This is a multicentre randomised, doubleblind, placebocontrolled feasibility study of glycopyrronium bromide glycopyrrolate and hyoscine hydrobromide hyoscine in patients with clozapineinduced hypersalivation. Procedure and guidance for the use of clozapine contents 1. Aug 21, 2014 metoclopramide as treatment of clozapine induced hypersalivation the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. One or more of these suggestions reducing clozapineinduced hypersalivation gurprit lamba, md, and james m. Because the adverse effects and benefits of the drug vary widely among patients, the risks, benefits, and alternatives need to be weighed for each patient, and clozapine can be restarted if the.
Hyoscine is a competitive antagonist of acetylcholine at postganglionic. This report describes the successful use of a local treatment, sublingually delivered ophthalmic atropine drops, to reduce sialorrhea in a child receiving palliative care. Effect of scopolamine butylbromide on clozapineinduced hypersalivation in schizophrenic patients. The rct in adults with schizophrenia and clozapine induced hypersalivation liang et al. Medical conditions that could influence hypersalivation e.
These results indicate that at least some schizophrenic patients with clozapineinduced hypersalivation would benefit from scopolamine butylbromide treatment. Hypersalivation caused by clozapine can lead to sleep deprivation, salivary gland swelling, 1 and aspiration pneumonia. Effect of scopolamine butylbromide on clozapineinduced. Families with children with disabilities are often pressed for time 33 which may have contributed to some dropouts during the study.
Current treatment strategies for clozapineinduced sialorrhea. In circumstances where patients do not respond to hyoscine, the. Each patch is a flat system of laminates, sealed around the edge, containing a clear oily filling. Hyoscine patches in clozapineinduced hypersalivation letter. Hypersalivation sialorrhoea is the excessive production of saliva. Druginduced hypersalivation what treatment options are available. At night, raising the height of pillows and covering them with a towel may make the problem more tolerable. Pharmacological strategies for clozapine induced hypersalivation. The wide range of options and lack of evidence does not support clinicians in their attempts to continue treatment. Some australian states have allowed sharedcare prescribing arrangements with gps, but from 1 july 2015 gps became eligible to prescribe maintenance clozapine without needing to be affiliated with a hospital. Treatment of clozapineinduced hypersalivation with ipratropium bromide. Clozapineinduced hypersalivation is a stigmatizing and debilitating side effect of clozapine treatment that may threaten adherence to treatment taylor et al. Clozapineinduced hypersalivation is a condition potentially difficult to manage.
After sedation it is the second most common side effect of clozapine and can be a deeply stigmatising and unpleasant problem. The exact mechanism of clozapineinduced hypersalivation is unknown however it is paradoxical to its antimuscarinic action. Hyoscine, also known as scopolamine, is a medication used to treat motion sickness and postoperative nausea and vomiting. Dec 27, 2015 sublingual administration of atropine eyedrops to cease drooling in children with disabilities showed promising results. Antimuscarinic drugs for example, hyoscine, benzatropine. Hioscino wikipedias hyoscine as translated by gramtrans. Published 21st october 2015, updated 3rd august 2017 southampton medicines advice service, ukmi. The management of excess oral secretions is a challenge in adults and children who are living or dying with this problem.
If hypersalivation is particularly bothersome at night, patients may find it useful. Search methods we searched the cochrane schizophrenia group trials register march 2007, inspected references of all identified studies for further trials, contacted relevant pharmaceutical companies, drug approval agencies and authors of. Comparative efficacy and tolerability of benztropine and terazosin in the treatment of hypersalivation secondary to clozapine. The average amount of hyoscine absorbed from each system in 72 hours is 1mg. Metoclopramide as treatment of clozapineinduced hypersalivation. The exact mechanism of clozapineinduced hypersalivation is. During autumn 20, a shortage of hyoscine tablets in the uk due to production problems required patients. A natural study of the efficacy of replacement medications for the treatment of clozapineinduced hypersalivation simon chu 1,2, inti qurashi 2, niall campbell 3, paul stephenson 2, ruth m. A common complication of treatment with clozapine is the development of sialorrhea. Is clonidine useful for treatment of clozapineinduced. Hypersalivation is an inconvenient, potentially embarrassing aspect of clozapine treatment that can cause avoidable distress. It tends to appear early on in treatment and is often worse at night. Treatment of clozapineinduced hypersalivation ashtons. When used by injection, effects begin after about 20 minutes and last for up to 8 hours.
