What is atropine for?

Contents

Atropine Injection BP

Generic Name: atropine sulfate
Product Name: Atropine Injection

Indication: What Atropine Injection is used for

Atropine sulfate belongs to a group of medicines called antimuscarinic agents. Atropine Injection is given before anaesthesia to decrease mucus secretions, such as saliva. During anaesthesia and surgery, atropine is used to help keep the heart beat normal. Atropine sulfate is also used to block or reverse the adverse effects caused by some medicines and certain type of pesticides.

Atropine Injection may be used for the management of other conditions that are not mentioned above. Your doctor will be able to tell you about the specific condition for which you have been prescribed Atropine Injection.

This medicine is available only with a doctor’s prescription.

Action: How Atropine Injection works

Atropine is often classified as an anticholinergic drug but is more accurately described as an antimuscarinic agent since it competitively inhibits the muscarinic actions of acetylcholine and has both peripheral and central actions. It reduces secretions especially salivary and bronchial secretions, and also reduces perspiration. It has little effect on intestinal, biliary or pancreatic secretions since these secretions are principally controlled by hormonal rather than vagal mechanisms.

Atropine Injection contains the active ingredient atropine sulfate 600 microgram per mL or 1.2 mg per mL. It also contains sodium chloride and Water for Injections.

It does not contain preservatives.

Dose advice: How to use Atropine Injection

Before you are given Atropine Injection

When you must not be given it

Do not use Atropine Injection if you have an allergy or have had an unusual reaction to atropine or any of the anticholinergic medicines such as hyoscyamine and belladonna.

Do not use Atropine Injection if you have or have had any medical conditions, especially the following:

  • Severe and chronic inflammation of the large intestine and rectum;
  • Gastrointestinal blockage and/or diseases;
  • Enlarged prostate;
  • Urinary tract blockage and/or bladder problems;
  • Fever, or if you are exposed to very high temperatures;
  • Glaucoma and/or family history of glaucoma;
  • Myasthenia gravis (severe muscle weakness);
  • Acute bleeding, especially if you have heart problems;
  • Heart disease;
  • High blood pressure due to pregnancy;
  • Overactive thyroid.

If you are not sure whether any of these apply to you, check with your doctor.

Before you are given it

Tell your doctor if you have allergies to any other medicines, foods, preservatives or dyes.

Tell your doctor if you have or have had any medical conditions, especially the following:

  • Brain damage and/or mental confusion;
  • Lung diseases;
  • Liver and/or kidney diseases;
  • Hormone problems;
  • High blood pressure;
  • Fast heart beat;
  • Hiatus hernia;
  • Heart diseases;
  • Stomach and intestinal problems;
  • Gastric ulcer, diarrhoea or gastrointestinal infection.

Tell your doctor if you are pregnant or plan to become pregnant or are breast-feeding.

Your doctor can discuss with you the risks and benefits involved.

Taking other medicines

Tell your doctor if you are taking any other medicines, including:

  • All prescription medicines;
  • All medicines, vitamins, herbal supplements or natural therapies you buy without a prescription from a pharmacy, supermarket, naturopath or health food shop.

Some medicines and atropine sulfate may interfere with each other. These include:

  • Medicines to treat irregular heartbeat e.g. disopyramide and quinidine;
  • Blood “thinning” medicines e.g. heparin, warfarin;
  • Medicines to treat Parkinson’s disease;
  • Metoclopramide, a medicine to treat nausea and vomiting;
  • Cisapride, a medicine used in certain stomach problems;
  • Anticholinergic medicines to prevent travel sickness, relieve stomach cramps or spasms;
  • Antispasmodics;
  • Bethanechol, a medicine used in bladder function disorders;
  • Antihistamines;
  • Medicines to treat depression such as tricyclic antidepressants;
  • Medicines used to treat certain mental and emotional conditions;
  • Ketaconazole, a medicine to treat fungal infections;
  • Narcotic analgesics to treat severe pain;
  • Medicines used for glaucoma e.g. pilocarpine, carbachol;
  • Medicines to treat Alzheimer’s disease e.g. rivastigmine and donepezil;
  • Muscle relaxants used during an operation.

If you are to receive Atropine Injection as a premedication, your doctor will advise if you should continue to take your regular medicines.

How Atropine Injection is given

Atropine sulfate will be injected by your doctor or nurse under the skin, into the muscle or directly into the blood stream.

Your doctor will decide what dose and how often you will receive Atropine Injection. The dosage you will be given will depend on your condition, what it is being used for and other factors, such as your age, and whether or not other medicines are being given at the same time.

If you are given too much (overdose)

This rarely happens as Atropine Injection is administered under the care of a highly trained doctor.

However, if you are given too much atropine sulfate, you may experience some of the effects listed under “Side effects” below. The signs of overdose are dilation of the pupils, difficulty in swallowing, hot dry skin, flushing and inability to pass urine. Rapid breathing, increased heart rate and hyperactivity may also occur.

Your doctor has information on how to recognise and treat an overdose. Ask your doctor if you have any concerns.

Storage

Atropine Injection will be stored in the pharmacy or on the ward. The injection is kept in a cool dry place, where the temperature stays below 25°C.

Schedule of Atropine Injection

Atropine Injection is an S4 – Prescription only medicine.

Side effects of Atropine Injection

Tell your doctor, nurse or pharmacist as soon as possible if you do not feel well after you have being given atropine sulfate.

Like other medicines, atropine sulfate can cause some side effects. If they occur, most are likely to be minor or temporary. However, some may be serious and need medical attention.

Ask your doctor or pharmacist to answer any questions that you may have.

Do not be alarmed by this list of possible side effects. You may not experience any of them.

