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Nebulized Scopolamine
Vol. 19 No. 5 May 2000
opioids are prescribed under severely restricted reimbursement. Donna Zhukovsky, MD Declan Walsh, MD Marie Doona, MD The Cleveland Clinic Cleveland, Ohio, USA PII S0885-3924(00)00135-4
References 1. Houde R. The use and misuse of narcotics in the treatment of chronic pain. In: Bonica JJ, ed. Advances in Neurology. New York: Raven Press, 1974;4: 527–538. 2. Kaiko R, Lacouture P, Hopf K, et al. Analgesic onset and potency of oral controlled-release (CR) oxycodone and CR morphine [abstract]. Clin Pharmacol Ther 1996;59:130. 3. Kaiko RF. The use of controlled release opioids. In: Parris WCV, ed. Cancer pain management: principles and practice. Boston: Butterworth–Heinemann, 1997:69–90. 4. Glare PA, Walsh D. Oxycodone: a substitute for morphine in cancer pain management [letter]. Palliat Med 1992;6:79–80. 5. Zhukovsky DS, Walsh D, Doona M. The relative potency between high dose oral oxycodone and intravenous morphine: a case illustration. J Pain Symptom Manage 1999;18:53–55. 6. Glare PA, Walsh TD. Dose-ranging study of oxycodone for chronic pain in advanced cancer. J Clin Oncol 1993;11:973–978. 7. Kalso E, Vainio A. Morphine and oxycodone hydrochloride in the management of cancer pain. Clin Pharmacol Ther 1990;47:639–646. 8. Houde RW. Systemic analgesics and related drugs: narcotic analgesics. In: Bonica JJ, Ventafridda V, eds. Advances in pain research and therapy, Vol 2. New York: Raven Press, 1979:263–273.
Nebulized Scopolamine To the Editor: Excessive oral secretions or difficulty swallowing saliva can cause unacceptable symptoms in some patients, particularly those with head and neck cancer, motor neuron disease, and Parkinson’s disease. Various drug treatments have been tried including scopolamine, atropine, and glycopyrrolate, with varying degrees
Letters
327
of response. Following the recent publication regarding nebulized scopolamine for the management or oral dribbling,1 we wish to report our experience with two patients. The first was a 57-year-old woman suffering from familial amyotrophic lateral sclerosis. On admission she had great difficulty swallowing or speaking and was fed via a gastrostomy. She had profuse oral secretions, for which she constantly kept absorbent gauze in her mouth, and drooling, which necessitated wearing a bib. She previously received propantheline bromide 7.5 mg 3 times a day orally with no improvement in the dribbling. She agreed to a trial of nebulized scopolamine and this was commenced at a dose of 800 g 3 times daily. Within 24 hours, nursing staff and family reported a noticeable reduction in oral secretions. However, the patient was not happy with the frequency of administration. She agreed to try once-daily administration only. The secretions quickly increased and she then agreed to return to the original scopolamine dose. This provided good symptom relief, and no side effects were noted. After 8 days of treatment it became apparent that she was concerned about dryness of her mouth immediately following nebulizations, and, to a lesser extent, change in taste sensation. We offered to stop the medication, but the patient refused this option. We therefore reduced the scopolamine dose to 400 g 3 times daily and then to 200 g 3 times daily due to persistent dry mouth. Rescue doses of 200 g were allowed, and these were accepted by the patient. At this lower regular dose, the patient was observed to be drooling more, requiring more changes of the gauze swabs and needing more suctioning for oral secretion. As the patient was requesting 1–2 extra nebulizations per day, the dose was increased to 200 g 4 times daily. In this brief clinical experience with this new route of administering scopolamine, the patient, family and staff were impressed with the reduction in oral secretions that occurred. Indeed, the most significant complication appeared to be excess dryness of the mouth immediately following the drug’s administration, which the patient found uncomfortable and which at one point produced a small fissure with resultant bleeding of the upper lip. We
328
