Glycopyrronium: clinical use

Prescribing considerations

• Confirm the licensed indication and formulation; routes, bioavailability and safety instructions differ.
• Assess anticholinergic burden, renal function, glaucoma risk, bladder outflow problems, bowel motility disorders and relevant cardiovascular disease.
• Oral treatment for neurological drooling should be initiated and reviewed by clinicians experienced in the relevant paediatric neurological population.
• The COPD inhaler is maintenance therapy, not acute-relief treatment.
• Check inhaler technique, liquid measurement and safe cream application.

Contraindications and cautions

• Hypersensitivity is a contraindication across formulations.
• Selected oral products are contraindicated with glaucoma, urinary retention, severe renal impairment, intestinal obstruction, ulcerative colitis, paralytic ileus, pyloric stenosis, myasthenia gravis, pregnancy, breastfeeding, solid oral potassium chloride and other anticholinergics.
• The cream is contraindicated where anticholinergic effects could exacerbate glaucoma, paralytic ileus, severe ulcerative colitis, toxic megacolon, myasthenia gravis or Sjögren syndrome.
• Check product-specific contraindications because they differ between routes.

Monitoring

• Monitor response, dry mouth, bowel function, urinary and visual symptoms, heart rate and heat intolerance.
• For oral treatment of drooling, involve the caregiver and reassess efficacy and tolerability regularly.
• Monitor closely for adverse reactions in renal impairment where use is permitted.
• Check inhaler technique and that capsules are inhaled rather than swallowed.
• For persistent dry mouth, reinforce dental hygiene and arrange appropriate dental review.

Clinical pharmacology

A competitive peripheral muscarinic-receptor antagonist with limited blood–brain barrier penetration. Renal excretion is important; oral absorption is low and reduced by food, while inhaled and topical preparations are designed mainly for local action.

Formulation and product differences

• Inhalation capsules provide long-acting bronchodilation and must be used only with the designated inhaler.
• Oral liquid and tablets treat severe neurological drooling but differ in excipients and administration.
• Pump cream is restricted to adult primary axillary hyperhidrosis and requires prevention of ocular and secondary skin exposure.
• Injection is used by healthcare professionals around anaesthesia.
• Formulations must not be assumed interchangeable on an equal-milligram basis.

Cream

Route: Cutaneous

Strengths: 2.2 mg

Capsule

Route: Oral

Strengths: 44 micrograms

Oral solution

Route: Oral

Strengths: 320 micrograms/mL, 400 micrograms/mL, 1 mg/5 mL