We would like to counter the suggestion to use benztropine or clonidine as a means to control clozapineinduced hypersalivation as suggested in reducing clozapineinduced hypersalivation pearls, current psychiatry, october 2011, p. Hyoscine hydrobromide patch when back in stock apply 1 patch every 72 hours all of the above are not licensed for hypersalivation but options 25 are licensed for other indications in the uk whereas option 1 is not licensed at all in the uk. Hypersalivation is a common and wellknown adverse effect of clozapine, and the use of. History of an allergic reaction to hyoscine hydrobromide 3. A natural study of the efficacy of replacement medications. This restricted any further increase in the dose of clozapine, despite the patients continued psychotic symptoms. Issn 2045 1253 it is advisable to refer to the publishers version if you intend to cite from the work. Clozapineinduced hypersalivation is the most prevalent adverse effect experienced by patients treated with clozapine and negatively impacts on quality of life, particularly if. Hypersalivation usually stops once the infection has been successfully treated. The dose usually recommended for hypersalivation is the same as for the prevention of travel sickness symptoms, i. Pharmacological interventions for clozapineinduced. Hypersalivation had at least a moderate impact on the quality of life of 15% of study participants. Excessive drooling, called sialorrhea, is a common symptom of parkinsons and can cause awkwardness in social situations. Patients have been treated for years, and the pharmacist would like to know if there is evidence for negative long term effects.
Clozapineinduced hypersalivation cih is a significant side effect, affecting about. Clozapineinduced hypersalivation cih is a significant side effect, affecting about onethird of patients taking this drug. The sublingual use of atropine in the treatment of clozapine. The combination of clozapine s antagonist activity at. Excess saliva hypersalivation or siallorrhoea is a distressing clozapine side effect which can occur in about 30% of patients. The dose of hyoscine hydrobromide is 1 patch applied to the skin behind the ear. Clonidine treatment of clozapine induced hypersalivation. Samir kumar praharaj, pankaj verma, dipayan roy, and anuradha singh. It should be noted hyoscine hydrobromide is not licensed for the treatment of hypersalivation either. Sublingual atropine drops for the treatment of pediatric. The method of measuring hypersalivation is described but not. Placing a towel over the pillow at night to absorb excess sali. Sublingual administration of atropine eyedrops in children.
Hyoscine hydrobromide oral tablet 300900 gday divided doses can be used for daytime hypersalivation the tablet must be sucked or chewed for optimal effect halflife is around 4 h worsens anticholinergic adverse effects of clozapine hyoscine patches 1. Hypersalivation is not always easy to differentiate from drooling due to parkinsonism induced by antipsychotics. It is also sometimes used before surgery to decrease saliva. Hyoscine can render a victim unconscious for 24 hours or more. In this report, we present a case of hypersalivation induced by olanzapine with fluvoxamine in a patient who suffered from delusional disorder. Refreshment management of clozapine induced sialorrhoea.
Hypersalivation induced by olanzapine with fluvoxamine. Sep 28, 2006 treatment of clozapine induced hypersalivation ipratropium bromide the safety and scientific validity of this study is the responsibility of the study sponsor and investigators. Hyoscine patches in clozapineinduced hypersalivation volume 25 issue 7 j. Fourteen inpatients diagnosed with treatmentresistant schizophrenia, treated with clozapine and suffering from hypersalivation were randomised to receive hyoscine. Hypersalivation can contribute to drooling if there is an inability to keep the mouth closed or difficulty in swallowing the excess saliva dysphagia, which can lead to excessive spitting.
