Oral Medications

Anticholinergics

The most commonly used medications for managing excessive sweating are anticholinergics. Anticholinergics help block signals from nerves that would otherwise tell sweat glands to produce sweat - thus, they help tackle the problem of too much sweating at the source. Anticholinergics include medicines such as glycopyrrolate, oxybutynin, benztropine, propantheline, and others. Aside from excessive sweating, anticholinergics are used to treat overactive bladder and peptic ulcer disease, among other things. "We understand how they work and how to manage them," says one IHhS board member and physician. The anticholinergics frequently used to treat excessive sweating are glycopyrrolate and oxybutynin. Glycopyrrolate is used for a number of reasons, aside from sweating, such as for excessive secretions in people with tracheotomies. Meanwhile, oxybutynin is the #1 medication used to treat bed wetting in children and is used for this purpose for years with considerable comfort. Brand names you might hear for these two medications in the U.S. are: Ditropan (oxybutynin) and Robinul and Cuvposa (both glycopyrrolate). Oxybutynin is available in at least 13 different countries. Glycopyrrolate is available in at least 32 countries. 

Many hyperhidrosis patients experience success with anticholinergic therapy, especially when it's used in combination with other sweat management techniques. Anticholinergics have not, however, been studied in controlled clinical trials specifically for hyperhidrosis. Their FDA approval is, on the other hand, based on studies involving other medical conditions. Their use for hyperhidrosis is, thus, “off-label”. Of course, it is common for medications to be used “off-label” and a substantial safe history of off-label use of these meds has helped most practitioners to feel confident about them. Some anticholinergics, such as glycopyrrolate and oxybutynin, have even been found to be safe in young children. One IHhS Board member indicates that she prescribes oral medications (specifically glycopyrrolate and/or oxybutynin) for pediatric hyperhidrosis in children as young as 4 years and she reminds us that about 80% of all the medications used in children, for all sorts of conditions, are being used "off-label." In her experience, pediatric patients (or their families) using an oral medication for excessive sweating almost always refill their prescriptions on-time (an indication of how valuable the treatment is to them). 

It should be noted that studies (in JAMA Neurology 2016 and JAMA Internal Medicine 2015) have reported a potential link between the development of dementia and/or brain atrophy and long-term, high-dose anticholinergic use by older people. Patients over (or near) the age of 65 may want to discuss these studies (JAMA Neurology 2016, JAMA Internal Medicine 2015) with their healthcare providers before embarking on or continuing anticholinergic therapy for excessive sweating. Of the anticholinergics available, the most appropriate for older adults may be glycopyrrolate because it is the one that is least likely to cross the blood-brain barrier. Also, 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 that list. 

Besides possibly in the older age group (and more studies are needed on this), anticholinergics do not, in general, affect the central nervous system (the brain and spinal cord). They work, instead, more peripherally by blocking the chemical messenger acetylcholine as it attempts to travel to receptors on the sweat glands that are responsible for triggering sweating. Similar receptors are, however, located in multiple areas of the body, so there can be a range of side effects from anticholinergic therapy such as dry mouth, constipation, impaired taste, blurred vision, dry eyes, urinary retention, and heart palpitations. These side effects can usually be managed by adjusting the individual’s dose. Of possible future use, a new medication that combines oxybutynin and pilocarpine (to combat dry mouth and other side effects) is being studied. David M. Pariser, MD, International Hyperhidrosis Society founding board member, and an expert in treating hyperhidrosis patients, characterizes the side effects of anticholinergic treatments as “predictable, manageable, and usually mild.”

That said, there are some hyperhidrosis patients who need to be cautious when using anticholinergics.

As mentioned above, patients age 65 or older may want to discuss anticholinergic use and potential dementia risks with their clinicians and which (if any) anticholinergic might be an option for them.

Similarly, other patients need to be informed, too. Because anticholinergic medications work systemically and cannot target any one body area in particular, they decrease sweating over the entire body, even in those locations where sweating is not a problem. This overall decrease in sweating can put the patient at risk for overheating and over-drying. Dee Anna Glaser, MD, president and founding board member of the International Hyperhidrosis Society, treats hundreds of hyperhidrosis patients each year and is well versed in anticholinergic use. She cautions her patients saying, “When taking anticholinergics, the body may have more difficulty keeping itself cool with the sweat mechanism ‘turned off.’ Therefore, athletes, people who participate in sports, people who work outdoors, and anyone who may potentially cause themselves injury by becoming overheated must use extra care when considering these treatments.” Patients or parents of children taking the medication must remain aware of temperature, water intake, exertion, and any symptoms of overheating such as pale skin, dizziness, muscle cramping, weakness, headache, and nausea. 