Tell your doctor if you notice any of the following:

  • Blurred vision and/or discomfort in the eyes especially if your eyes are more sensitive to light than normal, dilation of pupils;
  • Difficulty in urinating;
  • Constipation;
  • Fever;
  • Flushing, dryness of skin;
  • Skin rash, hives;
  • Headache, dizziness, drowsiness and/or weakness;
  • Nervousness, restlessness, confusion, unusual excitement shaking and/or tremor;
  • Nausea, vomiting;
  • Fast and/or irregular heartbeat;
  • Loss of taste;
  • Dryness of the mouth, nose and throat, thirst.

Other side effects not listed above may also occur in some patients. If you notice any other effects, check with your doctor or nurse.

For further information talk to your doctor.

Atropine

SIDE EFFECTS

Mild to moderate pain may be experienced at the site of injection.

The major and most common side effects of atropine can be attributed to its antimuscarinic action. These include dryness of the mouth, blurred vision, photophobia, confusion, headache, dizziness, tachycardia, palpitations, flushing, urinary hesitance or retention, constipation, abdominal distention, nausea, vomiting, loss of libido and impotency. Anhidrosis may produce heat intolerance and impairment of temperature regulation especially in a hot environment. Hypersensitivity reactions will occasionally occur with atropine: these are usually seen as skin rashes, on occasion progressing to exfoliation.

Amitai et al. (JAMA 1990) evaluated the safety of an atropine autoinjector in a case series of 240 children who received the atropine inappropriately (i.e., no nerve agent exposure) during the 1990 Gulf War Period. Overall, severity of atropinization followed a nonlinear correlation with dose. Estimated doses up to 0.045 mg/kg produced no signs of atropinization. Estimated doses between 0.045 mg/kg to 0.175 mg/kg and even greater than 0.175 mg/kg were associated with mild and severe effects respectively. Actual dosage received by children may have been considerably lower than estimated since incomplete injection in many cases was suspected. Regardless, adverse events reported were generally mild and self-limited. Few children required hospitalization. Adverse reactions reported were dilated pupils (43%), tachycardia (39%), dry membranes (35%), flushed skin (20%), temperature 37.8° C or 100° F (4%) and neurologic abnormalities (5%). There was also local pain and swelling. In patients with ECGs, 22 of 91 (24%) children had severe tachycardia of 160-190 bpm. Neurologic abnormalities consisted of irritability, agitation, confusion, lethargy, and ataxia.

The following adverse reactions were reported in published literature for atropine in both adult and pediatric patients:

Sinus tachycardia, supraventricular tachycardia, junctional tachycardia, ventricular tachycardia, bradycardia, palpitations, ventricular arrhythmia, ventricular flutter, ventricular fibrillation, atrial arrhythmia, atrial fibrillation, atrial ectopic beats, ventricular premature contractions, bigeminal beats, trigeminal beats, nodal extrasystole, ventricular extrasystole, supraventricular extrasystole, asystole, cardiac syncope, prolongation of sinus node recovery time, cardiac dilation, left ventricular failure, myocardial infarction, intermittent nodal rhythm (no P wave), prolonged P wave, shortened PR segment, R on T phenomenon, shortened RT duration, widening and flattening of QRS complex, prolonged QT interval, flattening of T wave, repolarization abnormalities, altered ST-T waves, retrograde conduction, transient AV dissociation, increased blood pressure, decreased blood pressure, labile blood pressure, weak or impalpable peripheral pulses.

Eye

Mydriasis, blurred vision, pupils poorly reactive to light, photophobia, decreased contrast sensitivity, decreased visual acuity, decreased accommodation, cycloplegia, strabismus, heterophoria, cyclophoria, acute angle closure glaucoma, conjunctivitis, keratoconjunctivitis sicca, blindness, tearing, dry eyes/dry conjunctiva, irritated eyes, crusting of eyelid, blepharitis.

Nausea, abdominal pain, paralytic ileus, decreased bowel sounds, distended abdomen, vomiting, delayed gastric emptying, decreased food absorption, dysphagia.

Hyperpyrexia, lethargy, somnolence, chest pain, excessive thirst, weakness, syncope, insomnia, tongue chewing, dehydration, feeling hot, injection site reaction.

Immunologic

Anaphylactic reaction.

Special Investigations

Leukocytosis, hyponatremia, elevated BUN, elevated hemoglobin, elevated erythrocytes, low hemoglobin, hypoglycemia, hyperglycemia, hypokalemia, increase in photic stimulation on EEG, signs of drowsiness on EEG, runs of alpha waves on EEG, alpha waves (EEG) blocked upon opening eyes.

Failure to feed.

Central Nervous System

Ataxia, hallucinations (visual or aural), seizures (generally tonic clonic), abnormal movements, coma, confusion, stupor, dizziness, amnesia, headache, diminished tendon reflexes, hyperreflexia, muscle twitching, opisthotonos, Babinski’s reflex/Chaddock’s reflex, hypertonia, dysmetria, muscle clonus, sensation of intoxication, difficulty concentrating, vertigo, dysarthria.

Agitation, restlessness, delirium, paranoia, anxiety, mental disorders, mania, withdrawn behavior, behavior changes.

Difficulty in micturation, urine urgency distended urinary bladder, urine retention, bed-wetting.

Pulmonary

Tachypnea, slow respirations, shallow respirations, breathing difficulty, labored respirations, inspiratory stridor, laryngitis, laryngospasm, pulmonary edema, respiratory failure, subcostal recession.

