The Potential of Scopolamine as an Antidepressant in Major Depressive Disorder: A Systematic Review of Randomized Controlled Trials

Major depressive disorder is one of the most severe mental disorders. It strongly impairs daily functioning, and, in extreme cases, it can lead to suicide. Although different treatment options are available for patients with depression, there is an ongoing search for novel therapeutic agents, such as scopolamine (also known as hyoscine), that would offer higher efficacy, a more rapid onset of action, and a more favorable safety profile. The aim of our study was to review the current clinical evidence regarding the use of scopolamine, a promising therapeutic option in the treatment of depression. A systematic literature search was performed using PubMed, Embase, and CENTRAL databases up to 5 June 2023. We included randomized placebo-controlled or head-to-head clinical trials that compared the clinical efficacy and safety of scopolamine in the treatment of major depressive disorder. Two reviewers independently conducted the search and study selection and rated the risk of bias for each study. Four randomized controlled trials were identified in the systematic review. The included studies investigated the use of scopolamine administered as an oral, intramuscular, or intravenous drug, alone or in combination with other antidepressants. The results indicated that scopolamine exerts antidepressant effects of varying intensity. We show that not all studies confirmed a statistically and clinically significant reduction of depressive symptoms vs. placebo. A broader perspective on scopolamine use in antidepressant treatment should be confirmed in subsequent large randomized controlled trials assessing both effectiveness and safety. Therefore, studies directly comparing the effectiveness of scopolamine depending on the route of administration are required.

Pharmacotherapy for gastric and intestinal cramping pain: ‎ current and emerging therapies

INTRODUCTION

Acute gastrointestinal cramping pain (GICP) is a debilitating condition that affects many people worldwide, significantly reducing their quality of life. As such, prompt treatment is crucial.

AREAS COVERED

This article will explore relevant literature from databases such as PubMed, Scopus, Google Scholar, Cochrane Library, and Web of Science. Additionally, we searched ClinicalTrials.gov and the WHO ICTRP database for the latest clinical trials.

EXPERT OPINION

Consensus dictates that antispasmodics such as hyoscine-N-butyl bromide and mebeverine should be the primary treatment for GICP. If these prove ineffective, patients can switch to an antispasmodic with a different mode of action or add acetaminophen/NSAIDs for more severe cases. Currently, several antispasmodics are undergoing clinical trials, including drotaverine, alverine, pinaverium, otilonium bromide, fenoverine, tiropramide, otilonium bromide, trimebutine, and peppermint oil. Well-designed head-to-head studies are necessary to evaluate current antispasmodics' safety, efficacy, pharmacokinetic, and pharmacoeconomics profiles. Recent studies have shown that fixed-dose combinations of antispasmodics + NSAIDs or two different antispasmodics can improve patient compliance and synergistically reduce GICP. Therefore, it is recommended that the global availability and accessibility of these products be enhanced.

Efficacy of hyoscine in pain management during hysteroscopy: a systematic review and meta-analysis

We conducted a systematic review and meta-analysis of relevant clinical trials from full-text, scientific journal archives to assess the efficacy of hyoscine for the management of pain during in-office hysteroscopy (OH) procedures. Cochrane CENTRAL, ClinicalTrials.Gov, MEDLINE, PubMed, SCOPUS and the Web of Science were searched for all clinical trials that matched our search criteria. A full assessment of bias was made using the Cochrane Group tool-set. The following outcomes were included: visual analogue scale (VAS) score for postoperative pain, postoperative need for analgesia, and procedure time. In the case of homogeneous data, the analysis was performed using a fixed effects system, and the random effects system was used with heterogeneous data. Inclusion criteria included only randomized clinical trials, and interventions that included patients receiving hyoscine-N-Butyl Bromide during OH, regardless of dose or mode of administration, and compared this with placebo. Three clinical trials were included. The actual mean difference (MD) of the VAS pain score showed no significant difference between hyoscine or placebo [MD: -0.28 (-1.08, 0.52), (p=0.49)]. For postoperative analgesia, the overall MD showed no significant difference between hyoscine or placebo [MD: 0.43 (0.16, 1.14), (p=0.09)]. For procedure time, the combined effect estimate failed to show any significant difference between hyoscine and placebo [MD: -0.66 (-2.77, 1.44) (p=0.54)]. Contrary to previously published data, our meta-analysis using the latest available RCTs fails to show hyoscine as being effective in reducing pain or the need for other forms of anesthesia in OH.

