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Synthesis and pharmacological effects of new, N-substituted soft anticholinergics based on glycopyrrolate.

To reduce the possibility of systemic side-effects in locally administered anticholinergics, two new N-substituted glycopyrrolate analogues designed using soft drug design approaches have been synthesized and evaluated in vitro and in vivo. Because stereospecificity is known to be important at muscarinic receptors, the new compounds SGM and SGE also have been prepared as their pure 2R isomers, 2R-SGM and 2R-SGE, by starting from optically pure (-)-cyclopentylmandelic acid, and the corresponding isomers were indeed found to be more active. The new soft glycopyrrolates were chemically more stable under acidic conditions, and the ethyl esters SGE were more stable than the methyl esters SGM. The new compounds were also found to be quite susceptible to extrahepatic metabolism, having half-lives of 20-30 min in rat plasma (in vitro), consistent with their soft nature. Binding studies at human muscarinic receptors (M(1)-M(4)) and guinea-pig ileum assays found 2R-SGM and 2R-SGE to have potencies somewhat less than, but close to, those of glycopyrrolate and N-methylscopolamine. They caused pupil dilation in rabbit eyes, but their mydriatic effects lasted for considerably less time than that of glycopyrrolate, and they did not induce dilation of the pupil in the contralateral, water-treated eyes, indicating that, in agreement with their soft nature, they are locally active, but safe and with a low potential to cause systemic side-effects.

Animals↗

Control of gastric acidity by glycopyrrolate premedication in the parturient.

The effect of premedication with the anticholinergic quaternary ammonium compound, glycopyrrolate (0.4 mg), on gastric juice pH was investigated in 23 parturients scheduled for elective cesarean section under general anesthesia, and the results were compared to a control group of 15 nonpremedicated obstetric patients and 25 parturients premedicated with atropine (0.6 mg). In the nonpremedicated control group, the mean gastric juice pH was 2.36 (SE +/- 0.23), 66% having a pH less than the critical level of 2.5. Premedication with atropine did not significantly increase the gastric pH, while in those premedicated with glycopyrrolate, the mean pH increased to 3.7 (+/- 0.35), and the incidence of pH less than the critical level dropped to 34%. The effect of glycopyrrolate on gastric juice pH was significantly increased when the premedication-induction time was prolonged to 60 to 120 minutes. It was concluded that glycopyrrolate premedication can be used in the parturient as an additional measure to safeguard against acid-aspiration syndrome.

Anesthesia, Obstetrical↗

Is premedication with oral glycopyrrolate as effective as oral atropine in attenuating cardiovascular depression in infants receiving halothane for induction of anesthesia?

The authors conducted a double-blind study to compare premedication with oral glycopyrrolate and oral atropine in prevention of bradycardia and hypotension during induction of anesthesia with halothane-N2O in 90 outpatient infants and children aged 1-18 mo who were randomized into three groups to receive either an oral placebo, oral atropine (0.02 mg/kg), or oral glycopyrrolate (0.05 mg/kg) approximately 1 h before induction of anesthesia. Heart rate and mean arterial pressure were measured before drug administration, just before induction of anesthesia, and every minute until surgical stimulation occurred. Glycopyrrolate, at the dose used, was significantly less effective than atropine in attenuating bradycardia during induction; neither glycopyrrolate nor atropine altered the incidence or degree of hypotension. Antisialagogic activity and side effects were comparable, except for significantly more flushing with atropine.

Administration, Oral↗

Dose effect and benefits of glycopyrrolate in the treatment of bradycardia in anesthetized dogs.

