Pharmacological interventions for antipsychotic-related sialorrhea: a systematic review and network meta-analysis of randomized trials

Antipsychotic-induced sialorrhea carries a significant burden, but evidence-based treatment guidance is incomplete, warranting network meta-analysis (NMA) of pharmacological interventions for antipsychotic-related sialorrhea. PubMed Central/PsycInfo/Cochrane Central database/Clinicaltrials.gov/WHO-ICTRP and the Chinese Electronic Journal Database (Qikan.cqvip.com) were searched for published/unpublished RCTs of antipsychotic-induced sialorrhea (any definition) in adults, up to 06/12/2023. We assessed global/local inconsistencies, publication bias, risk of bias (RoB2), and confidence in the evidence, conducting subgroup/sensitivity analyses. Co-primary efficacy outcomes were changes in saliva production (standardized mean difference/SMD) and study-defined response (risk ratios/RRs). The acceptability outcome was all-cause discontinuation (RR). Primary nodes were molecules; the mechanism of action (MoA) was secondary. Thirty-four RCTs entered a systematic review, 33 NMA (n = 1958). All interventions were for clozapine-induced sialorrhea in subjects with mental disorders. Regarding individual agents and response, metoclopramide (RR = 3.11, 95% C.I. = 1.39-6.98), cyproheptadine, (RR = 2.76, 95% C.I. = 2.00-3.82), sulpiride (RR = 2.49, 95% C.I. = 1.65-3.77), propantheline (RR = 2.39, 95% C.I. = 1.97-2.90), diphenhydramine (RR = 2.32, 95% C.I. = 1.88-2.86), benzhexol (RR = 2.32, 95% C.I. = 1.59-3.38), doxepin (RR = 2.30, 95% C.I. = 1.85-2.88), amisulpride (RR = 2.23, 95% C.I. = 1.30-3.81), chlorpheniramine (RR = 2.20, 95% C.I. = 1.67-2.89), amitriptyline (RR = 2.09, 95% C.I. = 1.34-3.26), atropine, (RR = 2.03, 95% C.I. = 1.22-3.38), and astemizole, (RR = 1.70, 95% C.I. = 1.28-2.26) outperformed placebo, but not glycopyrrolate or ipratropium. Across secondary nodes (k = 28, n = 1821), antimuscarinics (RR = 2.26, 95% C.I. = 1.91-2.68), benzamides (RR = 2.23, 95% C.I. = 1.75-3.10), TCAs (RR = 2.23, 95% C.I. = 1.83-2.72), and antihistamines (RR = 2.18, 95% C.I. = 1.83-2.59) outperformed placebo. In head-to-head comparisons, astemizole and ipratropium were outperformed by several interventions. All secondary nodes, except benzamides, outperformed the placebo on the continuous efficacy outcome. For nocturnal sialorrhea, neither benzamides nor atropine outperformed the placebo. Active interventions did not differ significantly from placebo regarding constipation or sleepiness/drowsiness. Low-confidence findings prompt caution in the interpretation of the results. Considering primary nodes' co-primary efficacy outcomes and head-to-head comparisons, efficacy for sialorrhea is most consistent for the following agents, decreasing from metoclopramide through cyproheptadine, sulpiride, propantheline, diphenhydramine, benzhexol, doxepin, amisulpride, chlorpheniramine, to amitriptyline, and atropine (the latter not for nocturnal sialorrhea). Shared decision-making with the patient should guide treatment decisions regarding clozapine-related sialorrhea.

Clinical efficacy of propantheline bromide in neurocardiogenic syncope: pharmacodynamic implications

