A study comparing hyoscine hydrobromide and glycopyrrolate in the treatment of death rattle

Abstract

This study looked at the efficacy of drug treatment in managing death rattle in a 30-bedded specialist palliative care unit. The study was conducted in two phases. In the first, patients received hyoscine hydrobromide as the antimuscarinic; glycopyrrolate was used in the second phase. The patients in the two phases were well matched for diagnosis, age, sex and duration of death rattle. A noise score scale of 0-3 was used, which was separately validated using a verbal rating scale and noise-meter readings. Noise scores were taken at the start; 30 min after an antimuscarinic drug was administered; an hour after the initial injection if a repeat dose was given at 30 min; and 4-hourly thereafter. Drug charts of all patients with death rattle were analysed to ascertain the amount of each drug given and the cost. The incidence of death rattle was 44% in phase I, and 36% in phase II. The percentage of patients with reduced noise scores 30 min after one injection of hyoscine was significantly greater than after one dose of glycopyrrolate (56% vs 27%, P = 0.002). The need for a second injection after 30 min was less using hyoscine (33% vs 50%, P = 0.03). There was no statistically significant difference in improvement at 1 h, or at the last recorded score before death. A comparison of the cost of drug treatment using hyoscine or glycopyrrolate was made, and the potential reduction in cost per patient in the glycopyrrolate group was largely offset by increased expenditure on other drugs, especially diamorphine, midazolam and levomepromazine. The results of this study suggest that: (1) glycopyrrolate 0.2 mg is less effective at reducing death rattle than hyoscine hydrobromide 0.4 mg when assessed at 30 min, (2) the use of glycopyrrolate may lead to an increased need for other sedative or anti-emetic medication such as diamorphine, midazolam or levomepromazine, and (3) the cost benefit of using glycopyrrolate over hyoscine hydrobromide is a small part of the total drug budget, and may be less than anticipated due to the increased need of these other drugs.

Respiratory Tract Secretions in the Dying Patient: A Comparison between Glycopyrronium and Hyoscine Hydrobromide

“…8 However, in a prospective study comparing hyoscine hydrobromide and glycopyrronium, glycopyrronium was inferior to hyoscine hydrobromide in controlling RTS at 30 minutes after subcutaneous injection and equal to hyoscine hydrobromide at 1 hour and at the final reading before death. 9 The same study failed to show any statistically significant difference in the use of sedatives between patients treated with glycopyrronium compared to patients treated with hyoscine hydrobromide despite the lack of sedating effects of glycopyrronium compared to hyoscine hydrobromide. Previously reported studies evaluating different treatment regimens for RTS have not been controlled or blinded.…”

“…1 The prevalence of RTS varies in different studies from 31% to 92%. [2][3][4][5][6][7][8][9] Treatment of RTS includes repositioning the patient, suction, and explaining the symptom to the relatives as well as the administration of antimuscarinic drugs. 10 The most commonly used antimuscarinic drug to treat RTS in dying patients is hyoscine hydrobromide but glycopyrronium is increasingly used as an alternative.…”

Terminal Care: The Last Weeks of Life

“…34 Subcutaneous hyoscine hydrobromide (scopolamine) was more immediately effective in one trial than subcutaneous glycopyrrolate but glycopyrrolate has a longer duration of action. [97][98][99] Although case studies and expert opinion suggest their effectiveness, no controlled studies of intravenous, oral, sublingual, or transdermal antimuscarinics were identified. [100][101][102] …”

Death Rattle Is Not Associated with Patient Respiratory Distress: Is Pharmacologic Treatment Indicated?

“…We measured the patient's death rattle severity with the Death Rattle Intensity Scale (DRIS), an instrument developed by Back and colleagues, 15 which we modified to standardize the distance from patient at the head of the bed, foot of the bed, and away from the bed: 0 = not audible, 1 = only audible at the head of the bed, 2 = clearly audible at the foot of the patient's bed, and 3 = clearly audible at 10 paces away from the foot of the bed. No psychometric testing was reported by Back et al, but the scale has face validity.…”