Adverse Drug Experiences
Dosage and Administration
Programmed to deliver in-vivo approximately 1.0
mg of scopolamine over 3 days
The Transderm Scōp (transdermal scopolamine) system
is a circular flat patch designed for continuous release
of scopolamine following application to an area of intact
skin on the head, behind the ear. Each system contains
1.5 mg of scopolamine base. Scopolamine is α-(hydroxymethyl)
benzeneacetic acid 9-methyl-3-oxa-9-azatricyclo [3.3.1.02,4]
non-7-yl ester. The empirical formula is C17H21NO4
and its structural formula is
Scopolamine is a viscous liquid that has a molecular weight of 303.35 and a pKa of 7.55 - 7.81. The Transderm Scōp system is a film 0.2 mm thick and 2.5 cm2, with four layers. Proceeding from the visible surface towards the surface attached to the skin, these layers are: (1) a backing layer of tancolored, aluminized, polyester film; (2) a drug reservoir of scopolamine, light mineral oil, and polyisobutylene; (3) a microporous polypropylene membrane that controls the rate of delivery of scopolamine from the system to the skin surface; and (4) an adhesive formulation of mineral oil, polyisobutylene, and scopolamine. A protective peel strip of siliconized polyester, which covers the adhesive layer, is removed before the system is used. The inactive components, light mineral oil (12.4 mg) and polyisobutylene (11.4 mg), are not released from the system.
The sole active agent of Transderm Scōp is scopolamine, a belladonna alkaloid with wellknown pharmacological properties. It is an anticholinergic agent which acts: i) as a competitive
inhibitor at postganglionic muscarinic receptor
sites of the parasympathetic nervous system,
and ii) on smooth muscles that respond to acetylcholine
but lack cholinergic innervation. It has
been suggested that scopolamine acts in the
central nervous system (CNS) by blocking
cholinergic transmission from the vestibular
nuclei to higher centers in the CNS and from the
reticular formation to the vomiting center1,2.
Scopolamine can inhibit the secretion of saliva
and sweat, decrease gastrointestinal secretions
and motility, cause drowsiness, dilate the pupils,
increase heart rate, and depress motor function2.
Scopolamine's activity is due to the parent drug.
The pharmacokinetics of scopolamine delivered
via the system are due to the characteristics of
both the drug and dosage form. The system is
programmed to deliver in-vivo
mg of scopolamine at an approximately constant
rate to the systemic circulation over 3 days. Upon
application to the post-auricular skin, an initial
priming dose of scopolamine is released from
the adhesive layer to saturate skin binding sites.
The subsequent delivery of scopolamine to the
blood is determined by the rate controlling membrane
and is designed to produce stable plasma
levels in a therapeutic range. Following removal
of the used system, there is some degree of continued
systemic absorption of scopolamine
bound in the skin layers.
Absorption: Scopolamine is well-absorbed percutaneously.
Following application to the skin
behind the ear, circulating plasma levels are
detected within 4 hours with peak levels being
obtained, on average, within 24 hours. The
average plasma concentration produced is 87
pg/mL for free scopolamine and 354 pg/mL for
total scopolamine (free + conjugates).
Distribution: The distribution of scopolamine is
not well characterized. It crosses the placenta
and the blood brain barrier and may be
reversibly bound to plasma proteins.
Metabolism: Although not well characterized,
scopolamine is extensively metabolized and
conjugated with less than 5% of the total dose
appearing unchanged in the urine.
Elimination: The exact elimination pattern of
scopolamine has not been determined.
Following patch removal, plasma levels decline
in a log linear fashion with an observed half-life
of 9.5 hours. Less than 10% of the total dose is
excreted in the urine as parent and metabolites
over 108 hours.
Clinical Results: In 195 adult subjects of different
racial origins who participated in clinical efficacy
studies at sea or in a controlled motion
environment, there was a 75% reduction in the incidence
of motion-induced nausea and vomiting3.
In two pivotal clinical efficacy studies in 391
adult female patients undergoing cesarean section
or gynecological surgery with anesthesia
and opiate analgesia, 66% of those treated with
Transderm Scōp (compared to only 46% of
those receiving placebo) reported no retching/
vomiting within the 24-hour period following
administration of anesthesia/opiate analgesia.
When the need for additional antiemetic medication
was assessed during the same period,
there was no need for medication in 76% of patients treated with Transderm Scōp as compared
to 59% of placebo-treated patients4,5.
Transderm Scōp is indicated in adults for prevention
of nausea and vomiting associated with
motion sickness and recovery from anesthesia
and surgery. The patch should be applied only
to skin in the postauricular area.