Efficacy of hyoscine in pain management during hysteroscopy: a systematic review and meta-analysis

Introduction

We conducted a systematic review and meta-analysis of relevant clinical trials from 6 different full-text scientific journal archives in order to assess the efficacy of hyoscine for the management of pain during in-office hysteroscopy procedures.

Methods

We searched Cochrane CENTRAL, Clinicaltrials.Gov, MEDLINE, PubMed, SCOPUS and the Web of Science site for all clinical trials that matched our selected search criteria. We then performed a full assessment of bias using the tools provided by the Cochrane Group. We included the following outcomes: visual analogue scale (VAS) score for postoperative pain, postoperative need for analgesia, and procedure time. In the case of homogeneous data, we performed our analysis using a fixed effects system, and we used the random effects system whenever analyzing heterogeneous data.

Results

We included three clinical trials. We found that the actual mean difference (MD), when calculated, of the VAS pain score showed no significant difference between either group (MD= -0.28 [-1.08, 0.52]), (P = 0.49). Regarding the need for postoperative analgesia, the overall mean difference showed no significant difference between hyoscine or the placebo (MD= 0.43 [0.16, 1.14]), (P = 0.09). The combined effect estimate failed to show any difference of statistical significance between hyoscine and placebo regarding procedure time (MD= -0.66 [-2.77, 1.44]) (P = 0.54).

Conclusion

Contrary to previously published data, our meta-analysis using the latest available RCTs fails to show hyoscine as being effective in reducing pain or the need for other forms of anesthesia in office hysteroscopy.

The Efficacy and Safety of Low Dose versus Usual Dose of Hyoscine During Endoscopic Retrograde Cholangiopancreatography: A Randomized Clinical Trial

Purpose

To evaluate the efficacy and safety of low dose versus usual dose of Hyoscine during endoscopic retrograde cholangiopancreatography (ERCP).

Patients and Methods

This randomized, open-label clinical trial included 282 patients undergoing ERCP who had duodenal peristalsis interfering with cannulation. Patients were randomly divided into two groups: Group one and two received low (5 mg) and usual (10 mg) dose of Hyoscine, respectively. Cardiovascular service consultation was performed for all patients before entering the study and performing ERCP. Hyoscine was injected intravenously, and the spasmolytic effect of the drug was assessed while the papilla was in a completely enface view. The time interval between cessation of peristalsis and its further onset was recorded by the chronometer. Also, patient’s heart rate and blood pressure were monitored during ERCP by digital monitoring.

Results

The results showed no statistically significant differences in the mean duration of peristalsis, the duration of the antispasmodic activity and the time required to increase the heart rate between two groups (P=0.38, P=0.48, P=0.32, respectively). No significant differences were observed regarding the average of heart rate and mean arterial blood pressure (MAP) before drug administration between the two groups (P=0.182 and P=0.29, respectively), but after the drug administration, tachycardia and hypotension were significantly higher in the second group (P=0.007 and P=0.001, respectively). There was no statistically significant difference in the frequency of arrhythmia between two groups (P=0.08). The results also showed that tachycardia and hypotension occurred more frequently in men and elderly patients (P <0.05).

Conclusion

A low dose of Hyoscine is as effective as the usual dose and its side effects such as alteration in blood pressure and heart rate are much fewer, especially in men and elderly patients.