Comparative efficacy and tolerability of benzatropine and terazosin in the treatment of hypersalivation secondary to clozapine. Clozapineinduced delirium the journal of neuropsychiatry. In large doses, it can cause respiratory failure and death. The exact mechanism of clozapineinduced hypersalivation is unknown 2,3,5. There is currently no convincing evidence for hyoscine, or any other medication, as an effective treatment for cih. Drooling is a common side effect in patients treated with typical antipsychotics.
The current study aims to examine the efficacyof hyoscine scopolamine for clozapineinduced hypersalivation. Objective methods such as the measurement of the diameter of the saliva on a patch on the pillow. Clozapineinduced hypersalivation is the most prevalent adverse effect experienced by patients treated with clozapine and negatively impacts on quality of life, particularly if daytime drooling is present. A history of clozapine induced severe neutropenia or agranulocytosis anc below 500microl is a relative contraindication for restarting clozapine. Current pharmacologic treatment options for clozapineinduced sialorrhea are limited in number and. A randomized, doubleblind, placebocontrolled crossover study. Possible long term effects of transdermal scopolamine to control clozapineinduced hypersalivation. Hyoscine patches in clozapine induced hypersalivation. Each system has a contact surface area measuring 2. Reducing clozapineinduced hypersalivation mdedge psychiatry.
Clozapineinduced hypersalivation occurs quite frequently. Clozapine induced sialorrhea cis is bothersome and has socially stigmatizing adverse effects, which result in poor treatment compliance. As stated in the article, clozapine is an antagonist for all known muscarinic receptors except m4where it is an agonistmaking it a potent. Clozapine induced hypersalivation is a condition potentially difficult to manage. Pharmacological interventions for clozapineinduced hypersalivation. Amisulpride, similar to sulpiride, is a substitute benzamide derivative with higher selective binding to the d 2 d 3 dopamine receptor. Glycopyrrolate in comparison to hyoscine hydrobromide and. The majority of these incidents occur in night clubs and bars, and usually men, perceived to be wealthy, are targeted by young, attractive women. Antimuscarinic medications and chewing gum can help prevent excess saliva from. How to remedy excessive salivation in patients taking clozapine.
It is most often administered in liquid or powder form in foods and beverages. There is a broad range of treatment alternatives but these appear equally unsupported in the literature. Potential use of ipratropium bromide for the treatment of clozapineinduced hypersalivation. This presents as drooling in children, young people and adults with a neurological condition, such as cerebral palsy or parkinsons disease. The beneficial effect of sulpiride augmentation of clozapine therapy for treatmentresistant schizophrenia patients is enhanced by its antisalivatory effect on clozapine induced hypersalivation cih.
Its severity varies from mild nocturnal hypersalivation that causes little problem for the patient to severe daytime drooling associated with significant distress. Increased salivation may be attributable to either clozapineinduced muscarinic m4 or adrenergic agonism 1,2,3,4. Hypersalivation can hyoscine hydrobromide be used to. Hypersalivation what are the treatment alternatives. Options in managing alternatives to hyoscine in clozapine. Because the agent can cause hypotension, start at 1 mgd for 1 week, then increase the dosage and monitor. Benztropine can cause dosedependent anticholinergic effects ranging from peripheral dry mouth. Pdf current treatment strategies for clozapineinduced sialorrhea. By michael dixon, lead pharmacist for medicines information.
Comms medicine bulletin hyoscine shortage 2017 final. Hyoscine hydrobromide causes, risk factors, symptoms. Validated scales such as the nocturnal hypersalivation rating scale nhrs and the drooling severity and frequency scale dsf 7 can be used. Alternative dose price hyoscine patches 1mg72 hours scopoderm patch dose of 1 patch every 3 days. Hypersalivation can also be an adverse effect of drug treatment for example, clozapine. Clozapine induced hypersalivation is a stigmatizing and debilitating side effect of clozapine treatment that may threaten adherence to treatment taylor et al. In circumstances where patients do not respond to hyoscine, the most popular choice was sublingual atropine.
