GLYCOPYRROLATE oral solution

Glycopyrrolate oral solution is indicated to reduce chronic severe drooling in patients aged 3 to 16 years with neurologic conditions associated with problem drooling (e.g., cerebral palsy).

Glycopyrrolate oral solution must be measured and administered with an accurate measuring device [see Patient Counseling Information ( 17)].
Initiate dosing at 0.02 mg/kg orally three times daily and titrate in increments of 0.02 mg/kg every 5 to 7 days based on therapeutic response and adverse reactions. The maximum recommended dosage is 0.1 mg/kg three times daily not to exceed 1.5 mg to 3 mg per dose based upon weight. For greater detail, see Table 1.
During the four-week titration period, dosing can be increased with the recommended dose titration schedule while ensuring that the anticholinergic adverse events are tolerable. Prior to each increase in dose, review the tolerability of the current dose level with the patient’s caregiver.
Glycopyrrolate oral solution should be dosed at least one hour before or two hours after meals.
The presence of high fat food reduces the oral bioavailability of glycopyrrolate if taken shortly after a meal [see Clinical Pharmacology ( 12.3)].
Table 1: Recommended Dose Titration Schedule (each dose to be given three times daily)

Glycopyrrolate Oral Solution is available as a 1 mg/5 mL clear, cherry-flavored solution for oral administration in 16 ounce (473 mL) bottles.

Glycopyrrolate oral solution is contraindicated in:
• Patients with medical conditions that preclude anticholinergic therapy (e.g., glaucoma, paralytic ileus, unstable cardiovascular status in acute hemorrhage, severe ulcerative colitis, toxic megacolon complicating ulcerative colitis, myasthenia gravis).
• Patients taking solid oral dosage forms of potassium chloride. The passage of potassium chloride tablets through the gastrointestinal (GI) tract may be arrested or delayed with coadministration of glycopyrrolate oral solution.

The following serious adverse reactions are described elsewhere in the labeling:
• Constipation or intestinal pseudo-obstruction [see Warnings and Precautions ( 5.1)]
• Incomplete mechanical intestinal obstruction [see Warnings and Precautions ( 5.2)]
The most common adverse reactions reported with glycopyrrolate are dry mouth, vomiting, constipation, flushing, and nasal congestion.

Drugs Affected by Reduced GI Transit Time
Glycopyrrolate reduces GI transit time, which may result in altered release of certain drugs when formulated in delayed- or controlled-release dosage forms.
• The passage of potassium chloride tablets through the GI tract may be arrested or delayed with coadministration of glycopyrrolate. Solid dosage forms of potassium chloride are contraindicated [see Contraindications ( 4)].
• Digoxin administered as slow dissolution oral tablets may have increased serum levels and enhanced action when administered with glycopyrrolate. Monitor patients receiving slow dissolution digoxin for increased action if glycopyrrolate is coadministered regularly. Consider the use of other oral dosage forms of digoxin (e.g., elixir or capsules).
Amantadine
The anticholinergic effects of glycopyrrolate may be increased with concomitant administration of amantadine. Consider decreasing the dose of glycopyrrolate during coadministration of amantadine.
Drugs Whose Plasma Levels May be Increased by Glycopyrrolate
Coadministration of glycopyrrolate may result in increased levels of certain drugs.
• Atenolol’s bioavailability may be increased with coadministration of glycopyrrolate. A reduction in the atenolol dose may be needed.
• Metformin plasma levels may be elevated with coadministration of glycopyrrolate, increasing metformin’s pharmacologic and toxic effects. Monitor clinical response to metformin with concomitant glycopyrrolate administration; consider a dose reduction of metformin if warranted.
Drugs Whose Plasma Levels May be Decreased by Glycopyrrolate
Coadministration of glycopyrrolate may result in decreased levels of certain drugs.
• Haloperidol’s serum level may be decreased when coadministered with glycopyrrolate, resulting in worsening of schizophrenic symptoms, and development of tardive dyskinesia. Closely monitor patients if coadministration cannot be avoided.
• Levodopa’s therapeutic effect may be reduced with glycopyrrolate administration. Consider increasing the dose of levodopa.