Amanita muscaria (fly agaric): from a shamanistic hallucinogen to the search for acetylcholine

The mushroom Amanita muscaria (fly agaric) is widely distributed throughout continental Europe and the UK. Its common name suggests that it had been used to kill flies, until superseded by arsenic. The bioactive compounds occurring in the mushroom remained a mystery for long periods of time, but eventually four hallucinogens were isolated from the fungus: muscarine, muscimol, muscazone and ibotenic acid. The shamans of Eastern Siberia used the mushroom as an inebriant and a hallucinogen. In 1912, Henry Dale suggested that muscarine (or a closely related substance) was the transmitter at the parasympathetic nerve endings, where it would produce lacrimation, salivation, sweating, bronchoconstriction and increased intestinal motility. He and Otto Loewi eventually isolated the transmitter and showed that it was not muscarine but acetylcholine. The receptor is now known variously as cholinergic or muscarinic. From this basic knowledge, drugs such as pilocarpine (cholinergic) and ipratropium (anticholinergic) have been shown to be of value in glaucoma and diseases of the lungs, respectively.

Antispasmodic drugs in colonoscopy: a review of their pharmacology, safety and efficacy in improving polyp detection and related outcomes

Antispasmodic drugs are cheap, effective and generally safe. They may improve outcomes in colonoscopy, however their use has not been consistent or widespread. This manuscript reviews the three most commonly used antispasmodics in colonoscopy, namely, hyoscine butylbromide (and related ammonium compounds), glucagon and peppermint oil. The pharmacology, action and safety of the agents, as well as the evidence for them improving colonoscopic outcomes will be discussed. In addition to polyp detection, other colonoscopic outcome endpoints of interest include cecal and ileal intubation, and patient comfort. The drugs studied were all found to be effective gastrointestinal antispasmodics with good safety profiles. There is insufficient evidence to conclude whether antispasmodics improve cecal intubation rate, predominantly because the baseline rates are already high. Antispasmodics probably have efficacy in reducing cecal intubation time especially in those with marked colonic spasm. Antispasmodics do not offer significant benefit in polyp detection or improving patient comfort during colonoscopy. Future studies should focus on inexperienced colonoscopists as well as those with marked colonic spasm, in whom the greatest benefit seems to lie.

Comparison between ketamine and hyoscine for the management of postoperative catheter-related bladder discomfort: A randomized controlled double-blind study

BACKGROUND AND AIM

Postoperative catheter-related bladder discomfort (CRBD) can be a distressing complication for patients in whom a urinary catheter was inserted intraoperatively and is accompanied with patients' dissatisfaction. This trial investigated the efficacy of hyoscine and ketamine on treatment of postoperative CRBD in patients undergoing various surgeries.

MATERIAL AND METHODS

This was a prospective randomized, double-blind study, which included 60 American Society of Anesthesiologists Class I-II male patients undergoing elective nonurological operations requiring intraoperative urinary catheterization under general anesthesia after ethical approval and written informed consent. Patients were allocated randomly into two groups: The hyoscine group (H group) (n = 30) received 20 mg of hyoscine intravenously and ketamine group (K group) (n = 30) received 0.25 mg/kg of ketamine intravenously immediately after the occurrence of CRBD. The severity of CRBD was assessed at 0, 1, 2, and 4 h postoperatively. Adverse effects of hyoscine and ketamine were also examined. Data were summarized using mean ± standard deviation, and comparisons between groups were done by unpaired t-test. For comparison of serial measurements within each group, ANOVA was used.

RESULTS

There was a significant difference between the two groups in the severity of CRBD measured by visual analog scale score only 30 min after drug administration where it was higher in ketamine group (44.50 ± 7.70) compared to hyoscine group (36.00 ± 8.55) (P < 0.001), otherwise there was no significant difference at other time points between the two groups, also there was a significant rise in heart rate in hyoscine group but no significant difference in mean arterial pressure.

CONCLUSION

Intravenous hyoscine 20 mg is more effective in control of CRBD than ketamine (0.25 mg/kg) in the first 30 min; later on they have the same effect.

Comparative study of hyoscine doses as antisialagogue for patients receiving ketofol sedation undergoing colonoscopy procedures

Objective:

To compare the effects of different regimens of hyoscine as antisialagogue in patients undergoing ketofol sedation for colonoscopy procedures.

Patients and Methods:

In this prospective double-blind randomized controlled trial 200 American Society of Anesthesiologists I-II aged 20–60-year-old undergoing colonoscopy were randomly assigned into four equal groups, group A received 5 mg hyoscine intravenous, group B received 10 mg, group C received 20 mg intravenous, and control group (D) that was received saline. All patients were sedated using ketofol titrated to achieve Ramsey Sedation Score 4, hemodynamic variables and occurrence of increased secretions were evaluated and recorded.