The pharmacological response with tilt-table testing predicts long-term efficacy in neurocardiogenic syncope. However, beta-blockers for neurocardiogenic syncope are often not tolerated or are ineffective. Since cholinergic tone is important in the efferent part of the neurocardiogenic reflex, we investigated the pharmacodynamics and efficacy of propantheline bromide in preventing neurocardiogenic syncope. We studied 16 patients (11 males) with a mean age of 48.8 (+/- 15.1) years with presyncope or syncope and who had positive baseline tilt-table studies at a mean of 15.8 (+/- 10.3) minutes into the upright 60 degrees tilt. They were given propantheline bromide orally, an anticholinergic agent, at a dose of 64.3 (+/- 21.8) mg/day for 7 days, and tilt-table testing was repeated 1 hour after readministration of propantheline bromide, 30 mg orally. After propantheline bromide treatment, 13 of 16 patients (81%) had no inducible presyncope or syncope on repeat tilt-table testing. In this group of responders, the mean minimum heart rate during upright tilt-table testing increased from 43.2 (+/- 77.3) beats/min to 77.3 (+/- 17.2) beats/min after propantheline bromide (p < 0.005). More significantly, the minimum mean arterial blood pressure increased from 42.2 (+/- 25) mmHg to 81.3 (+/- 16.7) mmHg (p < 0.0005) during upright tilt. At a follow-up of 15.2 (+/- 7.4) months, in the responder group (12 patients with long-term follow-up), the average dose of propantheline bromide was 32.5 (+/- 23.8) mg/day, which was significantly reduced from the initial dose (p < 0.05). A clinical recurrence of symptoms occurred in only 4 out of 12 patients on propantheline bromide (33%), none of which were directly attributable to drug failure. It was concluded from this study that propantheline bromide is highly effective in preventing neurocardiogenic syncope. In addition, propantheline bromide's effectiveness is more than would be expected by prevention of cardioinhibition in neurocardiogenic syncope and would support a role for direct cholinergic control of vascular tone.

Urinary urge incontinence: randomised crossover trials of penthienate versus placebo and propantheline

OBJECTIVE

To compare the efficacy of penthienate with that of propantheline and placebo for treatment of primary idiopathic detrusor instability.

DESIGN

Two prospective, randomised, crossover trials (double-blind for penthienate versus placebo and non-blinded for penthienate versus propantheline).

SETTING

Urology Clinic of Prince Henry Hospital, Sydney, NSW (an outpatient clinic of a tertiary referral hospital), in 1993-1994.

PARTICIPANTS

Neurologically intact patients with urodynamically proven detrusor instability, urgency and urge incontinence, but no stress incontinence (20 participated in the penthienate/placebo trial and 23 in the penthienate/propanthelin trial).

OUTCOME MEASURES

Cystometrography results before and after treatment; frequency and volumes of urine voided in weeks 1 and 4 of treatment; and patient scores for degree of continence, side effects, efficacy and acceptability of treatment.

INTERVENTIONS

Penthienate (5 mg), propantheline (15 mg) or placebo (all three times a day) for 4 weeks.

RESULTS

Penthienate produced significantly greater improvements than placebo in frequency (daytime, P = 0.002; and night-time, P = 0.02), incontinence scores (P = 0.002) and amplitude of unstable detrusor contractions, when present (P = 0.01), and significantly increased diurnal and nocturnal bladder capacity, both on cystometrography (P = 0.003) and by voiding-diary records (P < 0.001). It also increased residual urine volume over the baseline level, but not significantly. Side effects, especially dry mouth, were common with penthienate, and one patient developed urinary retention. Penthienate was significantly better than propantheline in improving cystometric capacity (P = 0.03), and reducing the amplitude of unstable detrusor contractions (P = 0.01), and was perceived as more effective by patients for frequency, nocturia and incontinence.

CONCLUSIONS

Penthienate (5 mg three times a day) was objectively and subjectively significantly better than both placebo and propantheline (15 mg three times a day) for treatment of primary idiopathic detrusor instability.

Randomized, double-blind, multicenter trial on treatment of frequency, urgency and incontinence related to detrusor hyperactivity: oxybutynin versus propantheline versus placebo

Clinical efficacy and adverse effects of oxybutynin and propantheline in the treatment of symptoms related to detrusor hyperactivity were studied in a randomized, controlled, double-blind multicenter trial. Of 169 patients entered into the study 154 were evaluable for statistical analysis. Mean grade of improvement (visual analogue scale) was significantly higher with oxybutynin (58.2%) versus propantheline (44.7%) and placebo (43.4%). Mean bladder volume at first involuntary cystometric contraction was significantly increased with oxybutynin (+57.0 ml.) versus placebo (-9.7 ml.). Mean maximum cystometric bladder capacity was also significantly increased with oxybutynin (+80.1 ml.) versus placebo (+22.5 ml.). Rate of inquired possible adverse effects was significantly higher for oxybutynin (63%) versus propantheline (44%) and placebo (33%). However, only 5 patients dropped out of the study because of adverse effects (oxybutynin 2 and propantheline 3). No serious or lasting adverse effects were encountered with dryness of the mouth being the major complaint. Oxybutynin has statistically significant effects on subjective symptoms and objective urodynamic parameters in patients with detrusor hyperactivity compared to propantheline.