Further, patients with glaucoma (especially narrow-angle glaucoma) and those who have impaired gastric emptying or a history or symptoms of urinary retention should not use anticholinergic therapy.

There are non-pill formulations of anticholinergic medications for children and adults who are unable or unwilling to swallow the pills. For example, two commonly prescribed anticholinergic medications are available in liquid formulations. The FDA has approved a liquid form of the anticholinergic glycopyrrolate (sold under the brand name Cuvposa) to reduce drooling in pediatric cerebral palsy patients. Oxybutynin is also available in a liquid formulation and is approved for use in pediatric patients with certain bladder and urinary conditions. Dr. Pariser says the benefits of oral anticholinergics in liquid form have been immediate. “I had an 8-year-old child who couldn't swallow the tablets, no matter how crushed or mixed with food. Here’s a great solution. And because this medicine is approved for children, it gives reassurance to patients of all ages who have safety concerns with this therapy.”

Beta Blockers and Benzodiazepines

There are other oral medications besides anticholinergics that are successful in treating patients with specific types of hyperhidrosis, as well. Beta-blockers (propranolol) and benzodiazepines work by “blocking” the physical manifestations of anxiety. Propranolol has been in use, even in small babies (for another medical reason), since ~1976. Propranolol "calms down" the body, slows the heart rate and can help with sweating when you know you will be agitated or nervous. These meds act on the central nervous system and are best for patients who experience episodic or event-driven hyperhidrosis (such as excessive sweating brought on by job interviews or presentations). Propranolol, for example, works well, says one expert, when taken 30 to 60 minutes before an event and not on a regular basis. Side effects limit their long-term use. For instance, benzodiazepines can be habit-forming, and many patients cannot tolerate the sedative effects caused by both of these drug therapies.

There have also been single-case or small samples of patients with specific types of hyperhidrosis who responded to a variety of other oral medications. Agents such as Clonidine, indomethacin, gabapentin, and multiple others have shown effectiveness in very specific cases of hyperhidrosis. Clonidine seems to be particularly useful to help manage sweating at specific times (situational sweating, as mentioned with propranolol above) - such as if you have an important interview or meeting or if you are going to be doing public speaking. Clonidine is part of class of medications called centrally acting alpha-agonist hypotensive agents. Clonidine is also used for high blood pressure, menopausal-related sweating, sweating that's a side effect of other medications (like anti-anxiety medications or anti-depressants). Clonidine seems to be especially appropriate for excessive cranial (head/face) sweating, although experts aren't sure why. It should be taken regularly if being used for this purpose. 

We are often asked whether oral medications to treat extreme sweating can be used if a person also takes an anti-anxiety prescription. This will depend on which anti-anxiety med is being used and which oral med for sweating is being considered. You should work with your medical provider or pharmacist, as always, to ensure that different medications are okay to be taken together. 

If you are pregnant, planning on becoming pregnant or breastfeeding, always discuss any/all of your medications and supplements with your ob/gyn doctor. Propranolol for sweating might be okay to continue during pregancy (but ask your doctor). Oxybutynin is a class B (learn about the pregnancy medication categories), meaning there have been some studies on it related to pregnancy, again, please discuss its use with your care provider. 

Of course, it's important to know about the side effects of oral mediations to treat excessive sweating. Some have already been discussed above. In general, side effects will vary based on the medication and the individual, and your practitioner and pharmacist will be the best sources of information on what side effects to expect and watch out for. Side effects such as dry mouth, say our experts, can be managed with some life hacks - like carrying a water bottle with you to sip from, using oral rinses (your practitioner can recommend the right choice), or adding another medication to combat dry mouth (again, your care provider would be the person to ask about this). There are drops available to help with dry eyes and constipation can often be handled with diet adjustments. If the side effects of one medication for excessive sweating are too much, perhaps a different dose or different medication might be the answer. 

As mentioned above, because oral meds for hyperhidrosis decrease the body's ability to sweat, athletes and those who work outside need to be aware and alert for signs of overheating. For teenagers or children in sports, a doctor's note to the coach or P.E./gym teacher can be helpful to explain the situation. 

On a side note, some clinicians and their patients have had great success treating sweaty palms and sweaty feet by adding a crushed anticholinergic tablet to the water used during iontophoresis. Learn more about iontophoresis and how anticholinergics can make the process even more effective.

If you are interested in learning more about using oral medications to treat excessive sweating or as an adjunct/addition to other treatments, find a healthcare provider who is well-versed in hyperhidrosis care and oral medications in the IHhS’s Clinician Finder database. 

What if a systemic oral medication isn't right for you at the moment? Maybe one will be in the future! There are innovative developments on the horizon in hyperhidrosis care and oral options. But keep in mind, also, that there are great treatments available right now.