Glycopyrrolate methobromide. 1. Effect on salivary secretion

Comparison of the Effects of Atropine and Glycopyrrolate on various End-Organs1

Atropine and glycopyrrolate (glycopyrronium bromide), a quaternary ammonium drug, were evaluated in volunteers following intramuscular administration with respect to effects on various end-organs with cholinergic innervation. Glycopyrrolate appears to be five to six times more potent than atropine in its antisialogogue effect and also exhibits a selective, though prolonged, effect on salivary secretion and sweat gland activity. It has minimal cardiovascular, ocular and central nervous system effects.

Use of glycopyrrolate in the treatment of Meniere's disease

OBJECTIVES/HYPOTHESIS

The objective of this study was to determine whether glycopyrrolate is useful as a vestibular suppressant in patients with Meniere's disease. The tested hypotheses were that glycopyrrolate would decrease the perception of dizziness measured by the Dizziness Handicap Inventory in patients with Meniere's disease and that placebo would cause no such decrease.

STUDY DESIGN

Randomized, prospective.

METHODS

Thirty-seven subjects with a diagnosis of Meniere's disease were administered either 2 mg of glycopyrrolate or placebo twice daily as needed for vertigo. All were also administered the regimen of 1500 mg sodium/day diet and diuretic. The following indices were examined: Dizziness Handicap Inventory, Tinnitus Handicap Inventory, Modified Somatic Perception Questionnaire, Beck Depression Inventory, hearing examination, and electronystagmography. After 4 to 6 weeks of the drug regimen, Dizziness Handicap Inventory, Tinnitus Handicap Inventory, Modified Somatic Perception Questionnaire, and Beck Depression Scale were reexamined. Paired t tests were performed to verify the significance of improvement before and after treatment.

RESULTS

Subjects who received glycopyrrolate had statistically significant reduction in Dizziness Handicap Inventory, Beck Depression Score, and Modified Somatic Perception Score. In the placebo group, no improvement in any index was found.

CONCLUSIONS

The hypothesis that glycopyrrolate is a useful vestibular suppressant in patients with Meniere's disease was statistically verified.

Management of secretions in esophageal cancer patients with glycopyrrolate

BACKGROUND

There has been little emphasis in the past upon management of excessive secretions in patients with esophageal cancer. We used the drug glycopyrrolate for controlling secretions in patients with esophageal cancer.

PATIENTS AND METHODS

Between January 1991 and September 1995, 45 patients with esophagus cancer were referred for evaluation. Seven of these patients were treated with glycopyrrolate for increased secretions. Secretions were measured in suction canisters which were used by patients.

RESULTS

All the patients showed a decrease in secretions within 24 48 hours of administration. The incidence of side effects was minimal.

CONCLUSIONS

Glycopyrrolate is quite effective in palliating esophageal cancer patients with excessive secretions.

Autonomic and cardiovascular effects of neuromuscular blockade antagonism in the dog

Autonomic and cardiovascular changes were studied when neuromuscular blockade was antagonized in 96 dogs with one of eight anticholinesterase-antimuscarinic drug combinations. Neostigmine (50 or 100 micrograms/kg) was administered before or after atropine (40 micrograms/kg) or glycopyrrolate (10 micrograms/kg). The high dose of neostigmine (100 micrograms/kg) caused bradyarrhythmias, salivation, and signs of bronchosecretion when used with either antimuscarinic agent and irrespective of the administration sequence. The heart rate increased, but not significantly, when atropine was injected before either dose of neostigmine. This did not occur when this administration sequence was reversed. Arrhythmias and cardiovascular and autonomic changes did not occur when glycopyrrolate was injected before or after neostigmine at 50 micrograms/kg.

Oral atropine enhances the risk for acid aspiration in children

Two modes of administration of an anticholinergic drug were compared in 58 healthy children undergoing adenoidectomy. The study was double-blind and randomized. All children were premedicated with oral midazolam 0.5 mg/kg. Twenty-nine children received oral atropine 0.03 mg/kg (Group A) and the rest were given i.v. glycopyrrolate 0.005 mg/kg at the induction of anaesthesia (Group G). In Group A, of 29 children, the stomach was empty in 2, pH was less than 2.5 in 23, the gastric volume was greater than 0.4 ml/kg in 19, and both these risk factors were present in 17 children. The same figures in Group G were 5 (NS), 14 (P less than 0.05), 10 (P less than 0.05) and 9 (P less than 0.05) children, respectively. The antisialagogue effect was similar in both groups.