Dry mucous membranes, dry warm skin, flushed skin, oral lesions, dermatitis, petechiae rash, macular rash papular rash, maculopapular rash, scarlatiniform rash, erythematous rash, sweating/moist skin, cold skin, cyanosed skin, salivation.

Read the entire FDA prescribing information for Atropine (Atropine)

Atropine Side Effects

Medically reviewed by Drugs.com. Last updated on Apr 15, 2019.

  • Overview
  • Side Effects
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  • Professional
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  • More

For the Consumer

Applies to atropine: parenteral injection

Warning

    Pesticide and Chemical Warfare Agent Poisoning

  • Primary protection against exposure to chemical nerve agents and insecticide poisoning is the wearing of protective garments (e.g., specialized masks).105
  • Do not rely solely on antidotes such as atropine and pralidoxime to provide complete protection from chemical nerve agents and insecticide poisoning.105
  • Seek immediate medical attention after injection with an atropine auto-injector.105

Side effects include:

Most adverse effects are manifestations of pharmacologic effects at muscarinic-cholinergic receptors and usually are reversible when therapy is discontinued.

Severity and frequency of adverse effects are dose related and individual intolerance varies greatly; adverse effects occasionally may be obviated by a reduction in dosage but this also may eliminate potential therapeutic effects.

Frequent effects include xerostomia (dry mouth), dry skin, blurred vision, cycloplegia, mydriasis, photophobia, anhidrosis, urinary hesitancy and retention, tachycardia, palpitation, xerophthalmia, and constipation, which may appear at therapeutic or subtherapeutic doses. In many patients, xerostomia is the dose-limiting effect.

Other common effects include increased ocular tension (especially in patients with angle-closure glaucoma), loss of taste, headache, nervousness, restlessness, drowsiness, weakness, dizziness, flushing, insomnia, nausea, vomiting, bloated feeling, anhidrosis (especially in hot environments), mild to moderate pain at the injection site, loss of libido, and erectile dysfunction (via block of cholinergically mediated vasodilation).

For Healthcare Professionals

Applies to atropine: compounding powder, injectable solution, intramuscular solution, intravenous solution, oral tablet

General

Although individual reactions vary greatly, systemic doses are likely to produce the following effects:

0.5 mg: Slight dryness of the nose and mouth, bradycardia

1 mg: Greater dryness of nose and mouth with thirst; slowing, then acceleration of the heart; slight mydriasis

2 mg: Very dry mouth, tachycardia with palpitations, mydriasis, slight blurring of near vision

5 mg: Increase in the above symptoms plus disturbance of speech, difficulty swallowing, headache, hot, dry skin, restlessness with asthenia

10 mg and over: Above symptoms to extreme degrees, plus ataxia, excitement, disorientation, hallucinations, delirium, and coma

65 mg: May be fatal

Cardiovascular

Common (1% to 10%): Tachycardia (arrhythmias, transient exacerbation of bradycardia)

Very rare (less than 0.01%): Atrial arrhythmias, ventricular fibrillation, angina, hypertensive crisis

Frequency not reported: Bradycardia, slowing then acceleration of heart, palpitations, circulatory collapse, blood pressure declines, sinus tachycardia, supraventricular tachycardia, junctional tachycardia, ventricular tachycardia, ventricular flutter, ventricular fibrillation, atrial arrhythmia, atrial fibrillation, atrial ectopic beats, ventricular premature contractions, bigeminal beats, trigeminal beats, nodal extrasystole, supraventricular extrasystole, asystole, cardiac syncope, prolongation of sinus node recovery time, cardiac dilation, left ventricular failure, myocardial infarction, intermittent nodal rhythm (no P wave), prolonged P wave, shortened PR segment, R on T phenomenon, shortened RT duration, widening and flattening of QRS complex, prolonged QT interval, flattening of T wave, repolarization abnormalities, altered ST-T waves, retrograde conduction, transient AV dissociation, increased blood pressure, labile blood pressure, weak or impalpable peripheral pulses, paradoxical atrioventricular block

Nervous system

Very common (10% or more): Loss of taste

Common (1% to 10%): Incoordination

Uncommon (0.1% to 1%): Seizure, drowsiness

Frequency not reported: Disturbance of speech, headache, asthenia, ataxia, coma, dizziness, tremor, locomotor difficulties, medullary paralysis, neurological abnormalities, lethargy, somnolence, syncope, runs of alpha waves on EEG, alpha waves (EEG) blocked upon opening eyes, seizures (generally tonic-clonic), abnormal movements, stupor, amnesia, diminished tendon reflexes, hyperreflexia, opisthotonos, Babinski’s reflex/Chaddock’s reflex, hypertonia, dysmetria, muscle clonus, sensation of intoxication, difficulty concentrating, vertigo, dysarthria, loss of taste, giddiness, staggering

Ocular

Very common (10% or more): Visual disturbances (mydriasis, inhibition of accommodation, blurred vision, photophobia)

Frequency not reported: Blurring of near vision, pupils poorly reactive to light, decreased contrast sensitivity, decreased visual acuity, cycloplegia, strabismus, heterophoria, cyclophoria, acute angle closure glaucoma, conjunctivitis, keratoconjunctivitis sicca, blindness, tearing, dry eyes/dry conjunctiva, irritated eyes, crusting of eyelids, blepharitis, increase in photic stimulation on EEG, increase in intraocular pressure

Gastrointestinal

Very common (10% or more): Dryness of mouth (difficulty swallowing and talking, thirst), parasympathetic inhibition of gastrointestinal tract (constipation and reflux), inhibition of gastric secretion, nausea, vomiting, bloated feeling

Frequency not reported: Abdominal distension, abdominal pain, paralytic ileus, decreased bowel sounds, delayed gastric emptying, decreased food absorption, dysphagia, retrosternal pain due to gastric reflux