continue to find that her oral salivation fluctuates between producing copious amounts or being excessively dry, depending on the timing of the nebulizations. However, overall we believe that this has resulted in a significant improvement in this patient’s problem. No evidence of CNS or gastrointestinal anticholinergic side effects was seen, and this suggests that the drug’s action was occurring through local absorption at the level of the salivary gland as proposed by Dr. Zeppetella.1 The second patient was a 75-year-old woman with metastatic squamous cell carcinoma of the floor of the mouth causing complete dysphagia for which a gastrostomy tube was inserted. She was referred to our outpatient Pain and Symptom Clinic with excessive oral secretions and pain. The secretions were causing her great distress and embarrassment and limiting her social activities. She also reported disturbed sleep, having to get up and suction the secretions several times each night. She scored this problem as 8/10 on the visual analogue scale. We prescribed scopolamine nebulizations 400 g 4 times daily and she used these regularly for 7 days. At review, the patient and her family reported that her oral secretions had reduced dramatically and her rating score of this problem had fallen to 3/10. No adverse side effects were reported and she is very keen to continue with this therapy. This appears to be an interesting new route for administration of scopolamine, which warrants further study. Further research in this area could include an N of 1 study with multi-
Letters
Vol. 19 No. 5 May 2000
ple crossovers between nebulized saline and nebulized scopolamine. Outcome could be measured using subjective sensation by the patient and blinded observer rating of oral secretions. A similar approach has been used previously to study the role of oxygen for dyspnea.2 In addition, to further investigate the benefits and side effects of nebulized vs. subcutaneous scopolamine, a double-blind, double-dummy, crossover study could be conducted using nebulized scopolamine vs. subcutaneous scopolamine with nebulized saline and subcutaneous saline as placebo controls. Julia Doyle, MB, BCh Pembridge Palliative Care Unit London, United Kingdom Paul Walker, MD Grey Nuns Community Hospital & Health Centre Edmonton, Alberta, Canada Eduardo Bruera, MD University of Texas, M. D. Anderson Cancer Center Houston, TX, USA PII S0885-3924(00)00132-9
References 1. Zeppetella G. Nebulized scopolamine in the management of oral dribbling. J Pain Symptom Manage 1999;17:293–295. 2. Bruera E, Schoeller T, MacEachern T. Symptomatic benefit of supplemental oxygen in hypoxemic patients with terminal cancer: the use of the N of 1 randomized controlled trial. J Pain Symptom Manage 1992;7:365–368.
opioids are prescribed under severely restricted reimbursement. Donna Zhukovsky, MD Declan Walsh, MD Marie Doona, MD The Cleveland Clinic Cleveland, Ohio, USA PII S0885-3924(00)00135-4
References 1. Houde R. The use and misuse of narcotics in the treatment of chronic pain. In: Bonica JJ, ed. Advances in Neurology. New York: Raven Press, 1974;4: 527–538. 2. Kaiko R, Lacouture P, Hopf K, et al. Analgesic onset and potency of oral controlled-release (CR) oxycodone and CR morphine [abstract]. Clin Pharmacol Ther 1996;59:130. 3. Kaiko RF. The use of controlled release opioids. In: Parris WCV, ed. Cancer pain management: principles and practice. Boston: Butterworth–Heinemann, 1997:69–90. 4. Glare PA, Walsh D. Oxycodone: a substitute for morphine in cancer pain management [letter]. Palliat Med 1992;6:79–80. 5. Zhukovsky DS, Walsh D, Doona M. The relative potency between high dose oral oxycodone and intravenous morphine: a case illustration. J Pain Symptom Manage 1999;18:53–55. 6. Glare PA, Walsh TD. Dose-ranging study of oxycodone for chronic pain in advanced cancer. J Clin Oncol 1993;11:973–978. 7. Kalso E, Vainio A. Morphine and oxycodone hydrochloride in the management of cancer pain. Clin Pharmacol Ther 1990;47:639–646. 8. Houde RW. Systemic analgesics and related drugs: narcotic analgesics. In: Bonica JJ, Ventafridda V, eds. Advances in pain research and therapy, Vol 2. New York: Raven Press, 1979:263–273.
