Glycopyrrolate Induced Dry Tongue in A Geriatric Case of Chronic Liver Disease: A Case Report

Background: It has been quite evident in the recent years that health problems of the geriatric population are multifaceted and hence complicated because of increased number of ADR’s associated with taking multiple drugs. In 2015, India alone accounted for 18.3% of the two million global liver disease-related deaths. The elderly population undergoes significant changes in multiple organ systems due to the aging process. Anaesthetic agents are chosen based on parameters like protein binding, distribution, and drug metabolism. However, it has been noted that glycopyrrolate should be used with precautions in elderly population considering age related changes in liver, heart and kidneys.

Methods: This case was collected from Surgery Department as a part of Pharmacovigilance elective under the Department of Pharmacology, CMC Ludhiana, which is an ADR Monitoring Centre. 

Conclusion: Glycopyrrolate is a versatile medication that is used by various healthcare professionals in different fields. Clinicians should monitor liver function tests and kidney function tests in elderly patients particularly when an anti-cholinergic drug is being given. Considering the nature of the adverse event which is very rare, it is of great necessity to report such a case.

An ADR is defined by WHO as “a response to a medication that is noxious and unintended and occurs at doses normally used in man.” ADRs are one of the leading causes of morbidity and mortality worldwide.[1] It has been quite evident in the recent years that health problems of the geriatric population are multifaceted and hence complicated because of increased number of ADR’s associated with taking multiple drugs. Hypertension appears to be the most prevalent condition, affecting 40.4% of the population. This is followed by diabetes at 31.2%, arthritis at 22.1%, sensory impairment at 10.1%, heart diseases at 7.8%, and dyslipidaemia at 7.0%. It’s also notable that 74.1% of participants had at least one morbidity, and 40.0% had multi-morbidity, which means they were dealing with more than one health condition at the same time [2].

In 2015, India alone accounted for 18.3% of the two million global liver disease-related deaths [3]. Common causes being Acute liver diseases, Chronic liver disease (Alcoholic, Non -Alcoholic, infective) [4, 5]. In addition, the elderly population undergoes significant changes in multiple organ systems due to the aging process. Due to these factors IN-hospital adverse events and prolonged duration of hospital stay are frequently observed in elderly patients. Appropriate preoperative assessment, proper anaesthetic technique, and careful postoperative management can help reduce adverse events [6].

In addition to this, anaesthesia and surgery can worsen liver function in patients with liver disease. It is crucial to identify, optimize, and manage anaesthesia carefully for the best outcomes in these patients. The Indian facilities lack a local evidence-based protocol for managing such patients, thereby increasing the risk of adverse health outcomes associated with the medicine use. 

Anaesthetic agents are chosen based on parameters like protein binding, distribution, and drug metabolism [7]. In this case, glycopyrrolate was given to a 75-year-old elderly female. However, it has been noted that glycopyrrolate should be used with precautions in elderly population considering age related changes in liver, heart and kidneys [8]. The patient developed dry tongue following the intake of the drug which is a very rare condition as only a single case of dry tongue has been reported according to Vigiaccess database [9].

Henceforth this case is worth reporting considering that dry mouth is one of the common ADR of glycopyrrolate, but dry tongue is very rare and thereby worth reporting.

This is a case of a 75-year-old lady, known case of chronic liver disease-NAFLD for 5 years, presented to casualty with complaints of passage of blood in stools (bright red colour) associated with feeling of mass on defecation and dull-abdominal pain. She was scheduled for an Upper Gastro-intestinal Endoscopy the following day for which she was given pre-operative medications including: Inj. Glycopyrrolate 0.2mg IV, Inj. Midazolam 1mg IV, Inj. Fentanyl 25mcg IV, Inj. Ketamine 20 mg IV and Inj. Propofol 20mg IV after which she developed dryness of tongue. On follow up, symptoms self-resolved within 6 hours post-op. The Naranjo's score was 5 (probable) and causality assessment showed probable correlation of the current adverse event with glycopyrrolate. The causal relationships of other drugs in the regimen with the reaction was evaluated and the score was 3 (possible) [10].

Figure 1: Depicts the dry tongue of the patient

Glycopyrrolate is a synthetic anticholinergic quaternary ammonium compound commonly used as anti-muscarinic agent in pre-operative procedures. Its acts as an anti-sialagogue, creates sedative and amnestic effect and prevents reflex bradycardia. Glycopyrrolate is a well-known anticholinergic drug. It binds to its respective muscarinic ACh-receptor (M3 receptor) and can inhibit sympathetic induced contraction of smooth muscles or secretion from the salivary glands [11]. It has been gaining popularity in the market ever since its introduction in 1961 (injection formulation in 1975). Diverse routes of administration (oral, intravenous, inhalational, and newly innovative formulations for topical application) have been used for treatment of various conditions such as peptic ulcers, excessive salivation, and chronic obstructive pulmonary disease (COPD) [12].

Glycopyrrolate has a rapid onset of action when given intravenously, which makes it a valuable drug in many clinical scenarios. Its elimination half-life of approximately 50 minutes allows for sustained effects, and its primary route of elimination is through the urine (95%) [13]. While it is widely agreed that Anti-muscarinic agents can cause mydriasis, hyperthermia, tachycardia, and cardiac arrhythmia, blurred vision, constipation, cycloplegia, dry mouth, dry skin, flushing, photophobia, urinary retention, and xerophthalmia, there is a discrepancy between data published in articles regarding how many people experienced such symptoms and the total number of cases reported to the world health database. Moreover, the frequency and duration of such ADRs is yet to be explored in the geriatric population as well as those hepatic failure [13]. Despite this, the safety profile of the drug seems appropriate so far as per the current FDA database. [14]. However, discretion is advised whilst administration to the vulnerable populace [15]. 

Glycopyrrolate is a versatile medication that is used by various healthcare professionals in different fields. It is important to note that while glycopyrrolate is a useful drug, it should always be used under the supervision of a healthcare provider due to its potential adverse effects. Clinicians should monitor liver function tests and kidney function tests in elderly patients particularly when an anti-cholinergic drug is being given. Considering the nature of the adverse event which is very rare, it is of great necessity to report such a case.