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Resident, Department of Psychiatry SUNY–Upstate Medical University 750 East Adams Street Syracuse, New York 13210-2306 FAX 315/464-3178 Kunwara{at}upstate.edu
Medical Student SUNY–Upstate Medical University
Resident, Department of Psychiatry SUNY–Upstate Medical University
Resident, Department of Psychiatry SUNY–Upstate Medical University
Published Online, July 2, 2003. www.theannals.com, DOI 10.1345/aph.1D127
Case Report. A 74-year-old white man with a history of non–insulin-dependent diabetes mellitus, gastroesophageal reflux disease, and hypertension presented with urinary retention. His only medications were rabeprazole and metformin. The patient was started on bethanechol 30 mg/d (10 mg 3 times daily), titrated to 100 mg/d (25 mg 4 times daily), which resulted in significant improvement of urinary retention. Three months later, the patient was referred to psychiatry for evaluation of depression, as he was increasingly socially withdrawn and isolating himself. His behavior was found to be secondary to distress regarding hypersalivation, which had started after initiation of bethanechol. The patient stated that he was unable to speak to anyone and constantly had to place a towel to his mouth to avoid salivary loss. Bethanechol was reduced to 60 mg/d, with some improvement in sialorrhea, but his urinary retention returned. The patient requested to resume the previous dose of bethanechol, as he felt that the need for self-catheterization was more self-defeating than sialorrhea. Bethanechol was increased to 100 mg/d, with improvement in urinary retention and return of sialorrhea. He was started on a trial of ipratropium bromide MDI 2 puffs every 6 hours directed to the buccal mucosa. On follow-up visits after 1 and 2 weeks, the sialorrhea had markedly improved without negative effects on urinary function. The patient was neither socially withdrawn nor isolating himself. At 4 months' follow-up, the patient continued to take ipratropium bromide MDI with benefit.
Discussion. Ipratropium bromide is an anticholinergic agent used for maintenance treatment of bronchospasm associated with chronic obstructive pulmonary disease.2 Due to its anticholinergic properties, a common adverse effect is dry mouth. Systemic anticholinergic agents, such as glycopyrrolate, have been used to treat sialorrhea. In our case, use of a systemic anticholinergic agent would have counteracted the beneficial effect of bethanechol.4 As ipratropium bromide is poorly lipid soluble, it has minimal systemic adverse effects. There is 1 previous report according to which ipratropium bromide nasal spray was successfully used for the treatment of clozapine-induced sialorrhea in a group of 6 patients.3 In that case series, ipratropium bromide was used intranasally; however, we felt that direct application to the buccal mucosa would provide more contact with the salivary glands.
The likelihood that the sialorrhea in this case was due to bethanechol scored a probable on the Naranjo probability scale.5 This case demonstrates the successful use of ipratropium bromide in the treatment of probable bethanechol-induced sialorrhea without interfering with bethanechol's systemic effects. Further trials are necessary to confirm the effectiveness and optimal dose of topical ipratropium bromide for drug-induced sialorrhea.
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