Dermatologic

Very common (10% or more): Anhidrosis, urticaria, rash

Common (1% to 10%): Flushing

Frequency not reported: Dry skin, hot skin, scarlatiniform rash, skin rashes, exfoliation, dry mucus membranes, warm skin, maculopapular rash, erythematous rash, sweating/moist skin, cold skin, cyanosed skin, salivation

Psychiatric

Common (1% to 10%): Excitement, confusion, hallucinations

Uncommon (0.1% to 1%): Psychotic reactions

Frequency not reported: Restlessness, disorientation, delirium, loss of libido, delirium, depression, manic behavior, irritability, agitation, insomnia, agitation, paranoia, anxiety, mental disorders, mania, withdrawn behavior, behavior changes, nervousness

Other

Common (1% to 10%): Hyperthermia

Frequency not reported: Death, fever, heat intolerance, impairment of temperature regulation (especially in a hot environment), fatigue, hyperpyrexia, chest pain, weakness, feeling hot, signs of drowsiness on EEG

Genitourinary

Common (1% to 10%): Inhibition of parasympathetic control of the urinary bladder, urinary retention

Frequency not reported: Urinary hesitancy, impotency, difficulty in micturition, urine urgency, distended urinary bladder, bed wetting

Hypersensitivity

Rare (less than 0.1%): Allergic reactions

Very rare (less than 0.01%): Anaphylaxis

Frequency not reported: Hypersensitivity

Respiratory

Frequency not reported: Dryness of nose, respiratory failure, tachypnea, slow respirations, shallow respirations, inspiratory stridor, laryngitis, laryngospasm, pulmonary edema, subcostal recession, reduced bronchial secretions, formation of bronchial plugs

Metabolic

Frequency not reported: Thirst, excessive thirst, dehydration, hyponatremia, hypokalemia, hypoglycemia, hyperglycemia

Musculoskeletal

Frequency not reported: Muscle twitching

Local

Frequency not reported: Pain at injection site, local swelling, injection site reaction, redness or other signs of irritation at the injection site

Hematologic

Frequency not reported: Leukocytosis, elevated hemoglobin, elevated erythrocytes, low hemoglobin

Renal

Frequency not reported: Elevated BUN

1. “Product Information. Atropine Sulfate (atropine).” American Regent Laboratories Inc, Shirley, NY.

2. “Product Information. Atropine Sulfate Injection, USP (atropine).” ESI Lederle Generics, Philadelphia, PA.

3. Cerner Multum, Inc. “Australian Product Information.” O 0

4. Cerner Multum, Inc. “UK Summary of Product Characteristics.” O 0

5. “Product Information. AtroPen (atropine).” Meridian Medical Technologies Inc, Columbia, MD.

Further information

Always consult your healthcare provider to ensure the information displayed on this page applies to your personal circumstances.

Some side effects may not be reported. You may report them to the FDA.

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Professional resources

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Related treatment guides

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Pharmacologic Pearls for End-of-Life Care

Table 4

Choice of Antiemetic Based on Cause of Nausea and Vomiting

Cause of nausea and vomiting Antiemetic

Anxiety, anticipatory, psychologic

Benzodiazepines, canniboids

Bowel obstruction

Octreotide (Sandostatin; see text)

Gastroparesis

Metoclopramide (Reglan)

Increased intracranial pressure, central nervous system pain

Dexamethasone

Inner ear dysfunction (rare in palliative care)

Anticholinergics, antihistamines

Medication (primarily chemotherapy)

5-HT3 and dopamine receptor blockers

Metabolic (e.g., uremia, cirrhosis)

5-HT3 and dopamine receptor blockers, antihistamines, steroids

Opioid bowel dysfunction

Methylnaltrexone (Relistor)

5-HT = 5-hydroxytryptamine.

Information from reference 34.

Table 4

Cause of nausea and vomiting Antiemetic

Anxiety, anticipatory, psychologic

Benzodiazepines, canniboids

Bowel obstruction

Octreotide (Sandostatin; see text)

Gastroparesis

Metoclopramide (Reglan)

Increased intracranial pressure, central nervous system pain

Dexamethasone

Inner ear dysfunction (rare in palliative care)

Anticholinergics, antihistamines

Medication (primarily chemotherapy)

5-HT3 and dopamine receptor blockers

Metabolic (e.g., uremia, cirrhosis)

5-HT3 and dopamine receptor blockers, antihistamines, steroids

Opioid bowel dysfunction

Methylnaltrexone (Relistor)

5-HT = 5-hydroxytryptamine.

Information from reference 34.

As mental status changes occur during the dying process, patients lose the capacity to clear upper respiratory secretions (“death rattle”). Nonpharmacologic interventions, such as positioning to facilitate drainage and very gentle anterior suctioning (not deep), are an appropriate initial response. Pharmacologic interventions may include glycopyrrolate (Robinul), scopolamine, octreotide, and the oral use of atropine eyedrops (Table 5).40 Patients do not report experiencing these sounds to be as distressing as family members or caregivers find them, and education regarding this issue may be as effective as positioning and medication.41 A randomized trial is presently underway comparing the effectiveness of different strategies.

Table 5

Treatment of Excessive Respiratory Secretions

Treatment Dosage

Atropine eye drops 1%

One to two drops orally or under the tongue; titrate every eight hours

Glycopyrrolate (Robunil)

1 mg orally or 0.2 mg subcutaneously or intravenously every four to eight hours as needed

Scopolamine

0.125 to 0.5 mg orally, under the tongue, subcutaneously, or intravenously every four hours as needed

Scopolamine

One to two patches applied topically and changed every 48 to 72 hours

Information from reference 40.

