Browse the corpus

©2013 UpToDate ® Print Email Anticholinergic therapy for drying secretions* at the end of life Agents Adult dose Glycopyrrolate (glycopyrronium) 0.2 mg SC every four to six hours [1] OR 0.2 mg SC once; followed after 30 minutes by SC or IV continuous infusion of 0.6 to 1.2 mg/day [1] OR 0.1 mg sublingually (SL) every six hours as needed (use commercially available or compounded oral liquid) [2] Scopolamine (hyoscine • ) base transdermal Apply one patch every 72 hours (1.5 mg patch releases ≈1 mg scopolamine base over 72 hours) Scopolamine (hyoscine • ) BUTYLbromide ( not available in US) SEE NOTE 20 mg SC every four to six hours OR 20 mg SC once; followed after 30 minutes by SC or IV continuous infusion of 20 to 60 mg per day [3]Δ Scopolamine (hyoscine • ) HYDRObromide ◊ SEE NOTE 0.3 mg PO or SL every four to six hours (PO/SL not available in US) OR 0.4 to 0.6 mg SC every four to eight hours OR 0.4 mg SC once; followed after 30 minutes by a SC or IV infusion of 1.2 to 2 mg per day [1,3] Atropine § 0.4 to 0.6 mg SC every four to six hours OR One to two drops of 1% ophthalmic solution (0.5 mg/drop) administered SL every two to four hours [4]◊ OR 0.4 mg SC once; followed after 30 minutes by a SC infusion of 1.2 to 2 mg per day [2] IMPORTANT NOTE: Doses of scopolamine (hyoscine) BUTYLbromide are NOT equivalent to scopolamine (hyoscine) HYDRObromide on a mg basis and may not be interchanged. Preparations not available in the US are widely available in other countries. SC: subcutaneous; IV: intravenous; PO: oral; SL: sublingual * Also known as "death rattle". • Hyoscine is an international generic name. Scopolamine is the US generic name. Δ Larger subcutaneous continuous infusion doses of scopolamine (hyoscine) BUTYLbromide up to 120 mg per day may be needed. [2]  Adjust dose depending upon response. Repeat SC dose if needed. [3] ◊ Scopoloamine (hyoscine) HYDRObromide penetrates central nervous system; it is sedating and can cause or worsen delirium. [2] § Atropine is a 2nd line choice. Disadvantages include risk of central nervous system toxicity (eg, hallucinations) and/or cardiotoxicity. Sublingual administration of ipratropium nasal solution (two sprays) may be a useful alternative. [4]

IMPORTANT NOTE: Doses of scopolamine (hyoscine) BUTYLbromide are NOT equivalent to scopolamine (hyoscine) HYDRObromide on a mg basis and may not be interchanged. Preparations not available in the US are widely available in other countries. SC: subcutaneous; IV: intravenous; PO: oral; SL: sublingual * Also known as "death rattle". • Hyoscine is an international generic name. Scopolamine is the US generic name. Δ Larger subcutaneous continuous infusion doses of scopolamine (hyoscine) BUTYLbromide up to 120 mg per day may be needed. [2]  Adjust dose depending upon response. Repeat SC dose if needed. [3] ◊ Scopoloamine (hyoscine) HYDRObromide penetrates central nervous system; it is sedating and can cause or worsen delirium. [2] § Atropine is a 2nd line choice. Disadvantages include risk of central nervous system toxicity (eg, hallucinations) and/or cardiotoxicity. Sublingual administration of ipratropium nasal solution (two sprays) may be a useful alternative. [4] [1] Hugel H, Ellershaw J, Gambles M. Respiratory Tract Secretions in the Dying Patient: A Comparison between Glycopyrronium and Hyoscine Hydrobromide. J Palliat Med 2006; 9:279. [2] Twycross R, Wilcock A (Eds). Hospice and palliative care formulary, 4th ed, Palliativedrugs.com Ltd. ©2012. p.637. [3] Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med 2002; 16:369. [4] Kintzel PE, Chase SL, Thomas W, et al. Anticholinergic medications for managing noisy respirations in adult hospice patients. Am J Health Syst Pharm 2009; 66:458.