Atropine, Hyoscine Butylbromide, or Scopolamine Are Equally Effective for the Treatment of Death Rattle in Terminal Care

Death rattle is a frequent symptom (25%-50%) in the terminal stage of life, but there is neither standardized treatment nor prospective investigation performed on the effectiveness of anticholinergic drugs. The aim of the present study was to investigate the effectiveness of three different anticholinergic drugs in the treatment of death rattle in the terminal stage of life. Terminal patients who developed death rattle were randomly assigned 0.5 mg atropine, 20 mg hyoscine butylbromide, or 0.25 mg scopolamine. Each treatment was initiated with a subcutaneous bolus, which was followed by continuous administration of the same drug. The intensity of death rattle and side effects were prospectively scored at different time points. Three hundred and thirty-three eligible patients were randomized to atropine, hyoscine butylbromide, or scopolamine after informed consent from the patient or the appointed representative. For the three drugs, death rattle decreased to a nondisturbing intensity or disappeared aft.,er one hour in 42%, 42%, and 37% of cases, respectively (P = 0.72). Further, effectiveness improved over time without significant differences among the treatment groups (effectiveness at 24 hours was 76%, 60%, and 68%, respectively). In an analysis on the three groups together, treatment was more effective when started at a lower initial rattle intensity; median survival after start of therapy was 23.9 hours. These data suggest that there are no significant differences in effectiveness or survival time among atropine, hyoscine butylbromide, and scopolamine in the treatment of death rattle. J Pain Symptom Manage 2009;38:124-133. (c) 2009 U.S. Cancer Pain Relief Committee. Published by Elsevier Inc. All rights reserved.