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