Table 5

Treatment Dosage

Atropine eye drops 1%

One to two drops orally or under the tongue; titrate every eight hours

Glycopyrrolate (Robunil)

1 mg orally or 0.2 mg subcutaneously or intravenously every four to eight hours as needed

Scopolamine

0.125 to 0.5 mg orally, under the tongue, subcutaneously, or intravenously every four hours as needed

Scopolamine

One to two patches applied topically and changed every 48 to 72 hours

Information from reference 40.

By: Elsa Thomas, PharmD Candidate c/o 2013

Atropine is an anticholinergic used to treat various conditions, such as bradycardia, neuromuscular blockade, mydriasis, nerve agent poisoning, and salivary hypersecretion.1,2 Pharmacologically, it inhibits smooth muscle and glands innervated by postganglionic cholinergic nerves.1,2 It also has functions in the central nervous system (CNS); it could stimulate or depress it based on the administered dose.1,2 Its utility for treating salivary hypersecretion (i.e. sialorrhea) is a result of muscarinic antagonism of acetylcholine, resulting in dry mouth and reduction of salivary, bronchial, gastric, and sweat gland secretions.1,2 For adults, to reduce salivation and bronchial secretions, an oral dose of 0.4 mg is suggested, which may be repeated every 4 to 6 hours as needed.1,2 In the form of an injection, 0.4 to 0.6 mg may be administered intramuscularly (IM), intravenously (IV), or subcutaneously (SC) over 30 to 60 minutes, and repeated every 4 to 6 hours as needed.1,2 Interestingly a 1% ophthalmic solution of atropine has also been widely used, sublingually, for the treatment of the same.1,2

Sublingual atropine sulfate appears to have several advantages over the conventional IM route, including better bioavailability, rapid onset of action, and early “atropinization.”3 It is a relatively safe and effective procedure (with the aim of substituting conventional IM injections), and is readily available in the form of ophthalmic drops.1-3 Yet, there are very few clinical studies on the safety and efficacy of sublingually delivered atropine for the treatment of sialorrhea.3-7

A single randomized controlled trial investigated the efficacy of atropine to reduce salivary hypersecretion with 2 drops of 0.5% SL atropine (0.5 mg total dose).4 In the 22 adults who were receiving palliative care in the trial, the drug failed to show any benefit versus placebo.3 The authors of this study suggested that their findings might have been a result of inadequate dosing.4 In contrast, sublingual atropine was a simple and inexpensive treatment for sialorrhea, as reported by an open-label pilot study of sublingual atropine drops for the treatment of sialorrhea in seven patients (six with Parkinson’s disease, one with progressive supranuclear palsy).5 Participants demonstrated statistically significant declines in saliva production, both objectively and subjectively, and the majority of patients did not experience any anticholinergic side effects.5

In 2000, there was a case report of a 44 year old female with chronic schizophrenia with hypersalivation secondary to clozapine.6 It cited resolution of persistent symptoms after administration of atropine 1% eye drops, 1 to 2 drops (0.5 to 1 mg) administered sublingually in the morning.6 The patient also reported no adverse effects from the treatment, which appeared to be the benefit of local administration of atropine versus systemic use (e.g. IM, IV).6 An updated report on the benefit of atropine drops for the treatment of sialorrhea induced by clozapine described that several patients experienced rebound sialorrhea due to the short duration of atropine, which necessitated repeat dosing.7

Although atropine does not require any specialized skill for use, unlike surgical removal, and has reversible effects, it is still contraindicated in patients with cognitive impairment, dementia, or hallucinations.1,2,4 These patients are at higher risks for overdose due to mishandled dropper bottles.1,2,4 Some patients reported difficulty in manipulating the dropper to ensure proper dosing.6 In addition, dropper sizes are not standardized; ideally, 1 drop of 1% atropine solution should contain 500 micrograms of atropine (if 20 drops are in 1 mL of solution).1,2 The potential for accidental overdose with drops is therefore, worrisome.6

Drug-related adverse effects caused by atropine include dry mouth, blurred vision, urinary hesitancy and retention, tachycardia, palpitation, and constipation.1,2 It may also produce CNS disturbances, ataxia, hallucinations, and delirium, but these effects are more common with systemic doses of atropine (exceeding 10 mg) and are rare with local administration.1,2 Therefore, it is necessary that a patient’s heart rate, blood pressure, and mental status be monitored closely while on extended and high daily dose therapy with this drug.1

Hence, even with limited trial data, it seems that 1-2 drops (0.5 to 1 mg) of 1% ophthalmic atropine sulfate every 4 to 6 hours (not exceeding 10 mg daily) may be both effective and safe in the treatment of sialorrhea.1-7

SOURCES:

Published by Rho Chi Post

Common Hospice Medications

Medication is of course an integral part of the hospice process. If you or a loved one are considering or already under hospice care, you should be informed about the types of medications used. This article is designed to do just that, without getting overly bogged down in confusing medical terminology. Many readers print out this article to have handy the next time they meet with a medical professional.

Hospice medications list.

Below is an alphabetical list of common hospice medications and what they are used for, along with additional relevant information.

Acetaminophen.

According to a study published by the National Institutes of Health (NIH), acetaminophen is the most commonly prescribed hospice medication. Known by the brand name Tylenol, it is used to reduce fever and pain. It temporarily relieves minor aches and pains due to headache, backache, toothache, the common cold, and minor pain related to arthritis. While side effects are rare, serious side effects can include nausea, upper stomach pain, itching, loss of appetite, dark urine, clay-colored stools, or jaundice (yellowing of the skin or eyes). Adverse interactions could occur with the following drugs: Warfarin (Coumadin), Isoniazid (Laniazid, Nydrazid), Diflunisal (Dolobid), Carbamazepine (Tegretol), phenobarbital (Luminal), and phenytoin (Dilantin).