This study evaluated the effectiveness of glycopyrrolate (0.005 or 0.01 mg/kg body weight (BW)) in anesthetized dogs (n = 40) for reversal of bradycardia (< 65 beats/min). Following random intravenous (i.v.) treatment, heart rate was determined at 5 min and, if it was < or = 70 beats/min, the lower dose was repeated. A 2-way analysis of variance considered dose and animal size (< or = 10 kg, > 10 kg) effects (P < 0.05). Glycopyrrolate produced a significant increase in heart rate and infrequent tachycardia (< or = 150 beats/min), which was not dose-related. The size of the dog produced a significant effect on baseline heart rate (higher in small), rate following the first dose (lower in small), and requirement for retreatment (47% in small, 13% in large). In a separate group of anesthetized dogs (n = 20), the blood pressure effect of glycopyrrolate (0.01 mg/kg BW, i.v.) treatment of bradycardia (65-85 beats/min, weight-adjusted) was studied. A significant increase in systolic, diastolic, and mean blood pressure was produced. In conclusion, the effective dose of glycopyrrolate treatment is size-related and produces a beneficial effect on blood pressure.

Adjuvants, Anesthesia↗

Craniofacial hyperhidrosis successfully treated with topical glycopyrrolate.

Treatment of craniofacial hyperhidrosis currently consists of thoracic sympathectomy, which is not widely available. Oral anticholinergic agents and beta-blockers may be effective but also carry significant side effects. We describe a healthy, active 27-year-old male resident physician who had excessive facial sweating with minimal exertion or stress. The sweating was especially pronounced on the forehead, nose, and upper lip. Daily topical application of a 0.5% glycopyrrolate solution to the face and forehead was offered. After the first treatment, facial sweating was significantly reduced and was well controlled under stressful situations, without any discomfort to the skin. No loss of efficacy was seen after multiple face washings. Facial hyperhidrosis recurred after withdrawal of the glycopyrrolate for 2 days, confirming its therapeutic effect. Two years later, he continues to use glycopyrrolate as needed. We conclude that topical glycopyrrolate is effective in treating craniofacial hyperhidrosis and is associated with few adverse effects.

Administration, Cutaneous↗

Organophosphate poisoning: grading the severity and comparing treatment between atropine and glycopyrrolate.

Organophosphate poisoning occurs worldwide and often requires admission to an ICU. Grading of patients may be of value to identify high-risk cases but this has never been prospectively evaluated. Conventional treatment with atropine may lead to CNS toxicity, although control of secretions may still be inadequate. We conducted a randomized, controlled trial in 44 patients to compare atropine with glycopyrrolate, a drug that may provide better control of secretions and does not cross the blood-brain barrier. Grading was performed prospectively and compared to outcome. Thirty-nine cases were evaluated (atropine 22, glycopyrrolate 17); the treatment groups were comparable at baseline. No differences could be detected in outcome except for a trend to fewer respiratory infections in the glycopyrrolate group. Thus, treatment with atropine and glycopyrrolate was equally effective. A grading of serious was associated with ventilation, complications, and a prolonged ICU stay. A revised simplified grading is proposed.

Adult↗

Ulcer healing and serum pepsinogen I in cimetidine and glycopyrrolate treated duodenal ulcer patients.

Cimetidine is effective in the treatment of acute duodenal ulcers. 26 endoscopically verified duodenal ulcer patients were treated for four weeks with either cimetidine 0.8 g/day or with the anticholinergic drug glycopyrrolate 4 mg/day on a double-blind basis. Gastroscopical healing was achieved in 10/13 (77%) of cimetidine treated patients and in 4/13 (31%) of glycopyrrolate treated patients (p less than 0.05). There were no major side-effects in either group. In this study cimetidine seemed to be more effective than glycopyrrolate in the treatment of acute duodenal ulcer. The pretreatment level of serum pepsinogen I was elevated (110.1 +/- 42.8 microgram/l; mean +/- SD) in these patients (normal range 20--100 microgram/l) and increased significantly after pentagastrin stimulation to 133.2 +/- 56.4 microgram/l (p less than 0.001). The post-treatment level measured 24 hours after termination of treatment had increased significantly in the cimetidine group but not in the glycopyrrolate group. In the cimetidine group the high pretreatment level of pepsinogen I tended to predict a poor response.

