CGS Buscopan Position Statement

October 5, 2019

Canadian Glaucoma Society Evidence-Based Recommendations for the Risk of Acute Angle Closure Glaucoma with Routine Use of Hyoscine-n-Butylbromide (Buscopan) for Gastroenterological Procedures

Background

Hyoscine-n-butylbromide (Buscopan) is a commonly used anticholinergic medication for gastroenterological endoscopic procedures because of its ability to induce smooth muscle relaxation and decrease spasm(1-10). It can also be used for radiologic procedures of the gastrointestinal tract(11-12). Buscopan may increase detection of colorectal adenoma by up to 30%, thus this medication should not be withheld needlessly(5).

Acute angle closure glaucoma is an emergent and potentially blinding condition. It typically presents with painful, red eye(s), decreased vision, headache, as well as nausea and vomiting(13). While rare, certain classes of medications may precipitate an attack of angle closure. These medications include anticholinergic medications such as Buscopan, as well as adrenergic and cholinergic agents, antidepressants, anticoagulants, and sulfa-based agents(13). Previous guidelines have stated that Buscopan should be withheld in patients with a history of angle closure glaucoma, resulting in a majority of gastroenterologists withholding the medication if the patient gave any history of glaucoma(2).

The practice of withholding Buscopan for a history of glaucoma is of limited value. Specifically, Buscopan does not cause open-angle glaucoma and therefore enquiring to a history of any form of glaucoma is not helpful(2,11). The practice of enquiring about a history of angle closure glaucoma is also not likely beneficial, as patients who report a history of angle closure or narrow angles have probably received treatment and are no longer at risk(14-16). The patients at risk of acute angle closure glaucoma are those who have not been diagnosed and treated for predisposing narrow angles and are therefore unaware of their condition.

Conclusion

Buscopan is a useful medication in gastroenterological procedures, but it does carry a small risk of inducing angle closure glaucoma. The practice of inquiring about a history of glaucoma in patients being considered for treatment with Buscopan is of minimal value, as the only patients at risk of angle closure glaucoma are those who are not aware of their condition. Consequently, the Canadian Glaucoma Society recommends that physicians using Buscopan should instead focus on counseling patients on signs and symptoms of acute angle closure: painful, red eye(s), decreased vision, headache, nausea and vomiting. Patients should be advised to present to the nearest emergency department should they develop any of these symptoms following their procedure.

References

1. Lee T., Anderson J., Thomas-Gibson S., Rees C. Use of intravenous hyoscine butylbromide (Buscopan) during gastrointestinal endoscopy. Frontline Gastroenterol. 2018; 9.

2. Bedford M.R., Reuser T., Wilson P., Karandikar S, Bowley D. Administration of hyoscinen-butylbromide during colonoscopy: a survey of current UK practice. Frontline Gastroenterology. 2012; 3:238-241.

3. Saunders B.P., Williams C.B. Premedication with intravenous antispasmodic speeds colonoscope insertion. Gastrointest Endosc. 1996; 43:209-11.

4. Chang F.Y., Guo W.S., Liao T.M., Lee S.D. A randomized study comparing glucagon and hyoscine N-butyl bromide before endoscopic retrograde cholangiopancreatography. Scand J Gastroenterol. 1995; 30:283-6.

5. Lee T.J.W, Rees C.R., Blanks R., Moss S.M., Nickerson C., Wright K.C., James P.W., McNally R.J., Patnick J., Rutter M.D. Colonoscopic factors associated with adenoma detection in a national colorectal cancer screening program. Endoscopy 2014; 46:203-11.

6. de Brouwer E.J., Arbouw M.E., van der Zwet W.C., van Herwaarden M.A., Ledeboer M., Jansman F.G., ter Borg F. Hyoscine N-butylbromide does not improve polyp detection during colonoscopy: a double-blind, randomized, placebo-controlled, clinical trial. Gastrointest Endosc 2012; 75(4):835-40.

7. Mui L.M., Enders K.W.N., Kang-chung C., Ng C.S., Yeung A.C., Chan S.K., Wong S.K., Chung S.C. Randomized, double-blinded, placebo-controlled trial of intravenously administered hyoscine n-butyl bromide in patients undergoing colonoscopy with patient controlled sedation. Gastrointest Endosc 2004; 59:22-7.

8. Lee J.M., Cheon J.H., Park J.J., Moon C.M., Kim E.S., Kim T.I., Kim W.H. Effects of Hyoscine n-butyl bromide on the detection of polyps during colonoscopy. Hepatogastroenterology 2010; 57:90-94.

9. Corte C., Dahlenburg L., Selby S., Griffin S, Byrne C., Chua T., Kaffes A. Hyoscine Butylbromide administered at the cecum increases polyp detection: a randomized double-blind placebo-controlled trial. Endoscopy 2012; 44:917-22

10. Saunders BP, Williams CB. Premedication with intravenous antispasmodic speeds colonoscope insertion. Gastrointestinal Endoscopy 1996; 43:209-11.

11. Dyde R., Chapman A.H., Gale R., Mackintosh A., Tolan D.J., Precautions to be taken by radiologists and radiographers when prescribing hyoscine-n-butylbromide. Clin Radiol. 2008; 63(7):739-43.

12. Fink A.M., Aylward G.W., Buscopan and glaucoma: a survey of current practice. Clin Radiol. 1995; 50(3):160-4.

13. Ah-Kee E.Y., Eging E., Shafi A., Lim L.T., Yim J.L. A review of drug-induced acute angle closure glaucoma for non-ophthalmologists. Qatar Medical Journal. 2015; 6.

14. Radhakrishnan S., Chen P.P., Junk A.K., Nouri-Mahdavi K., Chen T.C. Laser peripheral iridotomy in primary angle closure: A report by the American Academy of Ophthalmology. Ophthalmology. 2018; 125(7):1110-1120.

15. Sissons G.R., McQueenie A., Mantle M. The ocular effects of hyoscine-n-butylbromide (“Buscopan”) in radiological practice. The British Journal of Radiology. 1991; 64(763):584-6.

16. Kozak R.I., Bennet J.D., Brown T.C., Lee T.Y. The ocular effects of hyoscine-nbutylbromide (“Buscopan”) in radiological practice. Canadian Association of Radiologists. 1994; 45(3):209-11.