Benztropine, an acetylcholine antagonist used in parkinsons disease, can be started at 1 mg at night, when hypersalivation is most troublesome. Cih can be stigmatizing, can affect quality of life, and can. Atropine, ipratropium bromide, and clonidine also have shown benefit in small studies. M is a 44yearold male with an 18year history of schizophrenia characterized by somatic delusion, delusion of persecution, and episodes of. Listing a study does not mean it has been evaluated by the u. Sublingual atropine solution 1% was commenced one drop up to 3 timesday. Clozapineinduced hypersalivation cih is a significant side effect affecting about onethird of patients treated with clozapine. It is not clear at what dosage clozapine causes sialorrhea, but the higher the dosage the more severe the problem. Clozapineinduced hypersalivation cih is a significant side effect affecting. Scolpolamine patch for clozapineinduced sialorrhea psychiatric. If hypersalivation is particularly bothersome at night, patients may find it useful to cover their pillows with an absorbent towel. Clozapine is usually first prescribed by a psychiatrist according to a treatment protocol. Pdf effect of scopolamine butylbromide on clozapineinduced. To determine the clinical effects of pharmacological interventions for clozapineinduced hypersalivation.
Apr 01, 2008 the hematological, metabolic changes, sedation, and lowering of seizure threshold of clozapine is well known, but the occurrence of clozapine induced delirium has been less reported. Treatment of clozapineinduced hypersalivation ipratropium. Scolpolamine patch for clozapineinduced sialorrhea. Ellison, md, mph antimuscarinic medications and chewing gum can help prevent excess saliva from disrupting a. It is not clear at what dosage clozapine causes sialorrhea, but the higher the. We conclude that clozapineinduced hypersalivation is one factor of stress to patients. The treatment of druginduced hypersalivation is the same as other forms of hypersalivation, with antimuscarinics. Hypersalivation also often precedes emesis vomiting, where it accompanies nausea a feeling of needing to vomit. The sublingual use of atropine in the treatment of. Hypersalivation can hyoscine hydrobromide be used to treat it. For example, this can happen when the head is down, the mouth is held open involuntarily as happens in advanced pd or when a person is engaged in an. Atropine 1% eye drops bottles unit dose vials udvs. The consequences of hypersalivation can be embarrassing and in some cases life threatening. Druginduced hypersalivation what treatment options are.
How to remedy excessive salivation in patients taking. Clozapineinduced sialorrhoea is reported by about 3080% of patients. Clozapine is an atypical antipsychotic agent with proven efficacy in refractory schizophrenia, but its widespread use is limited by adverse effects such as agranulocytosis, seizures, sedation, weight gain, and sialorrhea. Hyoscine hydrobromide is the most popular treatment for hypersalivation, but has a poor evidence base syed et al.
If treatment is to be continued for more than 3 days, remove the first patch and apply a new one behind the opposite ear. Is clonidine useful for treatment of clozapineinduced sialorrhea. Evidencebased information on treat hypersalivation on clozapine from hundreds of trustworthy sources for health and social care. Any of the following contraindications to hyoscine as stated in the british national formulary and electronic medicines compendium. It ranges from mild wetting of the pillow during sleep to embarrassing outpourings of saliva during unguarded moments. The patch gradually releases hyoscine over a 72 hour period. Regardless of the age or the underlying condition, the cause of sialorrhea is the inability to handle ones own saliva, rather than hypersalivation. Drooling significantly improved from baseline with both medicines but. Mckane, charlotte hall, gazala akram skip to main content accessibility help we use cookies to distinguish you from other users and to provide you with a better experience on our websites. Terazocin, an alpha 1 receptor antagonist for hypertension, is effective at 2 mg qhs. Amisulpride treatment of clozapineinduced hypersalivation i. If clozapine dose reduction in appropriate patients has not alleviated symptoms and an alternative antipsychotic is not an option, various pharmacological interventions have been used to manage hypersalivation see table 1 for treatment options.