Adult↗

Thiopental-nitrous oxide- halothane anesthesia and repeated succinylcholine: comparison of preoperative glycopyrrolate and atropine administration.

The effects of glycopyrrolate and atropine given prior to thiopental-N2O-halothane anesthesia on bradyarrhythmias associated with the administration of succinylcholine were studied and compared. Sixty healthy adult patients were allocated at random to one of three groups. Three minutes before induction of anesthesia with thiopental (4 to 5 mg/kg) one group received glycopyrrolate, 0.0045 mg/kg IV, the second group, glycopyrrolate, 0.008 mg/kg IV, and the third group, atropine, 0.009 mg/kg IV. Succinylcholine, 1 mg/kg of body weight, was given 1 minute and 6 minutes after the conclusion of the thiopental injection. ECG monitoring was continuous, and serum K+ levels as well as PaO2 and paCO2 were repeatedly measured. In all three groups patients were adequately and equally protected against serious bradyarrhythmias following the second dose of succinylcholine by atropine and glycopyrrolate in the doses used.

Adult↗

The effect of glycopyrrolate premedication on postoperative sore throat.

Patients given general endotracheal anesthesia commonly experience postoperative sore throat and/or hoarseness. Our study examined whether the occurrence of postoperative sore throat was associated with the use of a glycopyrrolate premedication and found that it was. We randomly assigned 120 patients undergoing general endotracheal anesthesia for routine surgery to receive a preoperative mediation including or excluding glycopyrrolate. We controlled for factors known to increase the risk of a postoperative sore throat. After surgery, an interviewer, unaware of the subject's group assignment, questioned each subject about the presence of a sore throat and, if present, asked the patient to rate its severity. We found that patients who did not receive preoperative glycopyrrolate were significantly less likely to report having a sore throat or reported having a less severe sore throat than patients who did receive glycopyrrolate.

Adjuvants, Anesthesia↗

Studies on a soft glycopyrrolate analog, SG-1.

A short-acting soft drug analog (SG-1) of glycopyrrolate (G) was developed by retrometabolic design in order to minimize systemic side effects and optimize the therapeutic index. SG-1,3-(1'-hydroxycyclopentyl)phenylacetoxy-1-methyl-1- methoxycarbonylpyrrolidinium bromide, was synthesized by: (a) esterification of phenylacetic acid with N-methyl-3-pyrrolidinol by DCC to obtain N-methyl-3-pyrrolidinyl phenylacetate; (b) reaction of lithium salt of above phenylacetates with cyclopentanone to obtain N-methyl-3-pyrrolidinyl 3-(1'-hydroxycyclopentyl)phenylacetate; and (c) quarternization with methyl bromoacetate in acetonitrile to give the designed product. To evaluate the pharmacological effect of SG-1, its mydriatic activity in rabbit eyes was compared to that of glycopyrrolate. At the pharmacodynamically equivalent doses (the lowest dose that induces the maximum response) of SG-1 (1%) and glycopyrrolate (0.1%), the mydriatic activities lasted for 5 and 100 h, respectively. Compared to glycopyrrolate, the intrinsic pupil dilation potency of SG-1 was lower (approximately 1/10th) but the duration of action was much shorter (< 1/20th) as SG-1 is susceptible to facile enzymatic hydrolysis/deactivation in the rabbit eyes. In vitro metabolism and stability investigations further supported this finding. In vitro half lives of SG-1 in rat plasma, blood, and 20% liver and lung tissue homogenates were 15.62, 53.86, 263.43, and 318.35 min, respectively. In human plasma and blood, half-lives were 19.93 and 88.32 min, respectively. SG-1 was relatively stable under acidic conditions (pH 5 and lower). SG-1 is a promising, clinically useful short acting anticholinergic.

Animals↗

Glycopyrrolate treatment of chronic drooling.