Because glycopyrrolate is a quaternary amine which does not easily cross the blood-brain barrier, symptoms of glycopyrrolate overdosage are generally more peripheral in nature rather than central compared to other anticholinergic agents. In case of accidental overdose, therapy may include:
• Maintain an open airway, providing ventilation as necessary.
• Managing any acute conditions such as hyperthermia, coma and or seizures as applicable, and managing any jerky myoclonic movements or choreoathetosis which may lead to rhabdomyolysis in some cases of anticholinergic overdosage.
• Administering a quaternary ammonium anticholinesterase such as neostigmine to help alleviate-peripheral anticholinergic effects such as anticholinergic induced ileus.
• Administering activated charcoal orally as appropriate.

Glycopyrrolate is an anticholinergic drug available as an oral solution containing 1 mg glycopyrrolate per 5 mL. The chemical name for glycopyrrolate is Pyrrolidinium, 3-[(SR)-cyclopentylhydroxy phenylacetyl)oxy]-1,1-dimethyl-, [RS-]bromide;(RS)-[3-(SR)-Hydroxy-1,1-dimethylpyrrolidiniumbromide] α-cyclopentylmandelate. The chemical structure is:

glycopyrolateosstucture.

The empirical formula for glycopyrrolate is C ₁₉H ₂₈BrNO ₃and the molecular weight is 398.34. The inactive ingredients in glycopyrrolate oral solution are: citric acid monohydrate, glycerin, methyl paraben, non-crystallizing sorbitol solution (contains D-Sorbitol and Water), propylene glycol, propyl paraben, saccharin sodium, sorbitol, trisodium citrate dihydrate and ART cherry flavor.

Glycopyrrolate was evaluated in a multi-center, randomized, double-blind, placebo-controlled, parallel, eight-week study for the control of pathologic drooling in children (Study 1). The study enrolled 38 subjects aged 3 to 23 years; thirty-six subjects were aged 3 to 16 years and two patients were greater than 16 years. The subjects were male or female, weighed at least 13 kg (27 lbs), and had cerebral palsy, mental retardation, or another neurologic condition associated with problem drooling defined as drooling in the absence of treatment so that clothing became damp on most days (approximately five to seven days per week). Subjects were randomized in a 1:1 fashion to receive glycopyrrolate or placebo. Doses of study medication were titrated over a 4-week period to optimal response beginning at 0.02 mg/kg three times a day increasing doses in increments of approximately 0.02 mg/kg three times per day every 5 to 7 days, not to exceed the lesser of approximately 0.1 mg/kg three times per day or 3 mg three times per day.
Subjects were evaluated on the 9-point modified Teacher’s Drooling Scale (mTDS), which is presented below. The mTDS evaluations were recorded by parents/caregivers 3 times daily approximately two hours post-dose on evaluation days during pre-treatment baseline and at Weeks 2, 4, 6 and 8 of therapy.
Modified Teacher’s Drooling Scale
1= Dry: never drools
2= Mild: only the lips are wet; occasionally
3= Mild: only the lips are wet; frequently
4= Moderate: wet on the lips and chin; occasionally
5= Moderate: wet on the lips and chin; frequently  
6= Severe: drools to the extent that clothing becomes damp; occasionally
7= Severe: drools to the extent that clothing becomes damp; frequently
8= Profuse: clothing, hands, tray, and objects become wet; occasionally
9= Profuse: clothing, hands, tray, and objects become wet; frequently
Responders were defined as subjects with at least a 3-point reduction in mean daily mTDS scores from baseline to Week 8. Table 4 presents the proportion of responders at Week 8 and Figure 1 presents the mean mTDS values from baseline through Week 8.
Table 4: Percentage of Responders at Week 8

  Figure 1. Mean (± 2 Standard Errors) mDTS Scores

glycopyrolateosfig1

Glycopyrrolate Oral Solution 1 mg/5 mL is a clear, cherry-flavored solution.

2.5 ML UD Enfit Syringe NDC 17856-1016-01......... 120 Count

5 ML UD Cup NDC 17856-1016-02......... 72 Count

Store at 20°C to 25°C (68°F to 77°F) [see USP Controlled Room Temperature].

