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

This study looked at the efficacy of drug treatment in managing death rattl e in a 30-bedded specialist palliative care unit. The study was conducted i n two phases. In the first, patients received hyoscine hydrobromide as the antimuscarinic; glycopyrrolate was used in the second phase. The patients i n 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 val idated using a verbal rating scale and noise-meter readings. Noise scores w ere taken at the start; 30 min after an antimuscarinic drug was administere d: 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 we re analysed to ascertain the amount of each drug given and the cost. The in cidence of death rattle was 44% in phase I, and 36% in phase II. The percen tage of patients with reduced noise scores 30 min after one injection of hy oscine 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 significa nt difference in improvement at 1 h, or at the last recorded score before d eath. A comparison of the cost of drug treatment using hyoscine or glycopyr rolate was made, and the potential reduction in cost per patient in the gly copyrrolate group was largely offset by increased expenditure on other drug s, especially diamorphine, midazolam and levomepromazine. The results of th is study suggest that: (1) glycopyrrolate 0.2 mg is less effective at reduc ing 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 seda tive or anti-emetic medication such as diamorphine, midazolam or levomeprom azine, and (3) the cost benefit of using glycopyrrolate over hyoscine hydro bromide is a small part of the total drug budget, and may be less than anti cipated due to the increased need of these other drugs.