Anticholinergics.

Anticholinergic and antispasmodic drugs are used to regulate contraction and relaxation of muscles. Benadryl is a commonly known medication that falls in this category. Conditions that may require anticholinergics include Parkinson’s, COPD, asthma, overactive bladder, muscle spasms, breathing problems, diarrhea, gastrointestinal cramps, movement disorders, and others. Side effects of anticholinergic and antispasmodic drugs can include blurred vision, confusion, constipation, decreased sweat or urine production, delirium, dry eyes, dry mouth, or impaired memory. It’s important to note that these drugs can worsen the following conditions: Alzheimer’s disease, enlarged prostate, glaucoma, myasthenia gravis, and urinary bladder neck obstruction. Anticholinergics should not be used with the following: certain antidepressants, anti-diarrheal medications, certain antiemetics, antipsychotics, antispasmodics, histamine 1-receptor blockers (H1RA), or motion-sickness, overactive bladder (OAB), or Parkinson’s medications.

Antidepressant medications.

In that same study published by the NIH, antidepressants were 11th among the 20 most commonly prescribed classes of medication prescribed for hospice patients with cancer, dementia, and lung disease. Antidepressants are designed to help relieve symptoms of depression, social anxiety disorder, anxiety disorders, seasonal affective disorder, and dysthymia, or mild chronic depression, in addition to other conditions. Selective serotonin reuptake inhibitors (SSRIs) and serotonin and noradrenaline reuptake inhibitors (SNRIs) are the most commonly prescribed types of antidepressants. Prozac and Zoloft are two commonly recognized brands of antidepressants. Possible side effects include agitation, anxiety, constipation or diarrhea, dizziness, dry mouth, headache, hypoglycemia (low blood sugar), insomnia, low sodium, nausea, rash, sedation, sexual dysfunction, suicidal thoughts, sweating, tremors, and weight loss. Alcohol should be avoided when taking antidepressants. The following also can produce adverse interactions: anti-epileptics, benzodiazepines, Buspirone, Lithium, MAOIs, Metoprolol/Propranolol (blood pressure), NSAIDs including aspirin, Perhexilene, Selegline, Sibutramine, St. John’s Wart, Sumatriptan, Tramadol, and Warfarin.

Anxiolytics.

As their name suggests, these medications are used to treat anxiety. However, they can be used to treat other conditions, including alcohol withdrawal symptoms, depression, insomnia, itching, nausea, panic disorder, seizures, and vomiting. The International Association of Hospice and Palliative Care (IAHPC) lists anxiolytics as one of the “essential medicines in palliative care.” Side effects may include blurred vision, confusion, constipation, diarrhea, drowsiness, dry mouth, headache, increased heart rate, sedation, sexual dysfunction, stomach upset, suicidal thoughts, and weight gain. Anxiolytics should not be used with alcohol, Buspirone, Carbamazepine, hydroxyzine, MAOIs, pioglitazone (Actos), rosiglitazone (Avandia), SNRIs, or SSRIs.

Atropine Drops.

In a hospice setting, atropine eye drops are used instead of injections to reduce excess mucus secretion and saliva production. Atropine also is used to treat colitis, diverticulitis, excessive stomach and acid production, gastrointestinal spasms, certain heart disorders, IBS, Parkinson’s disease, peptic ulcers, and spastic bladder. Atropine came in fourth among commonly prescribed drugs in the NIH-published study. Drug-related adverse effects include blurred vision, constipation, dry mouth, palpitation, tachycardia, and urinary problems. Caution should be taken if using any of the following, among other drugs: belladonna; bladder or urinary medications; bronchodilators such as Spiriva, digitalis, Dramamine; and IBS medications.

Fentanyl.

Fentanyl is a hospice medication used to help relieve severe, ongoing pain such as that caused by cancer. Patients with consistent pain, particularly those with difficulty swallowing, are often prescribed a long-acting Fentanyl transdermal patch. This medication also can be dispensed in a dissolving, under-the-tongue tablet. Among drugs listed in the NIH study, Fentanyl came in 18th. Serious side effects include confusion, decreased urge to breathe, difficulty breathing or swallowing, extreme drowsiness, fainting, and slow or shallow breathing. Other possible serious side effects include agitation, changes in heartbeat, diarrhea, dizziness, fever, hives/rash/itching, hallucinations, loss of appetite, loss of coordination, muscle stiffness or twitching, nausea, seizures, shivering, sweating, vomiting, and weakness. Some products that may interact with Fentanyl include certain pain medications and naltrexone. It should be noted that many hospice service providers (including Crossroads) do not administer Fentanyl to patients as it is cost prohibitive and there are more efficient medications available for managing pain.

Haldol (also Known as Haloperidol).

Haldol is an antipsychotic drug used in the treatment of terminal agitation and delirium. It’s important to note that Haldol injection is not approved for the treatment of patients with dementia-related psychosis. It’s also important to note that some states view the drug as a chemical restraint and therefore put restrictions on its use at long-term care facilities. Serious side effects include confusion, dizziness, fainting, fast or pounding heartbeat, flu-like symptoms, high fever, restless or rigid muscles, seizures, sweating, and tremors. The following drugs may lead to adverse interactions when used with Haldol: amphetamine, anti-anxiety medications, certain antibiotics, anticholinergics, antidepressants, muscle relaxants, narcotic pain relievers, Parkinson’s medications, psychiatric medications, sleep aids, and those regulating heart rhythm.