Screening prescription drugs for possible carcinogenicity: eleven to fifteen years of follow-up

Using computerized pharmacy records from 1969 to 1973 for a cohort of 143,574 members of the Kaiser Permanente Medical Care Program, we have been testing associations of 215 drugs or drug groups with subsequent incidence of cancer at 56 sites. This paper presents findings with follow-up through 1984. There were 227 statistically significant (P less than 0.05, two-tailed) associations: 170 positive, 57 negative. Some were undoubtedly chance findings; others were likely due to confounding by unmeasured covariables. However, several associations suggested hypotheses for further studies and/or the need for continued observation. Most notable among findings not previously reported were associations of several antibiotics, both oral and topical, with lung cancer. These associations could not be explained by indications for drug use or by differences in smoking habits between users and nonusers, and suggest a possible link between the occurrence of bacterial infections and risk for cancer. In general, our results continue to suggest that most medications used during that period did not affect cancer incidence substantially. However, for less frequently prescribed medications, our power to detect moderate increases in cancer risk was quite low.

Oxybutinin versus propantheline in the management of detrusor instability. A patient-regulated variable dose trial

Two of the principal drugs used to treat detrusor instability, oxybutinin hydrochloride and propantheline bromide, were compared using clinical and urodynamic outcome measures in a randomized crossover trial with a patient-regulated variable dose regimen. Of the 23 women in the trial, 14 reported subjective improvement during treatment with oxybutinin hydrochloride compared with 11 during treatment with propantheline bromide. Apart from a greater increase in the maximum cystometric capacity with oxybutinin, there were no other objective differences between the two drugs. Oxybutinin significantly delayed the first desire to void, increased the maximum cystometric capacity and reduced the maximum detrusor pressure rise on filling. Propantheline significantly increased the maximum cystometric capacity and reduced the maximum detrusor pressure rise on filling. Three patients stopped treatment due to side-effects.

Pirenzepine and propantheline effects on esophageal pressure responses to bethanechol

Pirenzepine is an antisecretory anticholinergic type drug that has recently been shown to be relatively free of usual anticholinergic side effects on esophageal smooth muscle. It has also been suggested that this drug might release some of the inhibitory control of the esophagus and allow increased muscle contractions. To test this hypothesis, we compared the response of the lower esophageal sphincter (LES) and esophageal peristaltic contractions to bethanechol in 12 healthy controls after background oral doses of placebo, pirenzepine (50 mg), and propantheline (30 mg). After baseline placebo, bethanechol (40 micrograms/kg subcutaneously) produced the expected significant increases in LES pressure and amplitude of peristaltic contractions. Maximal increases were 51.9 +/- 14.9 and 29.5 +/- 7.0%, respectively. Also as expected, propantheline inhibited the cholinergic stimulation from bethanechol, allowing only a 10.1 +/- 13.6% increase in LES pressure and a decrease in peristaltic contraction amplitudes (-44.1 +/- 5.0%) after bethanechol. After background pirenzepine, the responses to bethanechol were intermediate between the other two drugs. A significant increase (44.2 +/- 16.4%) in LES pressure occurred after bethanechol while no significant changes (6.9 +/- 5.8%) were noted in peristaltic amplitudes with this drug. Typical side effects of dry mouth were noted in six of the 12 subjects with propantheline and in only three subjects after pirenzepine. These studies once again confirm the absence of usual anticholinergic side effects with oral pirenzepine compared to oral propantheline in the doses studied. We could find no evidence for a release of cholinergic inhibition after pirenzepine administration.