OBJECTIVE: To describe the use of glycopyrrolate in the control of drooling in children and young adults with cerebral palsy and related neurodevelopmental disabilities. DESIGN: Prospective, open-label study of drug dosage parameters, response to therapy, and side effects. Follow-up ranged from 8 months to 4 years. SETTING: Outpatient clinic of a rehabilitation hospital that is a regional referral center for children with disabilities. PATIENTS: Forty children and young adults with motor and/or cognitive disabilities who were experiencing drooling to a severe degree. INTERVENTION: Treatment with oral glycopyrrolate. OUTCOME MEASURES: Change in the quantity of drooling and side effects associated with treatment. RESULTS: Thirty-six patients (90%) had reduced drooling in response to medication; 2 (5%) could not be assessed and 2 (5%) received no benefit. Side effects resulted in discontinuation of treatment in 11 (28%). Overall, 26 (65%) continued to receive drug therapy because of the perceived benefit. The final effective dose ranged widely from 0.01 to 0.82 mg/kg per day. CONCLUSIONS: Glycopyrrolate therapy safely and effectively decreased but rarely abolished drooling in patients with cerebral palsy and related neurodevelopmental disabilities. The dose range was surprisingly broad. Side effects, although generally minor and predictable, often led to discontinuation of drug therapy.

Administration, Oral↗

Frey's syndrome: treatment with topical glycopyrrolate.

Gustatory sweating and flushing of the facial skin, or Frey's syndrome, is fairly common after parotidectomy. The most likely mechanism is aberrant reinnervation of the sweat glands of the face by the severed parotid parasympathetic nerve fibers. A survey of 61 patients having undergone parotidectomy yielded 29 (47.5%) with gustatory sweating. Twenty-three percent (14 patients) considered the symptoms severe. In a double-blind study, five of those 14 patients were alternately treated with topically applied placebo and with glycopyrrolate (an anticholinergic agent) as 0.5% lotion, 2% lotion, and 2% cream. All five patients showed some improvement with the test preparations, but had longer lasting and more effective lessening of symptoms with the 2% glycopyrrolate preparations. There were no adverse side effects. We therefore believe that the topical application of a 2% glycopyrrolate preparation is a safe and effective treatment for severe gustatory sweating following parotidectomy.

Administration, Topical↗

The use of glycopyrrolate in a case of intermediate syndrome following acute organophosphate poisoning.

PURPOSE: This report describes a case of organophosphate intoxication refractory to atropine in which glycopyrrolate was used to reduce cholinergic symptoms, and describes the development of intermediate syndrome, an uncommon subacute complication of organophosphate poisoning. CLINICAL FEATURES: A 44-yr-old woman presented in cholinergic crisis following malathion ingestion. Treatment was initiated with atropine and pralidoxime. Despite clinical signs of adequate atropinisation, the patient continued to have profuse bronchorrhoea, which resolved with glycopyrrolate. During her course in the intensive care unit, she displayed a subacute deterioration in neuromuscular and mental status with decrement-increment phenomenon on electromyography consistent with intermediate syndrome. The patient eventually made a complete recovery. CONCLUSION: This case report describes the successful use of glycopyrrolate in organophosphate intoxication and the development of the intermediate syndrome, characterised by onset of weakness of neck flexors, proximal limb muscles, and respiratory muscles within one to four days after poisoning. Recognition of the syndrome is important in light of the potential for respiratory depression requiring ventilatory support.

Acute Disease↗

Gastrointestinal side effects of intravenous erythromycin: incidence and reduction with prolonged infusion time and glycopyrrolate pretreatment.

