Anticholinergic agents for the treatment of “death rattle” in patients with myasthenia gravis

Abstract

Difficulty clearing upper airway secretions (death rattle) is a frequent problem at the end of life. Treatment often includes the use of anticholinergic drugs. Myasthenia gravis is a disease characterized by muscle weakness and fatigue caused by an immune-mediated deficiency of acetylcholine receptors at the neuromuscular junction, and it is treated with anticholinesterase agents. We report the case of a patient dying of myasthenia gravis who had problems with the "death rattle" and who presented a dilemma as to whether the use of anticholinergics would be helpful or would cause deterioration of her myasthenia. This is accompanied by a review of the relevant literature.

Administering Neostigmine as a Subcutaneous Infusion: A Case Report of a Patient Dying With Myasthenia Gravis

“…A case report by Kamel et al 8 described the successful management of nausea with oral cyclizine (12.5 mg twice a day) in a patient with myasthenia gravis. Anticholinergic agents 2,7 The use of anticholinergic medications, such as glycopyrronium and propantheline, is well defined in myasthenia gravis for the treatment of ''cholinergic'' side effects induced by acetylcholinesterase inhibitors. The use of anticholinergic agents for the palliative symptom management of patients with myasthenia gravis is, however, poorly defined.…”

“…The use of anticholinergic agents for the palliative symptom management of patients with myasthenia gravis is, however, poorly defined. A case report by Spiess et al 7 reported the safe and successful use of topical scopolamine for excessive oropharyngeal secretions in a patient with myasthenia gravis.…”

“…Case studies 7,8 discussing the palliative management of patients with myasthenia gravis show examples of pyridostigmine being administered via enteral routes for as long as possible, with no studies detailing the administration of parenteral acetylcholinesterase inhibitors or the consequences of suboptimal management during the end-of-life period. Moreover, pharmacological symptom management in palliative patients with myasthenia gravis is further complicated by a paucity of evidence thereon, and the fact that many of the medication classes commonly used in palliative medicine may exacerbate the underlying condition (see Table 1).…”

Life's Final Journey: The Oncology Nurse's Role

“…Other drugs that can assist with reducing secretions are atropine, glycopyrrolate, and hyoscyamine (Bennett et al, 2002;Spiess & Scott, 2003). In addition to those agents, diuretics such as furosemide can eliminate excess fl uids that build up in the upper airways.…”