Oxybutynin versus propantheline in patients with multiple sclerosis and detrusor hyperreflexia

Hyperreflexia is the most common urological finding in patients with multiple sclerosis. A prospective randomized study was done to compare the effectiveness of 2 commonly used drugs, oxybutynin and propantheline. Of the 34 patients entered into the trial 19 were treated with oxybutynin and 15 with propantheline. The urological symptoms (frequency, nocturia, hesitancy, urgency and urge incontinence) were graded according to severity from 0 to 3. Patients with urinary infection were excluded. Urodynamic examination, consisting of cystometrography and electromyography, was performed in all patients before treatment. Both groups of patients had comparable neurological, urological and urodynamic status before treatment. In 4 patients (21 per cent) treated with oxybutynin and in 4 (27 per cent) treated with propantheline side effects were so severe that the treatment had to be discontinued. Symptomatic response to oxybutynin was good in 10 patients (67 per cent), fair in 2 (13 per cent) and poor in 3 (20 per cent). Propantheline produced good symptomatic results in 4 patients (36 per cent), fair in 1 (9 per cent) and poor in 6 (55 per cent). The mean increase in maximum cystometric capacity on cystometrography was significantly larger in the oxybutynin group than in the propantheline group (144 +/- 115 versus 35 +/- 101). Our results indicate that oxybutynin is more effective than propantheline in the treatment of detrusor hyperreflexia in patients with multiple sclerosis.

Nitrofurantoin

For more than 30 years nitrofurantoin has been a widely prescribed and effective agent in the treatment of urinary tract infections. During this time, it has withstood the rigors of constant clinical evaluation and has competed successfully with more recent antibacterial agents. As with many widely used drugs, some serious and potentially hazardous reactions to therapy have been documented. This article reviews and analyzes major reported reactions and interactions from both published and unpublished sources. Incidence rates have been calculated for pulmonary, hepatic, neurological, and hematological responses. Calculated rates of occurrence were very low, and ranged from 0.001 percent of courses of therapy (all types of pulmonary reactions combined) to 0.0007 percent (neurological reactions). Reports on interactions of nitrofurantoin with alcohol, antacids, and oral contraceptives are unfounded and anecdotal. Interactions with nalidixic and oxolinic acids are not clinically significant, and only one case of interaction has been reported with phenytoin. Bioavailability is enhanced by food or propantheline. False positives occur with Benedict's test for urine glucose estimations.

[Contact sensitization to an antiperspirant with the active ingredient propantheline bromide]

In five patients developing axillary contact dermatitis subsequent to the use of an antiperspirant containing propantheline bromide patch testing was performed. Three patients reacted to propantheline bromide. The other two patients exhibited positive patch test reactions to the proprietary product; in these cases, the active ingredient was not tested individually. In all five patients, in addition to the antiperspirant, at least one other contact allergen was identified. In case of localized adverse reactions due to topical treatment of hyperhidrosis axillaris patch testing is recommended. If contact allergy to propantheline bromide is revealed, one should be aware of cross sensitization to methantheline bromide.

Review of cimetidine drug interactions

The literature on cimetidine drug interactions has been thoroughly reviewed. Several different mechanisms have been proposed for cimetidine-related drug interactions. These mechanisms include: (1) impaired hepatic drug metabolism due to inhibition of hepatic microsomal enzymes, (2) reduced hepatic blood flow, resulting in decreased clearance of drugs that are highly extracted by the liver, (3) increased potential for myelosuppression when administered concurrently with other drugs capable of causing myelosuppression, and (4) altered bioavailability of acid-labile drugs. Cimetidine binds reversibly to the hepatic cytochrome P-450 and P-448 systems, resulting in decreased metabolism of drugs that undergo Phase I reactions (e.g., dealkylation and hydroxylation). In contrast, glucuronidation pathways are unaffected. The rapid onset and reversal of cimetidine's inhibition of hepatic metabolism indicates an effect on hepatic enzyme systems. Cimetidine also has been reported to decrease hepatic blood flow. Drugs that are highly extracted by the liver, such as propranolol, lidocaine, and morphine, may be postulated to have a decreased hepatic clearance. Cimetidine, through its effect on gastric pH, may increase the absorption of acid-labile drugs or may decrease the absorption of drugs. There have been reports of increased potential for myelosuppression when cimetidine is administered concurrently with drugs capable of causing bone marrow suppression. An understanding of the mechanisms involved in cimetidine drug interactions allows the clinician to prevent and predict these interactions.

