thoroughly with soap and water immediately after application to prevent finger-to-eye contamination causing mydriasis and cycloplegia 1, 2
- Avoid touching or applying pressure to the patch once applied 1
- After 72 hours, remove first patch and apply new patch behind the opposite ear if continued therapy needed 1
Removal and Disposal:
- Fold used patch in half with sticky sides together and discard to prevent accidental contact or ingestion 1
- Wash hands and application site with soap and water after removal 1
- Monitor for withdrawal symptoms 24 hours or more after removal, including anticholinergic rebound effects 1
Contraindications
Absolute Contraindications:
- Angle-closure glaucoma (narrow-angle glaucoma) 1
- Hypersensitivity to scopolamine, other belladonna alkaloids, or any component of the formulation 1
Precautions and Warnings
Critical Timing Limitation:
Do NOT use transdermal patches in imminently dying patients expecting rapid secretion control—the 12-hour onset makes them inappropriate; use subcutaneous scopolamine 0.4 mg every 4 hours instead for immediate effect 5
Neuropsychiatric Effects (Most Important):
- Scopolamine readily crosses the blood-brain barrier, causing sedation, drowsiness, disorientation, confusion, and potential delirium, particularly pronounced in elderly patients 5, 1
- Monitor for new or worsening psychiatric symptoms during treatment, especially when combining with other drugs having similar psychiatric effects 1
- May cause toxic psychosis mainly in elderly and pediatric patients 2
- Impairs memory storage for new information and attention, with lowered alertness 6, 7
- May cause seizures and impair mental/physical abilities 1
Ophthalmologic Precautions:
- Monitor patients with open-angle glaucoma for increased intraocular pressure; adjust glaucoma therapy as needed 1
- Discontinue immediately if signs/symptoms of acute angle-closure glaucoma develop 1
- Avoid eye contact—finger-to-eye contamination causes blurred vision, mydriasis, and impaired accommodation lasting up to several days 1, 2
- Visual disturbances occur in significantly higher rates (RR=3.35,95% CI 1.78-6.32) at 24-48 hours compared to placebo 3
- Hypermetropic ("long-sighted") individuals are at particular risk for visual problems, which increase with repeated applications 6
Gastrointestinal and Urinary Disorders:
- Consider more frequent monitoring in patients with suspected intestinal obstruction, pyloric obstruction, or impeded urine flow 1
- Discontinue if patient develops difficulty urinating 1
- Use caution when combining with other anticholinergic drugs 1
Pregnancy-Related Precautions:
- Avoid use in patients with severe preeclampsia due to risk of eclamptic seizures 1
- Scopolamine readily crosses the placenta; administer to pregnant women only under observation 7
- Compatible with nursing and considered nonteratogenic 7
Alternative Agent Considerations:
For elderly patients, post-CVA patients, or those requiring frequent neurological assessments, glycopyrrolate (0.2-0.4 mg IV/SC every 4 hours PRN) is preferable because it does not effectively cross the blood-brain barrier and causes minimal CNS side effects compared to scopolamine 5, 8
Common Adverse Effects
Motion Sickness (>15% incidence):
PONV (≥3% incidence):
- Dry mouth, dizziness, somnolence, agitation, visual impairment, confusion, mydriasis, pharyngitis 1
Other Notable Effects:
- Allergic contact dermatitis in 10% of patients 2
- Bradycardia 6
- Headache, rashes, erythema (occasional) 2
- Produces about half the drowsiness of oral dimenhydrinate or cinnarizine 2
Key Clinical Pitfalls to Avoid
Do NOT apply patches expecting immediate effect—requires 6-8 hours minimum, with optimal efficacy at 8-12 hours post-application 5, 1, 2
Do NOT confuse scopolamine-induced altered mental status with other causes such as increased intracranial pressure after head injury 5
Do NOT forget to wash hands immediately after application—finger-to-eye contamination causes prolonged mydriasis and cycloplegia 1, 2
Do NOT use in imminently dying patients—12-hour onset makes it inappropriate for urgent secretion control 5
Monitor elderly patients closely for delirium risk, particularly when combining with other anticholinergic medications 5, 1
Be aware that 20-30% of subjects fail to attain protective plasma concentrations, which may explain treatment failures 2