Twelve-hour bronchodilation in asthma with a single aerosol dose of the anticholinergic compound glycopyrrolate

Anticholinergic aerosols provide effective bronchodilation in some patients with obstructive lung disease. Glycopyrrolate is a quaternary ammonium anticholinergic compound that is poorly absorbed from mucus membranes, thus reducing anticholinergic side effects. In 20 adult patients with asthma, we evaluated bronchodilation to a single administration of metered-dose glycopyrrolate aerosol (GA) to ascertain its onset and duration of action along with evaluation of safety. In this randomized, double-blind, placebo-controlled, single-dose, crossover trial, bronchodilation was evaluated on five separate occasions to either placebo or a GA dose of 80, 240, 480, or 960 micrograms. Baseline spirometry for each patient on each visit was similar (mean FEV1 +/- SD of 62.2 +/- 13.6% predicted). After aerosol dosing, spirometry was measured at 30 minutes and then at hourly intervals up to 12 hours. Compared to placebo, metered-dose aerosols of 240, 480 and 960 micrograms elicited significantly greater bronchodilation at each test time. Furthermore, significant bronchodilation was noted within 30 minutes of dosing and was sustained for at least 12 hours. Bronchodilation with the 480 and 960 micrograms dose was equal, and both were greater than 240 micrograms. A subset of four asthma patients with baseline FEV1 values less than 50% predicted did not have a bronchodilating response with GA. No notable side effects occurred. Thus, a single aerosol dose of GA provides clinically significant, safe 12-hour bronchodilation in patients with asthma without severe airway obstruction (i.e., FEV1 greater than 50% predicted).

Prolonged effect of inhaled glycopyrrolate in asthma

Glycopyrrolate, a quaternary ammonium anticholinergic compound is a potentially useful bronchodilator. To determine the efficacy, optimal dose, and duration of action of inhaled glycopyrrolate, we gave the drug to 11 asthmatic patients. Each subject received placebo or glycopyrrolate (100, 200, 600, or 1,200 micrograms) by inhalation in a double-blind, randomized, crossover design. Measurements included FEV1, FVC, heart rate, and blood pressure before administration of the drug and periodically for 12 hours. For eight hours following all doses of glycopyrrolate, both FEV1 and FVC (both as percent of predicted) were significantly greater for drug than for placebo. Glycopyrrolate may be a useful long-acting drug for the treatment of asthma.

Effect of inhaled glycopyrrolate and atropine in asthma. Precipitated by exercise and cold air inhalation

We compared the effects of inhaled glycopyrrolate (G), 1.3 mg, and atropine (A), 2.6 mg, and placebo on FEV1 and specific conductance (sGaw) before and after exercise in six men with exercise-induced asthma. Subjects exercised with cold air (-2 degrees C) 30 and 120 minutes after each aerosol treatment. Spirometry was performed and sGaw determined before aerosol treatment (baseline) and before and after exercise. Decreased airway tone was noted before exercising with A and G but not with placebo. The decreases in FEV1 and sGaw resulting from exercise were not significantly different among the three treatment groups at either exercise session. Postexercise FEV1 and sGaw were significantly higher after A and G compared to P. Dry mouth, flushing, and resting tachycardia were prominent with group A. Symptoms in G did not differ from those in P. This study suggests that A and G do not prevent bronchoconstriction induced by exercise and cold air but improve postexercise pulmonary function by achieving preexercise bronchodilation. Systemic side effects were minimal with G compared to A.

Glycopyrrolate: pharmacology and clinical use

This is a review of glycopyrrolate whose function in clinical practice is compared with that of atropine.

Atropine and glycopyrrolate: changes in cardiac rate and rhythm in conscious and anaesthetised children

Heart rate and rhythm were studied in conscious children and children under nitrous oxide and halothane anaesthesia following intravenous administration of atropine or glycopyrrolate. Both drugs produced a similar increase in heart rate when the potency of glycopyrrolate is considered twice that of atropine. There is no difference in the response of anaesthetised and awake children. Junctional rhythm is the main dysrhythmia observed which appears to occur more frequently in anaesthetised children. The administration of both drugs is safe in paediatric patients.

Effects of intravenous administration of glycopyrrolate and atropine in anaesthetised patients

The effects of glycopyrrolate in doses of 5, 10 and 15 microgram/kg and atropine 10, 20 and 30 microgram/kg on heat rate and rhythm was studied in anesthetised patients. Both drugs produced a dose-related increase in heart rate. Glycopyrrolate was approximately twice as potent as atropine in increasing heart rate. The average time taken to achieve peak effect was 2-6 and 3-7 minutes for atropine and glycopyrrolate respectively, and this was significantly different. The smallest doses of both drugs were generally associated with supraventricular dysrhythmias, whereas these were mainly ventricular following the highest dose of both drugs.