Results:

Hyoscine in a dose of 10 mg was the optimum dose to achieve least salivation with the least side effect while hyoscine 5 mg was not efficient to achieve dry field or good surgical conditions. However, hyoscine 20 mg achieved dry field and fair surgical conditions in expenses of tachycardia.

Conclusion:

Hyoscine 10 mg was the least effective dose that significantly reduced hypersalivation in patients receiving ketofol sedation for colonoscopy procedures, this dose was as effective as 20 mg in draying secretion but with significantly less tachycardia.

Hyoscine-N-butylbromide premedication on cardiovascular variables of horses sedated with medetomidine

OBJECTIVE

To evaluate the effects of intravenous (IV) or intramuscular (IM) hyoscine premedication on physiologic variables following IV administration of medetomidine in horses.

STUDY DESIGN

Randomized, crossover experimental study.

ANIMALS

Eight healthy crossbred horses weighing 330 ± 39 kg and aged 7 ± 4 years.

METHODS

Baseline measurements of heart rate (HR), cardiac index (CI), respiratory rate, systemic vascular resistance (SVR), percentage of patients with second degree atrioventricular (2(o) AV) block, mean arterial pressure (MAP), pH, and arterial partial pressures of carbon dioxide (PaCO2 ) and oxygen (PaO2 ) were obtained 5 minutes before administration of IV hyoscine (0.14 mg kg(-1) ; group HIV), IM hyoscine (0.3 mg kg(-1) ; group HIM), or an equal volume of physiologic saline IV (group C). Five minutes later, medetomidine (7.5 μg kg(-1) ) was administered IV and measurements were recorded at various time points for 130 minutes.

RESULTS

Medetomidine induced bradycardia, 2(o) AV blocks and increased SVR immediately after administration, without significant changes in CI or MAP in C. Hyoscine administration induced tachycardia and hypertension, and decreased the percentage of 2(o) AV blocks induced by medetomidine. Peak HR and MAP were higher in HIV than HIM at 88 ± 18 beats minute(-1) and 241 ± 37 mmHg versus 65 ± 16 beats minute(-1) and 192 ± 38 mmHg, respectively. CI was increased significantly in HIV (p ≤ 0.05). Respiratory rate decreased significantly in all groups during the recording period. pH, PaCO2 and PaO2 were not significantly changed by administration of medetomidine with or without hyoscine.

CONCLUSION AND CLINICAL RELEVANCE

Hyoscine administered IV or IM before medetomidine in horses resulted in tachycardia and hypertension under the conditions of this study. The significance of these changes, and responses to other dose rates, requires further investigation.

The drooling reduction intervention trial (DRI): a single blind trial comparing the efficacy of glycopyrronium and hyoscine on drooling in children with neurodisability

BACKGROUND

Drooling saliva is a common problem in children with neurodevelopmental disorders. The negative consequences of drooling include skin breakdown, dehydration, and damage to clothing and equipment. Children and families often suffer social embarrassment due to drooling. There is no evidence about the relative effectiveness, side effect profiles or patient acceptability of the two medications most commonly used to reduce drooling - glycopyrronium and hyoscine. Consequently, there is no consensus or guideline to aid clinical decisions about which drug to use, and at what dose.

METHODS/DESIGN

A multi-centre, randomised trial of treatment with glycopyrronium or hyoscine in children with problematic drooling and non-progressive neurodisability. Ninety children aged between 3 and 15 years who have never received medication for drooling will be stratified by severity of drooling and care centre. Randomisation to receive treatment with glycopyrronium or hyoscine will be computer generated from the trial randomisation website. Dose adjustment and side effect monitoring will occur via telephone consultation. Medication arm will be known to participants and clinicians but not the Trial Outcome Assessor.The primary outcome measure is the Drooling Impact Scale score at four weeks, at which time all children will be on the maximum tolerated dose of their medication. Secondary outcome measures include change in Drooling Impact Scale score between baseline, 4, 12 and 52 weeks, change in Drooling Severity and Frequency Scale score and difference between groups in the Treatment Satisfaction Questionnaire for Medication score. A structured interview with children and young people of sufficient age, cognitive and communication ability will explore their perceptions of drooling and the effectiveness and acceptability of the medications.

