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Atropine sublingual
Posted by: Mr Robin Brown (IP Logged)
Date: March 09, 2005 05:47PM

I have had a question from one of the nurses at a palliative care hospice that we serve for pharmacy supplies and consult. The nurses have been asked about atropine eye drops to be used sublingually 1-2 drops for drying terminal secretions (death rattle). This area has tended to use atropine more than some of the other agents with better evidence (hyoscine) due to cost. The thought with this request is for the same reason as injectable atropine is not covered for palliative patients so they must pay out of pocket but the eye drops would be. My question is whether anyone may have experience in doing this and what sort of results they have had.

Re: Atropine sublingual
Posted by: Doctor Joni Berry (IP Logged)
Date: March 10, 2005 07:13PM

We use hyoscamine drops (Levsin) as it is created for this use. However, it is common in the US to use atropine eye drops orally for the indication you mentioned. I do not know what dose is used but I am sure a comparasion with Levsin doses would give good guidance.

Re: Atropine sublingual
Posted by: Mrs sally Margaret molineux (IP Logged)
Date: March 10, 2005 08:33PM

I to would be interested in this, but have not heard of it.I will check with our local hospices and palliative care team.

Re: Atropine sublingual
Posted by: Doctor Duncan Brown (IP Logged)
Date: March 11, 2005 10:52AM

We have used atropine 1% eye drops occasionally for drooling/hypersalivation, largely in MND patients with very good results (dry pillow in the morning!). We used one drop at night or bd and had no problems with side-effects, although our pharmacist suggested we didn't use bigger doses for this reason, i.e to avoid confusion and other anticholinergic side-effects. We have not used it in the terminal phase as we tend to use injectable hyoscine butylbromide (buscopan) or glycopyrronium for respiratory secretions, although I gather atropine eye drops have been used successfully elsewhere. The main disadvantage of atropine, as hyoscine hydrobromide is the risk of central side effects but I have never seen them.

Duncan Brown

Re: Atropine sublingual
Posted by: Doctor charmaine jones (IP Logged)
Date: March 11, 2005 01:02PM

Hi Robin.
We have used atropine eye drops sublingually with excellent results both in end of life care as well as other situations, such as ALS.
Biggest risk is delirium but at very end of life, when most other medications with atropine side/effects have been stopped, this is less of a risk. It is less fearful for some families than SQ, is covered by ODB. I did mention it as an option in one of my "electronic Pearls" which go out to our team monthly.
Hope all is well in Cambridge area and with Lisaard House.

Re: Atropine sublingual
Posted by: Ms Eva Zivitz (IP Logged)
Date: March 11, 2005 01:23PM

Our local hospice uses this quite frequently. We have done no research on this, but nurses report anecdotally that the 1% opthalmic drops used 10 drops q 1hr directly onto the tongue can be quite effective. Our other stand-by is transdermal scopolamine, although it is probably because we are lucky enough to have a local compounding pharmacy that makes a cream that works more quickly than the standard patch behind the ear.

Re: Atropine sublingual
Posted by: Ms Cinthia West (IP Logged)
Date: March 11, 2005 04:34PM

We use atropine drops SL for the terminal secretions & the nurses are very pleased with the results and have not had any problems with side effects. wE USE 2-3 DROPS sl Q4-6H PRN EXCESS SECRETIONS.
Cindy West

Re: Atropine sublingual
Posted by: Doctor Jorge Eisenchlas (IP Logged)
Date: March 14, 2005 01:26PM

Having performed a pilot study which showed efficacy of atropine in treating drooling we have evaluated the effectiveness of sublingual atropine -0.5mg q.6 hs.- in the relief of drooling in a randomized placebo controlled, double-blind crossover trial in 22 patients with upper digestive cancer.

Variables measured were the impact of sialorrhoea ?primary outcome-, choking, interference with daily and social activities and global impact from drooling, as well as patients? choice at the end of the study.

Both interventions significantly decreased sialorrhoea but there were no statistical significative differences between groups neither for primary nor secondary outcomes. There were any severe toxicity episode.

We wonder if the absence of effectiveness could be due to a low atropine dose (as there were neither benefit nor adverse effect) and a new study using greater atropine doses is prompt to begin.
This study will be presented (poster) at the EAPC Congress in Aachen.

Dr Jorge Eisenchlas
Associate Researcher
Buenos Aires

Re: Atropine sublingual
Posted by: Doctor John Moyle (IP Logged)
Date: March 16, 2005 08:43AM

We have had a recent situation where a patient with a very "slow" form of MND (ALS) and a very good quality of life was resucitated from a cardiac arrest and is now recovering in CCU. No known IHD BUT she had been using atropine eye drops subligually for some time for drooling and had run out the day before the arrest. Cause or coincidence??

Re: Atropine sublingual
Posted by: Mrs Sandy White (IP Logged)
Date: March 21, 2005 04:21AM

Apparently our nurses have given atropine s/l to dry up secretions for ALS (Lou Gehrig's patients with some success.
Hope this helps.

Re: Atropine sublingual
Posted by: Ms Sue Greenberg (IP Logged)
Date: April 29, 2005 12:39PM

We regularly use Atropine eye drop solution for terminal secretions...10 drops every hour as needed. Additionally, we use scopolamine patches.

I had a patient a few days ago with endstage cardiac disease and kidney failure have an exhorbitant amount of terminal was in the last 5 hours of his life...I could not reduce the secretions with the atropine nor the patch...this patient was in the home and his family was at the bedside...the psychic pain they were all experiencing from seeing and hearing this will haunt me forever...what else could I have done? I had ordered a suction machine but it came after his death.

Re: Atropine sublingual
Posted by: Mr Dave Stewart (IP Logged)
Date: April 30, 2005 07:17AM

I try to remember and share with clients and families that dying is sometimes not a pleasant experience. I am in awe of the body and what it s various systems do. I try to reassure families that the body is doing whatever it can to stay alive and that at the end the brain is probably not getting enough oxygen to support the higher levels (consciousness). So while it is haunting to see the energy the body is using in trying to breathe we are witnessing the miracle of the body and its functions slowly, sometimes excrutiatingly, coming to a close. Suctioning probably is not the answer. And overdosing with opioids to end the process early is against hospice practice of not hastening death. I hope the nurse who is haunted can eventually find some peace in connection with the unpleasant death. Hopefully the dying person had a wish for those relatives (and nurse) to be there and at some level found a profound peace from their support.

Re: Atropine sublingual
Posted by: Mrs Eileen Collins (IP Logged)
Date: May 11, 2005 11:35PM

Could any one point me in the direction of any research to support the use of atropine eye drops given sublingually for end stage secretions. It seems apparent that quite a number of users of this site find them very successful.

Many thanks,

Eileen Collins

Re: Atropine sublingual
Posted by: Mr Bill Axness (IP Logged)
Date: May 12, 2005 03:06PM

We have used the atropine eye gtts po/sl successfully for excessive secretions for several years. We start with 1-2 drops po/sl q4 hrs scheduled or prn. If necessary, we have used higher doses, without significant side effects. One reference is Hyson, HC etal. Sublingual atropine for sialorrhea secondary to parkinsonism. Movement Disorders. 2002;17(6)1318-20. An older reference is Kanto, J etal. Oropharyngeal absorption of atropine. International J Clin Pharmacol. 1986;24(11);627-29. An article describing absorption of opthalmic drops from ocular admin. is Kaila, T etal. Systemic bioavailability of ocularyly applied 1% atropine eyedrops. Acta Ophthalmol Scand. 1999;77(2);193-96.

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