Reversal of non-depolarising neuromuscular block in children: a comparison of atropine and glycopyrrolate in a mixture with neostigmine

Atropine and glycopyrrolate were compared when given in a mixture with neostigmine for the reversal of non-depolarising neuromuscular block in children. Glycopyrrolate was an effective antimuscarinic agent and could be safely used as an alternative to atropine, although the advantages in this age group were not as marked as have been observed in adults.

Comparison of Glycopyrrolate, atropine and hyoscine in mixture with neostigmine for reversal of neuromuscular block following closed mitral valvotomy

Atropine, glycopyrrolate and hyoscine were compared in a mixture with neostigmine for the reversal of neuromuscular block in patients undergoing closed mitral valvotomy. Both atropine and glycopyrrolate were effective in counteracting the muscarinic effects of neostigmine. Glycopyrrolate was, associated with less initial increase in heart rate, a factor of importance in patients with mitral stenosis. The incidence of significant dysrhythmias was low in this small series. The control of secretions was better with glycopyrrolate. Administration of hyoscine was associated with unacceptable falls in heart rate and is not recommended.

Intravenous administration of glycopyrronium: effects on cardiac rate and rhythm

Intravenous administration of glycopyrronium in doses up to 0.2 mg, was associated with minimal changes in cardiac rate and rhythm. Sinus arrhythmia, nodal rhythm and occasional atrial ectopics were the dysrhythmias observed. There were no accompanying changes in blood pressure.

Atropine and hyoscine

The drugs atropine and hyoscine are reviewed in the context of their use by anaesthetists. The results of recent studies are stressed and guidelines given for use of these drugs in modern anaesthetic practice.

Effects on muscarinic receptors of various agents in reversal of neuro-muscular blockade: a study evaluating atropine, glycopyrron, neostigmine and pyridostigmine

The effects were studied of various drug combinations, recommended for use in reversal of neuromuscular blockade, on heart rate and salivary secretions in 80 healthy patients anaesthetized with nitrous oxide-oxygen-halothane and relaxed with d-tubocurarine. The drug combinations were mixtures of atropine 1 mg--neostigmine 2.5 mg, atropine 1 mg--pyridostigmine 15 mg, glycopyrron 0.5 mg--neostigmine 2.5 mg, and glycopyrron 0.5 mg--pyridostigmine 15 mg, respectively. It was found that administration of the atropine-containing mixtures induced more pronounced initial increases and delayed decreases in heart rate than the mixtures containing glycopyrron. Pyridostigmine-containing mixtures elicited a somewhat more pronounced initial increase in heart rate than neostigmine-containing mixtures, but a less pronounced and delayed decrease in heart rate. Supraventricular arrhythmias occurred less frequently in the pyridostigmine groups than in the neostigmine groups. No such difference was found between the atropine and glycopyrron groups. Glycopyrron caused a more intense dryness of the mouth than atropine. A differential attitude towards the use of drugs for reversal of neuromuscular blockade, based on the cardiovascular state of the particular patient, might be recommendable.

Evaluation of the anticholinergic actions of glycopyrronium bromide

1. Glycopyrronium was evaluated by intramuscular, intravenous and oral routes in six adult volunteers for its efficacy as an antisialogogue as also for its action on other aspects of cholinergic activity. 2. It was found to be an effective antisialogogue of long duration of action by all three routes. When given orally the effects were delayed in onset and persisted for too long. Intramuscular and intravenous routes were useful. The intramuscular absorption of the drug is rapid and consistent. 3. Sweat gland activity was affected in a similar fashion but less consistently and other parameters were mostly unaffected. 4. Glycopyrronium 0.2 mg intramuscularly was found to be the optimal dose. Larger doses produced subjective discomfort out of proportion to a further reduction in salivary secretion. 5. Intravenous administration causes no changes in cardiovascular stability.

Glycopyrrolate methobromide: 2. comparison with atropine sulphate in anaesthesia

A double blind study of 98 patients was undertaken to compare the clinical usefulness of atropine and glycopyrrolate for pre-anaesthetic medication and their relative effectiveness in antagonizing the muscarinic effects of neostigmine methylsulphate given to reverse neuromuscular blockade. Intramuscular administration of atropine 0.4 mg or of glycopyrrolate 0.2 mg produced the same degree of dryness of the pharynx. However, glycopyrrolate was found to be a more potent antagonizer of the increased salivation induced by neostigmine. By intramuscular administration, both drugs produced the same degree of tachycardia, although atropine tended to cause no change in the pulse rate or even to produce bradycardia in a greater number of patients. Administered intravenously, atropine produced a more significant tachycardia in a large number of patients prior to neostigmine administration, although the protection against a decreased pulse rate from neostigmine is greater in those patients who received glycopyrrolate. It would appear, therefore, that glycopyrrolate is more effective in antagonizing the muscarinic effects of neostigmine methylsulphate.