The most commonly used medications for managing excessive sweating are anticholinergics. These include medicines such as glycopyrrolate, oxybutynin, benztropine, propantheline, and others.
Many hyperhidrosis patients experience success with anticholinergic therapy. 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”. It is common for medications to be used “off-label” and a substantial safe history of off-label use of these meds has helped many 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 of Directors member indicates that she prescribes oral medications for pediatric hyperhidrosis in children as young as 4 years.
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-level 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. 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 this 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, 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 a 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.”
Another option for anyone 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, but may be prescribed off-label by medical providers 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 of the mouth - rather than through the digestive system like regular pills. Each tablet of Dartisla ODT is 1.7mg of glycopyrrolate, which is equivalent to 2mg of a regular pill of glycopyrrolate when it goes through the GI tract. If your clinician prescribes Dartisla ODT for you, be sure 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 your mouth. Patients can receive Dartisla ODT for as little as $0 through Phil, an online pharmacy, or as little as $20 at other pharmacies.
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. 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). 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.
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.
Have you talked to your medical provider about excessive sweating? If not, now is the time! Learn more about how you and your healthcare team can work together to find the right treatment, or combination of hyperhidrosis treatments, to manage your hyperhidrosis.
If you’re considering an oral medication to treat excessive sweating, please know that experts in the field recommend that you try antiperspirants, iontophoresis, or Botox injections first (or a combination of these). Click on the links provided to learn more about the usefulness of these treatments.
And remember, because hyperhidrosis is a serious medical condition - you deserve insurance coverage and reimbursement for your medical visits and treatments! We’ve got tips to help you navigate the health insurance realm and receive coverage.
Research and References
Want to learn more about oral medications for the treatment of excessive sweating? Below are links to relevant articles and abstracts published in medical journals. More studies regarding other treatments can be found here:
Pariser D, Krishnaraja J, Tremblay T, Rubison M, Love T, McGraw B. Randomized, Placebo- and Active-Controlled Crossover Study of the Safety and Efficacy THVD-102, a Fixed-dose Combination of Oxybutynin and Pilocarpine, in Subjects with Primary Focal Hyperhidrosis. Journal of Drugs in Dermatology 2017 Feb 1;16(2): 127-132.
Risacher SL, McDonald BC, Tallman EF, et al. "Association between anticholinergic medication use and cognition, brain metabolism, and brain atrophy in cognitively normal adults." JAMA Neurol. doi:10.1001/jamaneurol.2016.0508. Published online April 18, 2016.
Campbell, Noll L. PharmD & Boustani, Malaz A. MD, MPH. “Adverse cognitive effects of medications. Turning attention to reversibility.” Invited commentary. JAMA Intern Med doi: 10.1001/jamainternmed.2014.7667. Published online January 26, 2015.
Hund, Martina, et al. “Randomised, placebo-controlled, double-blind clinical trial for the evaluation of the efficacy and safety of oral methanthelinium bromide (Vagantin®) in the treatment of focal hyperhidrosis”.JDDG;2004· 2:343-349.