Systemic medications, like the anticholinergic glycopyrrolate, may be used for the treatment of generalized or focal hyperhidrosis in a variety of patients. For example, medications can be useful for patients with: cranio-facial hyperhidrosis, focal hyperhidrosis affecting large areas such as the back, multi-focal hyperhidrosis, hyperhidrosis that is not satisfactorily treated with other methods, or temporary, short-term event-specific hyperhidrosis management (ex. for a wedding, speech, or performance).
Additionally, experienced practitioners in hyperhidrosis care (including IHhS Board of Directors members) report effective use of systemic medications as adjunctive therapy to help patients find more relief from hyperhidrosis symptoms than other treatments are providing alone. For example, the anticholinergic glycopyrrolate may be used in addition to antiperspirants, iontophoresis (or in the water trays of iontophoresis), and/or injectables.
Glycopyrrolate is a preferred anticholinergic in part because it is less likely than others in the class to cross the blood-brain barrier. Glycopyrrolate is not on the Beers list of potentially inappropriate medications for the elderly put out by the American Geriatric Society, and is the only anticholinergic not on the list.
There are non-pill formulations of glycopyrrolate for children and adults who are unable or unwilling to swallow pills and IHhS Board of Directors members indicate they use glycopyrrolate in young children with hyperhidrosis, even as young as 4 years old.
Cuvposa is a liquid glycopyrrolate. Cuvposa is FDA-approved to reduce drooling in pediatric cerebral palsy patients. Its hyperhidrosis use, like all systemic meds for hyperhidrosis at this time, is "off-label."
Another option for patients with difficulty swallowing pills is recently-launched (2022) Dartisla ODT, the first FDA-approved orally disintegrating tablet of glycopyrrolate. Dartisla ODT is FDA-approved as an add-on treatment to reduce symptoms of peptic ulcer. It may be prescribed off-label by healthcare providers, as they deem appropriate, for their patients with excessive sweating. Dartisla ODT comes as a freeze-dried tablet that disperses almost instantly in the mouth and is absorbed by the mucous membranes. Each tablet of Dartisla ODT is 1.7mg of glycopyrrolate, which is bioequivalent to 2mg of traditional oral tablets of glycopyrrolate. If prescribing Dartisla ODT, educate patients to handle doses with dry hands as the tablets will disintegrate upon any contact with moisture. Blister packs make it possible to open a dose and drop it into the mouth. Patients can receive Dartisla ODT for as little as $0 through Phil, an online pharmacy, or as little as $20 at other pharmacies.
If iontophoresis with plain tap water or tap water with baking soda doesn't produce desired dryness, another use for glycopyrrolate is as an addition to iontophoresis water trays. An oral tablet must be crushed for this purpose. Dartisla ODT may be useful in this scenario due to its ability to rapidly disperse in water - we await feedback on this. Dee Anna Glaser, MD, President and founding board member of the International Hyperhidrosis Society, says: "In the majority of cases, this [adding an anticholinergic to iontophoresis water trays] is effective and results in dramatically drier hands and/or feet."
In an article in the American Journal of Managed Care, authors note (in the 7th paragraph) the following regarding the use of glycopyrrolate for hyperhidrosis:
"Multiple studies have evaluated the efficacy of glycopyrrolate in the treatment of hyperhidrosis. For example, a 2012 study by Lee et al reported that glycopyrrolate (1 mg twice daily, then 2-8 mg/day) resulted in a 75% reduction in perspiration (P <.0001)... Treatment doses ranged from a start of 1 mg every other day or daily to doses that were increased gradually to 6 mg per day."