Oral Glycopyrrolate - A Snapshot
- Hyperhidrosis remains a significant problem in our community leading to variable psychosocial impact on our patients.
- Recently, the long-term safety on the use of traditional anticholinergics such as oxybutynin and propantheline has been questioned with concerns about potential neurological sequelae such as dementia and Alzheimer’s with cumulative use (1,2).
- Whilst the study was limited to patients over age 65, concerns about unknown long-term safety in children, teenagers and adults has also been raised.
- Oral glycopyrrolate is being used increasingly as an alternative anticholinergic for hyperhidrosis. Its main advantage over traditional anticholinergics is the absence of blood-brain-barrier permeation (3). This also results in reduced neurological side effects such as somnolence.
- Numerous studies on oral glycopyrrolate used in paediatric populations have been published.
- References on relevant studies are listed below.
- Glycopyrrolate in a form for oral dosing is not currently available in Australia. It can be compounded into capsules at compounding pharmacies.
Clinical Perspective
‘I find oral glycopyrrolate useful in settings where the hyperhidrosis is multifocal or generalised. I tend to start adult patients at 1mg twice daily and teenagers at 1mg once daily. I educate patients about the nature of its potential side effects and allow them to uptitrate their dose until their hyperhidrosis is no longer affecting their daily function. I allow a maximum of 2 mg twice daily for adults and 1mg twice daily in teenagers, unless reviewed again. Most patients I have treated with oral glycopyrrolate tend to respond at such doses. Most do not experience significant side effects at these doses. The most common side effect that my patients have complained about is dry mouth and advice about adequate hydration and chewing gum appears to benefit these patients. I advise about the possibilities of other anticholinergic side effects including dry eyes, constipation, urinary retention, nausea, mydriasis and acute angle closure glaucoma. I also inform patients of the off-label nature of its use.’ Dr Chris Jalilian, Dermatologist (Conflict of interest declaration: Clinical Advisor of Skin Plus Compounding Pharmacy).
REFERENECES
1. Gray SL, Anderson ML, Dublin S, et al. Cumulative use of strong anticholinergics and incident dementia: a prospective cohort study. JAMA Intern Med. 2015; 175(3):401-407
2. Elston DM. Primum non nocere: Anticholinergics and dementia. J Am Acad Dermatol. 2018 Sep;79(3):439-440.
3. Toft P, Rømer UD. Glycopyrrolate compared with atropine in association with ketamine anaesthesia. Acta Anaesthesiol Scand. 1987 Jul;31(5):438-40
4. Park HH, Conic RRZ, Zhang S, Lieu A, Haft M, Hightower GK. Oral glycopyrrolate for primary focal hyperhidrosis in a pediatric population: A cross-sectional study. JAAD Int. 2021 Jul 30;4:65-66. 10.1016/j.jdin.2021.07.002. PMID: 34409395; PMCID: PMC8361902.
5. Patra S, Kaur M, Sharma VK. Stepwise treatment of primary focal hyperhidrosis with aluminum chloride hexahydrate lotion (20%) and oral glycopyrrolate: a retrospective study from a tertiary care center. Dermatol Ther. 2020 Nov;33(6):e13914. doi: 10.1111/dth.13914. Epub 2020 Jul 28.
6. Del Boz J, Millán-Cayetano JF, Rivas-Ruiz F, de Troya-Martín M. Oral glycopyrrolate after the failure of oral oxybutynin in the treatment of primary hyperhidrosis. Br J Dermatol. 2017 Mar;176(3):821-823. doi: 10.1111/bjd.14876. Epub 2017 Jan 22.
7. Kumar MG, Foreman RS, Berk DR, Bayliss SJ. Oral glycopyrrolate for refractory pediatric and adolescent hyperhidrosis. Pediatr Dermatol. 2014 Jan-Feb;31(1):e28-30. doi: 10.1111/pde.12236. Epub 2013 Nov 25.
8. Gong TK, Kim DW. Effectiveness of oral glycopyrrolate use in compensatory hyperhidrosis patients. Korean J Pain. 2013 Jan;26(1):89-93. doi: 10.3344/kjp.2013.26.1.89. Epub 2013 Jan 4.
9. Paller AS, Shah PR, Silverio AM, Wagner A, Chamlin SL, Mancini AJ. Oral glycopyrrolate as second-line treatment for primary pediatric hyperhidrosis. J Am Acad Dermatol. 2012 Nov;67(5):918-23.