Cimetidine or propantheline combined with antacid therapy for short-term treatment of duodenal ulcer

Seventy-one patients with duodenal ulcer disease completed a 3- to 6-week controlled randomized trial in which cimetidine (1 g daily) was compared with an optimally effective dose of propantheline. Both groups had free access to an antacid suspension. There were no significant differences between the groups concerning ulcer healing, relief of ulcer symptoms, antacid consumption, or patient compliance. After 3 weeks of treatment, endoscopic examination revealed complete ulcer healing in 63% of the cimetidine and 47% of the propantheline treated patients. The corresponding figures after 6 weeks were 94% and 86%, respectively. After 12 weeks, ulcer recurrence was confirmed in 26% of the cimetidine- and 23% of the propantheline-treated patients. Except for the absence of anticholinergic adverse reactions, no significant advantages could be confirmed for combined cimetidine and antacid treatment.

Gastrointestinal radiography with glucagon

This report summarizes the results of nine diagnostic radiographic studies done double blind crossover comparing glucagon to placebo and to anticholinergic drugs in volunteers. In seven studies the subjects were administered drug intramuscularly and in two studies intravenously. There were five diagnostic studies of the upper gastrointestinal tract, one for esophageal varices and three of the colon. The results indicate that glucagon can be given intramuscularly and intravenously. When given intravenously it has a rapid onset and predictable length of action depending on the dose given. Reports of side effects were few consisting primarily of nausea and or vomiting. These results indicate that glucagon is the drug of choice for hypotonic diagnostic examinations.

Anticholinergic drugs, buccal ulceration and mucosal potential difference

Measurement of changes in buccal mucosal potential difference produced by contact with drug formulations may provide a means of predicting their mucosal toxicity and ulcerogenic activity.

The use of Pro-Banthine to induce gastrointestinal hypotonia

Immediate and satisfactory gastrointestinal hypotonia was induced in 48 patients with 5--10 mg of intravenous Pro-Banthine during radiographic examination; side-effects were minimal. If given intravenously in small doses, Pro-Banthine is a satisfactory alternative when glucagon is contraindicated or not available.

Sialoceles: medical treatment first

There are numerous methods described in the literature for sialocele treatment. Surgical modalities usually involve an operation with possible facial nerve injury, with the risk of a general anesthetic, and with prolonged hospitalization to be considered. Among non-surgical modalities radiation and laissez-faire are of questionable efficacy. Propantheline bromide, which medically interrupts the parasympathetic control of salivary secretion, has proved a safe, effective means of rapid sialocele control.

Prolongation of gastric emptying by oral propantheline

The present study shows that a single oral recommended dose of propantheline bromide normally doubles the mean gastric half-emptying time in man. In a prospective, double-blind, randomized crossover design 13 normal subjects were given 30 mg propantheline or placebo 90 min before taking a 113m-indium-labeled liquid test meal, the volume of which was adjusted to body weight. The disappearance of radioisotope from the area of the stomach was determined by external gamma counting. After placebo the mean half-emptying time was 68 min and after propantheline it was 135 min (p less than 0.005). Although salivary flow decreased and pulse rate increased there were no visual disturbances. In studies already reported maximally tolerated oral doses of quaternary ammonium anticholinergic drugs have not consistently retarded gastric emptying in man.

Propantheline as a diagnostic tool--a serious complication

Propantheline bromide is a synthetic quaternary ammonium compound widely used in urologic patients to block the action of acetylcholine at the postganglionic nerve endings of the bladder's parasympathetic innervation. It is used clinically in a wide range of doses in ambulatory outpatients as well as hospitalized patients. To document its effects on the bladder, test doses are given with a cystometrogram documenting the dynamic changes. Herein we report a case of serious cardiac toxicity from a diagnostic test dose.

Double-blind evaluation of glucagon and propantheline bromide (pro-banthine) for hypotonic duodenography

The hypotonic effect of glucagon (2 mg) and propantheline bromide (Pro-Banthine, 30 mg) on the upper gastrointestinal tract was compared in a double-blind study in 12 healthy volunteers and 36 patients. The solvent solution for the two drugs was used as a placebo. Both drugs and placebo were administered intramuscularly. The time of onset of the hypotonic effect was similar for both drugs, with maximum effect achieved 10 min after injection. Effects of glucagon dissapeared rapidly after 30 min, while Pro-Banthine still retained 50% of its maximum effect 2 1/2 hr after injection. Side effects of Pro-banthine were related to the long duration of the hypotonic effect (4-6 hr). A significant placebo effect on the duodenal C loop was observed. Glucagon appears to be the drug of choice since its hypotonic and hypomotile effects on the gastrointestinal tract are comparable to propantheline bromide while having the advantage of shorter duration and practically no side effects.