See FDA-approved patient labeling (Patient Information)
• Advise patients/caregivers to measure glycopyrrolate oral solution with an accurate measuring device. A household teaspoon is not an accurate measuring device. Patients/caregivers should use a dosing cup available in pharmacies to accurately measure the correct milliliter dose. An oral syringe, also available in pharmacies, should be used to dispense glycopyrrolate oral solution into the child’s mouth from the cup. A pharmacist can recommend an appropriate measuring device and can provide instructions for measuring the correct dose.
• Administering glycopyrrolate oral solution with a high fat meal substantially reduces the amount of glycopyrrolate absorbed. Administer glycopyrrolate oral solution at least one hour before or two hours after meals.
• Glycopyrrolate oral solution is started at a low dose and gradually titrated over a period of weeks based on therapeutic response and adverse reactions. Patients/caregivers should not increase the dose without the physician’s permission.
• Common adverse reactions from glycopyrrolate include overly dry mouth, constipation, vomiting, flushing of the skin or face, and urinary retention. Side effects can sometimes be difficult to detect in some patients with neurologic problems who cannot adequately communicate how they feel. If side effects become troublesome after increasing a dose, decrease the dose to the prior one and contact your physician.
• Constipation is the most common side effect of glycopyrrolate, and if constipation occurs, stop administering glycopyrrolate to the patient and call their healthcare practitioner.
• Inability of the patient to urinate, dry diapers or undergarments, irritability or crying may be signs of urinary retention, and if urinary retention occurs, patients/caregivers should stop administering glycopyrrolate and call their healthcare practitioner.
• If the patient develops a skin rash, hives or an allergic reaction, parents/caregivers should stop administering glycopyrrolate and call their healthcare practitioner as this could be a sign of hypersensitivity to this product.
• Drugs like glycopyrrolate can reduce sweating, and if the patient is in a hot environment and flushing of the skin occurs this may be due to overheating. Avoid exposure of the patient to hot or very warm environmental temperatures to avoid overheating and the possibility of heat exhaustion or heat stroke.

Distributed By:

Atlantic Biologicals Corp.

Miami, FL 33179

Glycopyrrolate Oral Solution
(GLY koe PIE roe late)

Please read the Patient and Caregiver Information that comes with glycopyrrolate oral solution before you start giving it to your child, and each time you get a refill. This leaflet does not take the place of talking with your doctor about your child’s medical condition or treatment.

What is glycopyrrolate oral solution?

Glycopyrrolate oral solution is a prescription medicine used in children with medical conditions that cause too much (abnormal) drooling.

Who should not take glycopyrrolate oral solution?

Do not give glycopyrrolate oral solution to anyone who:
• has problems urinating
• has a bowel problem called paralytic ileus
• lacks normal bowel tone or tension
• has severe ulcerative colitis or certain other serious bowel problems with severe ulcerative colitis
• has myasthenia gravis

What should I tell my doctor before giving glycopyrrolate oral solution to my child?

Tell your doctor if your child:
• has any allergies
• has any stomach or bowel problems, including ulcerative colitis
• has any problems with constipation
• has thyroid problems
• has high blood pressure
• has heart problems or abnormal heart beats
• has a hiatal hernia with gastroesophageal reflux disease (GERD)
• has any eye problems
• has any problems urinating
• has any other medical conditions
• is pregnant or plans to become pregnant. It is not known if glycopyrrolate oral solution can harm an unborn baby.
• is breastfeeding or plans to breastfeed. It is not known if glycopyrrolate passes into breast milk and if it can harm the baby.

Tell your doctor about all of the medicines that your child takes,including prescription and non-prescription medicines, vitamins, and herbal supplements. Some medicine may affect the way glycopyrrolate works, and glycopyrrolate may affect how some other medicines work.

How should I give glycopyrrolate oral solution?