Find out more about Haldol.

Lorazepam (Ativan).

Lorazepam is used to treat anxiety. Per the previously mentioned study, Lorazepam was the second most-prescribed drug among hospice patients. Possible serious side effects include difficulty breathing or swallowing, fever, irregular heartbeat, shuffling walk, skin rash, tremors, and yellowing of the skin or eyes. Additional side effects can range from fatigue to stomach and urinary problems. Medications to avoid when taking Lorazepam include antidepressants, antihistamines, anti-seizure drugs, asthmas/cold/allergy medications, muscle relaxants, Parkinson’s disease medications, and sedatives.

Find out more about Lorazepam.

Prochlorperazine.

Prochlorperazine suppositories and tablets are used to control severe nausea and vomiting; tablets are also used to treat the anxiety that could not be controlled by other medications, as well as schizophrenia. This drug was ranked sixth in the NIH study. Prochlorperazine is not approved by the FDA for the treatment of behavior problems in older adults with dementia. Possible side effects include agitation, increased appetite/weight gain, blank facial expression, blurred vision, breast enlargement/milk production, constipation, difficulty urinating, dizziness, drooling, dry mouth, headache, nausea, change in size of pupils, shaking, shuffling walk, sleep issues, and stuffy nose. Caution should be taken when using Lorazepam in conjunction with any of the following: anti-anxiety medications, antidepressants, antidiarrheal (such as Lomotil), antihistamines, anti-seizure medications, blood thinners, diuretics, Epipen, IBS medications, lithium, motion sickness medications, narcotics, Parkinson’s disease medications, sedatives, and ulcer or urinary medications.

Roxanol (Morphine Sulfate).

Commonly known as morphine, this opioid drug is a narcotic analgesic used to control severe acute and chronic pain. According to American Nurse Today, the official journal of the American Nurses Association, pain is the most common end-of-life symptom. Morphine is among the most common hospice medications used to treat pain, with morphine the preferred drug for cancer-related pain. Morphine also is the most commonly used drug for shortness of breath. Its side effects can include shallow breathing/slow heartbeat, convulsions, cold/clammy/pale skin, confusion, weakness, infrequent urination, and trouble swallowing. Some products that may interact with morphine include certain pain medications (mixed opioid agonist/antagonists such as pentazocine, nalbuphine, or butorphanol) and naltrexone.

Find out more about Roxanol.

Does hospice just “dope up” patients?

In addition to medication, the emotional and spiritual needs of the patient also must be taken into consideration. That’s why each patient’s team includes not just medical professionals but also social workers, clergy, and volunteers. Crossroads Hospice & Palliative Care Services also provides unique life experiences such as a Gift of a Day and Life Journals.

For answers to other hospice-related questions you may have, visit our FAQ.

Have more questions about common hospice medications?

If you have any questions about the medicines listed above, or other medicines not listed here, please contact us. The blue help bar at the top of this page gives you 24-hour access to caring hospice professionals ready to help.

Atropine (Muscarinic Receptor Antagonist)

General Pharmacology

The vagus (parasympathetic) nerves that innervate the heart release acetylcholine (ACh) as their primary neurotransmitter. ACh binds to muscarinic receptors (M2) that are found principally on cells comprising the sinoatrial (SA) and atrioventricular (AV) nodes. Muscarinic receptors are coupled to the Gi-protein; therefore, vagal activation decreases cAMP. Gi-protein activation also leads to the activation of KACh channels that increase potassium efflux and hyperpolarizes the cells.

Increases in vagal activity to the SA node decreases the firing rate of the pacemaker cells by decreasing the slope of the pacemaker potential (phase 4 of the action potential); this decreases heart rate (negative chronotropy). The change in phase 4 slope results from alterations in potassium and calcium currents, as well as the slow-inward sodium current that is thought to be responsible for the pacemaker current (If). By hyperpolarizing the cells, vagal activation increases the cell’s threshold for firing, which contributes to the reduction the firing rate. Similar electrophysiological effects also occur at the AV node; however, in this tissue, these changes are manifested as a reduction in impulse conduction velocity through the AV node (negative dromotropy). In the resting state, there is a large degree of vagal tone on the heart, which is responsible for low resting heart rates.

There is also some vagal innervation of the atrial muscle, and to a much lesser extent, the ventricular muscle. Vagus activation, therefore, results in modest reductions in atrial contractility (inotropy) and even smaller decreases in ventricular contractility.

Muscarinic receptor antagonists bind to muscarinic receptors thereby preventing ACh from binding to and activating the receptor. By blocking the actions of ACh, muscarinic receptor antagonists very effectively block the effects of vagal nerve activity on the heart. By doing so, they increase heart rate and conduction velocity.

Specific Drugs and Therapeutic Indications

Atropine is a muscarinic receptor antagonist that is used to inhibit the effects of excessive vagal activation on the heart, which is manifested as sinus bradycardia and AV nodal block. Therefore, atropine can temporarily revert sinus bradycardia to normal sinus rhythm and reverse AV nodal blocks by removing vagal influences.

Side Effects and Contraindications

The anticholinergic effects of atropine can produce tachycardia, pupil dilation, dry mouth, urinary retention, inhibition of sweating (anhidrosis), blurred vision and constipation. However, most of these side effects are only manifested with excessive dosing or with repeated dosing. Atropine is contraindicated in patients with glaucoma.

Revised 03/15/07

This information from Lexicomp® explains what you need to know about this medication, including what it’s used for, how to take it, its side effects, and when to call your healthcare provider.