Sensitization to propantheline bromide, trichlorocarbanilide and propylene glycol in an antiperspirant

Out of 14 patients with axillary dermatitis due to an antiperspirant, and with positive patch test reactions to the product, the sensitizer could be demonstrated in 12. Of these, 11 were positive to propantheline bromide, 3 to trichlorocarbanilide and one to propylene glycol. The antiperspirant contains 90% propylene glycol, which is an irritant under occlusion. When applied in the axillae, where occlusive conditions usually prevail, an irritant effect of propylene glycol may have promoted sensitization to the ingredients of the antiperspirant.

Hypotonic duodenography with glucagon. A clinical comparison study

This clinical double-blind study shows that glucagon (2 mg) is a valuable agent for hypotonic duodenography. Pro-Banthine (45 mg) is slightly more effective as a hypotonic agent, but there is no doubt that its use is associated with more side effects and subsequent patient discomfort; contraindications to its use are more commonly encountered in a general hospital population.

The use of intramuscular propantheline in the short bowel syndrome

A patient is presented with the short bowel syndrome who because of massive diarrhea was unable to maintain fluid and electrolyte balance with the aid of the usual antidiarrhea drugs. Her bowel remnant consisted of approximately 155 cm of proximal jejunum. Intramuscular propantheline has allowed this patient to function normally for the past 36 months. Balance studies are presented to document the benefit of this drug. Propantheline's effectiveness is probably secondary to its marked slowing of intestinal motility.

[Clinical treatment of inflammatory and benign ulcerous diseases of the stomach and duodenum with a new combination preparation (Aci-Tensilan) (author's transl)]

A gastroduodenal combination preparation was introduced at a deliberately high dosage into a clinical treatment schema. A marked improvement of the subjective symptoms already appeared after a short treatment in hospital, pain in particular being rapidly affected. Younger patients tolerated the preparation excellently, older ones had a marked sedation. Because of the danger of concealment, stenoses in the region of the gastrointestinal tract, ileus and preileus are particular contraindications. The dosage of 3 X 3 to 3 X 4 dragees should be reserved for hospital treatment. The dosage of 3 X 1 dragee for ambulant practice and also for prolonged therapy (ca. 6-8 weeks) is unobjectionable, reference being made to possible initial tiredness and disturbances of accomodation.

[Hypotonic oesophagography using propanthelin bromide (Pro-Banthine) (author's transl)]

Hypotonic oesophagography was performed in 149 patients after the intravenous injection of propanthelin bromide (Pro-Banthine). An injection of 0.25-0.50 mug/kg body weight led to hypotonia of the oesophagus in 96% of cases. During hypotonia, it was possible to demonstrate oesophageal varices in 24 out of 27 patients, and small hiatus hernias in 10 out of 23 patients. Conventional examination demonstrated oesophageal varices in only 13 of the 27 cases and hiatus hernias in four out of the 23 cases. Hypotonic oesophagography thus leads to an improvement in the accuracy in the diagnosis of oesophageal varices and small hiatus hernias. Following injections of Pro-Banthine, transient side effects were observed consisting of tachycardia, difficulties in accomodation, reduction in salivary excretion and difficulties in micturition. Pro-Banthine is contra-indicated in the presence of glaucoma, severe cardiac and circulatory diseases and urinary obstruction.

Pharmaco-radiology in barium examinations with special reference to glucagon

The reasons for and objections to the use of drugs as adjuncts in barium meal and follow-through examinations are briefly reviewed. Physiological factors related to gastric emptying are considered, including the volume, temperature and osmolarity. The drugs considered include those that speed gastric emptying and small bowel transit such as metoclopramide, those that delay gastric emptying such as propantheline and gastrointestinal hormones such as glucagon. Glucagon first produces gastric and duodenal dilatation and subsequently speeds transit through the small bowel. The indications, contra-indications and side effects of these drugs are also considered and tabulated.