DISCUSSION

The primary objective of the study is to identify whether glycopyrronium or hyoscine is more effective in treating drooling in children with non-progressive neurodisability. The study will also determine which medications at what doses are most acceptable and have fewest side effects. This information will be used to develop evidence based guidance to inform the medical treatment of drooling.

DRI TRIAL REGISTRATION

Current Controlled Trials: ISRCTN75287237.EUDRACT: 2013-000863-94.Medicines and Healthcare products Regulatory Agency (MHRA): 17136/0264/001-0003.

Comparison of the neurokinin-1 antagonist GR205171, alone and in combination with the 5-HT3 antagonist ondansetron, hyoscine and placebo in the prevention of motion-induced nausea in man

AIMS

In man a neurokinin-1 (NK1) receptor antagonist has previously been shown to be ineffective in the prevention of motion-induced nausea. The antiemetic efficacy of NK1 receptor antagonists against chemotherapy-induced emesis is, however, enhanced when combined with a 5-HT3 receptor antagonist. Hence the efficacy of the NK1 antagonist GR205171 in combination with the 5-HT3 antagonist ondansetron (Zofrantrade mark) was assessed in motion-induced nausea.

METHODS

GR205171 25 mg i.v., with and without concomitant administration of ondansetron 8 mg i.v., and hyoscine hydrobromide 0. 6 mg orally (positive control) were compared with placebo in a model of motion-induced nausea. The study was performed to a four-period, randomized, balanced, double-blind, crossover design in 16 healthy subjects. The end-point was the exposure to the motion stimulus required to produce moderate nausea in the subjects.

RESULTS

The motion stimulus required to produce moderate nausea was significantly greater for the positive control than placebo (P < 0. 001). There was no significant difference between either GR205171 or GR205171 plus ondansetron and placebo (P = 0.648 and 0.342, respectively).

CONCLUSIONS

The enhancement of NK1 receptor antagonist antiemetic activity through combination with a 5-HT3 receptor antagonist is not replicated in motion-induced nausea.

Comparison of the effects of a selective muscarinic receptor antagonist and hyoscine (scopolamine) on motion sickness, skin conductance and heart rate

AIMS

Hyoscine (scopolamine), which is effective in the prophylaxis of motion sickness, shows similar binding affinities to all of the five known muscarinic receptor sub-types. The effectiveness of hyoscine was compared with zamifenacin (UK-76654), which binds selectively to the muscarinic M3 and m5 receptors.

METHODS

Eighteen subjects received hyoscine hydrobromide 0.6 mg, zamifenacin 20 mg, or placebo (double-blind cross-over design). Sessions were 1 week apart and the drug (oral) was given 90 min prior to a motion sickness test. Motion sickness was elicited by cross-coupled stimulation on a turntable. The rotational velocity was incremented by 2 degrees s-1 every 30 s, and a sequence (seq) of eight head movements of 45 degrees was completed every 30 s. Motion tolerance was assessed as the number of sequences of head movement required to achieve moderate nausea. Pulse rate was recorded before and at 1 and 2 h after drug administration. Skin conductance activity in the frequency band 0.005-0.48 Hz, an index of sweat gland activity, was measured using Ag/AgCl electrodes on the palmar surfaces of fingers and across the forehead.

RESULTS

Both zamifenacin and hyoscine produced an increase in tolerance to the motion challenge (P < 0.01) with no significant difference between the two drugs (5.0 +/- 1.6 vs 5.7 +/- 1.6 seqs. respectively, mean +/- s.e.mean). Compared with placebo or zamifenacin, pulse rate fell following hyoscine administration (9 beats min-1, P < 0.01). Skin conductance was reduced following hyoscine compared with zamifenacin or placebo (P < 0.001).

CONCLUSIONS

These results suggest that compounds with selective M3 and/or m5 antagonism possess activity against motion sickness. Antagonism at these receptors may be the basis of the anti-motion sickness action of hyoscine.