OBJECTIVE: To determine the frequency of gastrointestinal toxicity due to intravenous (IV) erythromycin and to attempt to decrease this toxicity by prolonging the infusion time of erythromycin and/or pretreating with the peripheral anticholinergic, glycopyrrolate 0.1 mg IV. DESIGN: Randomized, double-blind, placebo-controlled trial. SETTING: General medical wards of a tertiary medical center. PATIENTS: A total of 51 hospitalized patients 18 years of age or older who were prescribed IV erythromycin lactobionate (EMLB) 500 mg every 6 hours by their attending physicians. INTERVENTIONS: Each of eight consecutive infusions of EMLB was randomly assigned to one of four groups: control--30-minute infusion/placebo pretreatment; 60/P--60-minute infusion/placebo pretreatment; 30/G--30-minute infusion/glycopyrrolate pretreatment; and 60/G--60-minute infusion/glycopyrrolate pretreatment. MAIN OUTCOME MEASURES: Each infusion was accompanied by a questionnaire in which patients rated the magnitude of nausea and vomiting on a scale of 1 (no toxicity) to 9 (severe toxicity). Scores for both nausea and vomiting were added together for a total toxicity score ranging from 2 to 18. A total score of greater than 8 was defined as clinically important. RESULTS: The 51 patients received a total of 356 infusions with gastrointestinal toxicity occurring in 27 of 51 (53%) patients. Among patients under the age of 40, 22 of 33 (67%) experienced toxicity compared with only five of 18 patients (28%) over the age of 40 (p = 0.018). Clinically important toxicity was seen in 19 of 51 patients (37%), including five who withdrew during the study because of severe nausea and vomiting. In this group, the combination of a 60-minute erythromycin infusion and glycopyrrolate pretreatment decreased clinically important toxicity by 79% from 47% to 10%, a statistically and clinically significant 37% (95% CI, 14% to 60%) difference (p = 0.007). CONCLUSIONS: Gastrointestinal toxicity associated with the IV infusion of erythromycin is common and is more likely to occur in younger patients. A 1-hour infusion of erythromycin combined with pretreatment with glycopyrrolate, 0.1 mg IV, is effective in reducing this toxicity.

Adolescent↗

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.

Esophageal Neoplasms↗

Effects of glycopyrrolate and cimetidine on gastric volume and acidity in patients awaiting surgery.

Glycopyrrolate or cimetidine was administered before operation to patients undergoing elective surgery. After the induction of anaesthesia, the stomach contents were retrieved and the volume and pH measured. Neither drug diminished the volume of gastric contents compared with control. Glycopyrrolate produced little diminution in hydrogen ion concentration. Cimetidine caused a marked increase in pH with a mean [h+] 3.2 x 10(-3) g litre-1 compared with 1.4 x 10(-2) g litre-1 in the controls and 1.1 x 10(-2) g litre-1 in the glycopyrrolate group. Seventy-seven per cent of the patients receiving cimetidine had a pH greater than 2.5.

Cimetidine↗

Glycopyrrolate in children.

The effects of glycopyrrolate 10 microgram kg-1 i.v. given at induction of anaesthesia were compared with those of atropine 20 microgram kg-1 i.v. given at induction and oral atropine 30 microgram kg-1 given 90 min before operation. Antisialagogue effect, changes in axillary temperature, heart rate, frequency of cardiac arrhythmia and postoperative restlessness were determined. Patients who had received oral atropine had more pharyngeal secretions, a lower heart rate and a greater frequency of cardiac arrhythmia than when either atropine or glycopyrrolate was given i.v. Secretions were significantly less during operation when i.v. glycopyrrolate was used.

Administration, Oral↗

Comparison of atropine and glycopyrrolate in a mixture with pyridostigmine for the antagonism of neuromuscular block.

Neuromuscular block was antagonized using pyridostigmine 250 micrograms kg-1 in two groups of 50 patients; one group received atropine 20 micrograms kg-1 and the other glycopyrrolate 10 micrograms kg-1 with the anticholinesterase drug. Atropine was associated with a greater initial tachycardia than was glycopyrrolate. The subsequent bradycardia was also greater in this group, although the decreases in heart rate were smaller than those generally observed following mixtures of atropine and neostigmine. Arrhythmias were transient and required no treatment in either group. Better control of secretions was achieved with glycopyrrolate.

Adult↗