Brand Names: US

Isopto Atropine

Brand Names: Canada

Isopto Atropine; Minims Atropine Sulfate; Odan-Atropine

What is this drug used for?

  • It is used to widen the pupil before an eye exam or eye surgery.
  • It is used to treat eye swelling.
  • It is used to treat lazy eye (amblyopia).

What do I need to tell the doctor BEFORE my child takes this drug?

  • If your child is allergic to this drug; any part of this drug; or any other drugs, foods, or substances. Tell the doctor about the allergy and what signs your child had.
  • If your child has glaucoma.
  • If your child has had a bad reaction to this drug in the past.

This is not a list of all drugs or health problems that interact with this drug.

Tell the doctor and pharmacist about all of your child’s drugs (prescription or OTC, natural products, vitamins) and health problems. You must check to make sure that it is safe for your child to take this drug with all of his/her drugs and health problems. Do not start, stop, or change the dose of any drug your child takes without checking with the doctor.

What are some things I need to know or do while my child takes this drug?

All eye products:

  • Tell all of your child’s health care providers that your child is taking this drug. This includes your child’s doctors, nurses, pharmacists, and dentists.
  • Have your child avoid tasks or actions that call for clear eyesight while your child’s pupils are dilated.
  • Bright lights may bother your child for some time after using this drug. Have your child wear sunglasses for as long as you were told by your child’s doctor.
  • This drug may cause harm if swallowed. If this drug is swallowed, call a doctor or poison control center right away.
  • Use with care in children. Talk with the doctor.

If your child is pregnant or breast-feeding a baby:

  • Talk with the doctor if your child is pregnant, becomes pregnant, or is breast-feeding a baby. You will need to talk about the benefits and risks to your child and the baby.

Eye drops:

  • Do not give this drug to a child younger than 3 months of age.

What are some side effects that I need to call my child’s doctor about right away?

WARNING/CAUTION: Even though it may be rare, some people may have very bad and sometimes deadly side effects when taking a drug. Tell your child’s doctor or get medical help right away if your child has any of the following signs or symptoms that may be related to a very bad side effect:

  • Signs of an allergic reaction, like rash; hives; itching; red, swollen, blistered, or peeling skin with or without fever; wheezing; tightness in the chest or throat; trouble breathing, swallowing, or talking; unusual hoarseness; or swelling of the mouth, face, lips, tongue, or throat.
  • Signs of high blood pressure like very bad headache or dizziness, passing out, or change in eyesight.
  • A fast heartbeat.
  • A heartbeat that does not feel normal.
  • Flushing.
  • Restlessness.
  • Feeling irritable.
  • Dry mouth.
  • Dry skin.
  • Change in eyesight, eye pain, or very bad eye irritation.

What are some other side effects of this drug?

All drugs may cause side effects. However, many people have no side effects or only have minor side effects. Call your child’s doctor or get medical help if any of these side effects or any other side effects bother your child or do not go away:

  • Blurred eyesight.
  • Stinging.
  • Eye irritation.
  • Feeling sleepy.

These are not all of the side effects that may occur. If you have questions about side effects, call your child’s doctor. Call your child’s doctor for medical advice about side effects.

You may report side effects to your national health agency.

How is this drug best given?

Give this drug as ordered by your child’s doctor. Read all information given to you. Follow all instructions closely.

All eye products:

  • For the eye only.
  • Wash hands before and after use.
  • Do not touch the container tip to your child’s eye, lid, or other skin.

Eye drops:

  • Tilt your child’s head back and drop drug into the eye.
  • After giving this drug, ask your child to keep eyes closed. Put light pressure on the inside corner of the eye. Do this for 1 to 2 minutes. This keeps the drug in your child’s eye.
  • Have your child take out contact lenses before using this drug. Talk with the doctor to see when lenses may be put back in after this drug is given. Do not put lenses back in if your child’s eyes are irritated or infected.

Eye ointment:

  • Gently pull down the lower lid and squeeze in how much the doctor told you to use.
  • Let go of the lower eyelid and have your child keep eyes closed for 1 to 2 minutes.

What do I do if my child misses a dose?

  • Give a missed dose as soon as you think about it.
  • If it is close to the time for your child’s next dose, skip the missed dose and go back to your child’s normal time.
  • Do not give 2 doses at the same time or extra doses.

How do I store and/or throw out this drug?

  • Store at room temperature.
  • Protect from heat.
  • Keep all drugs in a safe place. Keep all drugs out of the reach of children and pets.
  • Throw away unused or expired drugs. Do not flush down a toilet or pour down a drain unless you are told to do so. Check with your pharmacist if you have questions about the best way to throw out drugs. There may be drug take-back programs in your area.

General drug facts

  • If your child’s symptoms or health problems do not get better or if they become worse, call your child’s doctor.
  • Do not share your child’s drug with others and do not give anyone else’s drug to your child.
  • Some drugs may have another patient information leaflet. If you have any questions about this drug, please talk with your child’s doctor, nurse, pharmacist, or other health care provider.
  • If you think there has been an overdose, call your poison control center or get medical care right away. Be ready to tell or show what was taken, how much, and when it happened.

Consumer Information Use and Disclaimer

This information should not be used to decide whether or not to take this medicine or any other medicine. Only the healthcare provider has the knowledge and training to decide which medicines are right for a specific patient. This information does not endorse any medicine as safe, effective, or approved for treating any patient or health condition. This is only a brief summary of general information about this medicine. It does NOT include all information about the possible uses, directions, warnings, precautions, interactions, adverse effects, or risks that may apply to this medicine. This information is not specific medical advice and does not replace information you receive from the healthcare provider. You must talk with the healthcare provider for complete information about the risks and benefits of using this medicine.

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