Anticholinergic (antimuscarinic) therapy for drying secretions* at the end of life

Agents	Adult dose
Glycopyrrolate (glycopyrronium)^[1,2] Preferred over scopolamine	0.2 mg SubQ every 4 to 6 hours as needed OR 0.2 mg SubQ once; followed after 30 minutes by continuous SubQ or IV infusion of 0.6 to 1.2 mg/day OR 0.1 mg SL every 6 hours as needed (use commercially available or compounded oral liquid)
Scopolamine transdermal patch	Apply one 1.5 mg (1 mg/3 days) patch behind ear for up to 72 hours; if needed for more than 72 hours, remove old patch and place new one behind other ear.
Scopolamine (hyoscine^¶) BUTYLbromide^[2-4] If glycopyrrolate is not available, preferred over scopolamine hydrobromide and scopolamine transdermal patch Not available in United States SEE NOTE	20 mg SubQ every 4 to 6 hours as needed OR 20 mg SubQ once; followed after 30 minutes by SubQ or IV continuous infusion of 20 to 60 mg/day
Scopolamine (hyoscine^¶) HYDRObromide^[1-3] Not available in United States SEE NOTE	0.3 mg orally or sublingually every 4 to 6 hours as needed OR 0.4 mg SubQ every 4 to 8 hours as needed OR 0.4 mg SubQ once; followed after 30 minutes by continuous SubQ or IV infusion of 1.2 to 1.6 mg/day

NOTE: Scopolamine butylbromide and scopolamine hydrobromide formulations are not equivalent and are not interchangeable on a milligram-to-milligram basis. Scopolamine butylbromide salt is a quaternary derivative with fewer CNS effects (eg, less risk of delirium and agitation) compared with scopolamine hydrobromide and patch (base) formulations.

SubQ: subcutaneous; IV: intravenous.
* Also known as "death rattle." Anticholinergic (antimuscarinic) effects may contribute to patient discomfort (eg, dryness, urinary retention) and do not dry secretions already present. Refer to UpToDate topics on palliative care for guidance on use and limitations of anticholinergic therapy.
¶ Scopolamine is also known as "hyoscine" in many countries.

Hugel H, Ellershaw J, Gambles M. Respiratory Tract Secretions in the Dying Patient: A Comparison between Glycopyrronium and Hyoscine Hydrobromide. J Palliat Med 2006; 9:279.
Bennett M, Lucas V, Brennan M, et al. Using anti-muscarinic drugs in the management of death rattle: evidence-based guidelines for palliative care. Palliat Med 2002; 16:369.
Hughes A, Wilcock A, Corcoron R, et al. Audit of three antimuscarinic drugs for managing retained secretions. Palliat Med 2000; 14:221.

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Anticholinergic (antimuscarinic) therapy for drying secretions* at the end of life