Nebulized Scopolamine To the Editor: Excessive oral secretions or difficulty swallowing saliva can cause unacceptable symptoms in some patients, particularly those with head and neck cancer, motor neuron disease, and Parkinson’s disease. Various drug treatments have been tried including scopolamine, atropine, and glycopyrrolate, with varying degrees
Letters
327
of response. Following the recent publication regarding nebulized scopolamine for the management or oral dribbling,1 we wish to report our experience with two patients. The first was a 57-year-old woman suffering from familial amyotrophic lateral sclerosis. On admission she had great difficulty swallowing or speaking and was fed via a gastrostomy. She had profuse oral secretions, for which she constantly kept absorbent gauze in her mouth, and drooling, which necessitated wearing a bib. She previously received propantheline bromide 7.5 mg 3 times a day orally with no improvement in the dribbling. She agreed to a trial of nebulized scopolamine and this was commenced at a dose of 800 g 3 times daily. Within 24 hours, nursing staff and family reported a noticeable reduction in oral secretions. However, the patient was not happy with the frequency of administration. She agreed to try once-daily administration only. The secretions quickly increased and she then agreed to return to the original scopolamine dose. This provided good symptom relief, and no side effects were noted. After 8 days of treatment it became apparent that she was concerned about dryness of her mouth immediately following nebulizations, and, to a lesser extent, change in taste sensation. We offered to stop the medication, but the patient refused this option. We therefore reduced the scopolamine dose to 400 g 3 times daily and then to 200 g 3 times daily due to persistent dry mouth. Rescue doses of 200 g were allowed, and these were accepted by the patient. At this lower regular dose, the patient was observed to be drooling more, requiring more changes of the gauze swabs and needing more suctioning for oral secretion. As the patient was requesting 1–2 extra nebulizations per day, the dose was increased to 200 g 4 times daily. In this brief clinical experience with this new route of administering scopolamine, the patient, family and staff were impressed with the reduction in oral secretions that occurred. Indeed, the most significant complication appeared to be excess dryness of the mouth immediately following the drug’s administration, which the patient found uncomfortable and which at one point produced a small fissure with resultant bleeding of the upper lip. We
328
continue to find that her oral salivation fluctuates between producing copious amounts or being excessively dry, depending on the timing of the nebulizations. However, overall we believe that this has resulted in a significant improvement in this patient’s problem. No evidence of CNS or gastrointestinal anticholinergic side effects was seen, and this suggests that the drug’s action was occurring through local absorption at the level of the salivary gland as proposed by Dr. Zeppetella.1 The second patient was a 75-year-old woman with metastatic squamous cell carcinoma of the floor of the mouth causing complete dysphagia for which a gastrostomy tube was inserted. She was referred to our outpatient Pain and Symptom Clinic with excessive oral secretions and pain. The secretions were causing her great distress and embarrassment and limiting her social activities. She also reported disturbed sleep, having to get up and suction the secretions several times each night. She scored this problem as 8/10 on the visual analogue scale. We prescribed scopolamine nebulizations 400 g 4 times daily and she used these regularly for 7 days. At review, the patient and her family reported that her oral secretions had reduced dramatically and her rating score of this problem had fallen to 3/10. No adverse side effects were reported and she is very keen to continue with this therapy. This appears to be an interesting new route for administration of scopolamine, which warrants further study. Further research in this area could include an N of 1 study with multi-
Letters
Vol. 19 No. 5 May 2000
ple crossovers between nebulized saline and nebulized scopolamine. Outcome could be measured using subjective sensation by the patient and blinded observer rating of oral secretions. A similar approach has been used previously to study the role of oxygen for dyspnea.2 In addition, to further investigate the benefits and side effects of nebulized vs. subcutaneous scopolamine, a double-blind, double-dummy, crossover study could be conducted using nebulized scopolamine vs. subcutaneous scopolamine with nebulized saline and subcutaneous saline as placebo controls. Julia Doyle, MB, BCh Pembridge Palliative Care Unit London, United Kingdom Paul Walker, MD Grey Nuns Community Hospital & Health Centre Edmonton, Alberta, Canada Eduardo Bruera, MD University of Texas, M. D. Anderson Cancer Center Houston, TX, USA PII S0885-3924(00)00132-9
References 1. Zeppetella G. Nebulized scopolamine in the management of oral dribbling. J Pain Symptom Manage 1999;17:293–295. 2. Bruera E, Schoeller T, MacEachern T. Symptomatic benefit of supplemental oxygen in hypoxemic patients with terminal cancer: the use of the N of 1 randomized controlled trial. J Pain Symptom Manage 1992;7:365–368.