• Give glycopyrrolate oral solution exactly as prescribed by your child’s doctor.
• Give glycopyrrolate oral solution 1 hour before or 2 hours after meals.
• Your doctor will tell you how much (milliliters or mLs) of glycopyrrolate oral solution to give your child.
• Do not change the dose of glycopyrrolate oral solution unless your doctor tells you to.
• You must measure the dose of glycopyrrolate oral solution before giving it to your child. Use a special marked dose measuring cup (available at most pharmacies) to measure the right dose of glycopyrrolate oral solution.
• To help make sure that your child swallows the dose, you should use an oral syringe to give the child each dose of glycopyrrolate, after you measure the dose needed with a dose measuring cup. Oral syringes are also available at most pharmacies.
• If you have questions about how to measure the dose or how to use an oral syringe, ask your pharmacist or doctor.
• The dose of glycopyrrolate oral solution that is needed to control drooling may be different for each child. Glycopyrrolate oral solution is usually started at a low dose, and slowly increased as directed by your doctor. This slow increase in dose continues until the best dose for your child is reached, to control drooling.
• During this time it is important to stay in close contact with your child’s doctor, and tell the doctor about any side effects that your child has. See “What are the possible side effects of glycopyrrolate oral solution?”

What should I avoid while taking glycopyrrolate oral solution?

• Glycopyrrolate oral solution may cause sleepiness or blurred vision. Do not drive a car, operate heavy machinery, or do other dangerous activities while taking glycopyrrolate oral solution.
• Avoid overheating. See “What are the possible side effects of glycopyrrolate oral solution?”

What are the possible side effects of glycopyrrolate oral solution?

Glycopyrrolate oral solution can cause serious side effects including:
• Constipation. Constipation is common with glycopyrrolate oral solution. Tell your doctor if your child strains with bowel movements, goes longer between bowel movements, cannot have a bowel movement, or their stomach is firm and large. The dose of glycopyrrolate oral solution may need to be decreased or stopped.
• Diarrhea and intestinal blockage.Diarrhea can be an early symptom of a blockage in the intestine. This is especially true if your child has a colostomy or ileostomy. Tell your doctor if your child has any diarrhea while taking glycopyrrolate oral solution.
• Problems with control of body temperature (overheating or heat stroke).Glycopyrrolate oral solution can cause your child to sweat less. Your child can become overheated, and develop heat stroke if they are in an area that is very hot. Avoid overheating. Call your doctor right away if your child becomes sick and has any of these symptoms of heatstroke:
• hot, red skin
• decreased alertness or passing out (unconsciousness)
• fast, weak pulse
• fast, shallow breathing
• increased body temperature (fever)

The most common side effects of glycopyrrolate oral solution include:
• dry mouth
• vomiting
• flushing of the face or skin
• nasal congestion
• headache
• swollen sinuses (sinusitis)
• upper respiratory tract infection
• problems urinating, difficulty starting urination

Tell your doctor if your child has any side effect that concerns you or that does not go away. These are not all the possible side effects of glycopyrrolate oral solution.

Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088.

How should I store glycopyrrolate oral solution?

Store glycopyrrolate oral solution between 68°F to 77°F (20°C to 25°C).
Keep glycopyrrolate oral solution out of the reach of children.

General information about glycopyrrolate oral solution:

Medicines are sometimes prescribed for purposes other than those listed in a Patient Information leaflet. Do not use glycopyrrolate oral solution for a condition for which it was not prescribed. Do not give glycopyrrolate oral solution to other people even if they have the same condition. It may harm them.
This leaflet summarizes the most important information about glycopyrrolate oral solution. If you would like more information, talk with your doctor. You can ask your doctor or pharmacist for information about glycopyrrolate oral solution that is written for health professionals.

What are the ingredients in glycopyrrolate oral solution?

Active Ingredient: glycopyrrolate
Inactive Ingredients: citric acid monohydrate, glycerin, methyl paraben, non-crystallizing sorbitol solution (contains D-Sorbitol and Water), propylene glycol, propyl paraben, saccharin sodium, sorbitol, trisodium citrate dihydrate and ART cherry flavor.

Patient Information available at camberpharma.com/medication-guides

Distributed By:

Atlantic Biologicals Corp.

Miami, FL 33179

Glycopyrrolate Oral Solution 0.5 mg/2.5 ml Label....17856-1016-01

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Glycopyrrolate Oral Solution 1 mg/5 ml Label....17856-1016-02

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