Transderm Scōp is contraindicated in persons
who are hypersensitive to the drug scopolamine
or to other belladonna alkaloids, or to any ingredient
or component in the formulation or delivery
system, or in patients with angle-closure
(narrow angle) glaucoma.
Glaucoma therapy in patients with chronic
open-angle (wide-angle) glaucoma should be
monitored and may need to be adjusted during
Transderm Scōp use, as the mydriatic effect of
scopolamine may cause an increase in intraocular
Transderm Scōp should not be used in children
and should be used with caution in the elderly.
Since drowsiness, disorientation, and confusion
may occur with the use of scopolamine, patients
should be warned of the possibility and cautioned
against engaging in activities that require
mental alertness, such as driving a motor vehicle
or operating dangerous machinery.
Rarely, idiosyncratic reactions may occur with
ordinary therapeutic doses of scopolamine. The
most serious of these that have been reported
are: acute toxic psychosis, including confusion,
agitation, rambling speech, hallucinations,
paranoid behaviors, and delusions.
Scopolamine should be used with caution in
patients with pyloric obstruction or urinary bladder
neck obstruction. Caution should be exercised
when administering an antiemetic or
antimuscarinic drug to patients suspected of
having intestinal obstruction.
Transderm Scōp should be used with caution in
the elderly or in individuals with impaired liver or
kidney functions because of the increased likelihood
of CNS effects.
Caution should be exercised in patients with a
history of seizures or psychosis, since scopolamine
can potentially aggravate both disorders.
Skin burns have been reported at the patch site
in several patients wearing an aluminized transdermal
systems during a Magnetic Resonance
Imaging scan (MRI). Because Transderm Scōp
contains aluminum, it is recommended to
remove the system before undergoing an MRI.
Information for Patients
Since scopolamine can cause temporary dilation
of the pupils and blurred vision if it comes
in contact with the eyes, patients should be
strongly advised to wash their hands thoroughly
with soap and water immediately after handling
the patch. In addition, it is important that
used patches be disposed of properly to avoid
contact with children or pets.
Patients should be advised to remove the patch
immediately and promptly contact a physician
in the unlikely event that they experience symptoms
of acute narrow-angle glaucoma (pain and
reddening of the eyes, accompanied by dilated
pupils). Patients should also be instructed to
remove the patch if they develop any difficulties
Patients who expect to participate in underwater
sports should be cautioned regarding the
potentially disorienting effects of scopolamine.
A patient brochure is available.
The absorption of oral medications may be
decreased during the concurrent use of scopolamine
because of decreased gastric motility
and delayed gastric emptying.
Scopolamine should be used with care in
patients taking other drugs that are capable of
causing CNS effects such as sedatives, tranquilizers,
or alcohol. Special attention should be
paid to potential interactions with drugs having
anticholinergic properties; e.g., other belladonna
alkaloids, antihistamines (including meclizine),
tricyclic antidepressants, and muscle relaxants.
Laboratory Test Interactions
Scopolamine will interfere with the gastric
Carcinogenesis, Mutagenesis, Impairment
No long-term studies in animals have been
completed to evaluate the carcinogenic potential
of scopolamine. The mutagenic potential of
scopolamine has not been evaluated. Fertility
studies were performed in female rats and
revealed no evidence of impaired fertility or
harm to the fetus due to scopolamine hydrobromide
administered by daily subcutaneous injection.
Maternal body weights were reduced in
the highest-dose group (plasma level approximately
500 times the level achieved in humans
using a transdermal system).
Transderm Scōp scopolamine
Transdermal Therapeutic System
Pregnancy Category C
Teratogenic studies were performed in pregnant
rats and rabbits with scopolamine hydrobromide
administered by daily intravenous injection. No
adverse effects were recorded in rats.
Scopolamine hydrobromide has been shown to
have a marginal embryotoxic effect in rabbits
when administered by daily intravenous injection
at doses producing plasma levels approximately
100 times the level achieved in humans
using a transdermal system. During a clinical
study among women undergoing cesarean section
treated with Transderm Scōp in conjunction
with epidural anesthesia and opiate analgesia,
no evidence of CNS depression was found in
the newborns.There are no other adequate and
well-controlled studies in pregnant women.
Other than in the adjunctive use for delivery by
cesarean section, Transderm Scōp should be
used in pregnancy only if the potential benefit
justifies the potential risk to the fetus.
Because scopolamine is excreted in human milk,
caution should be exercised when Transderm
Scōp is administered to a nursing woman.
Labor and Delivery
Scopolamine administered parenterally at higher
doses than the dose delivered by Transderm
Scōp does not increase the duration of labor,
nor does it affect uterine contractions. Scopolamine
does cross the placenta.
The safety and effectiveness of Transderm Scōp
in children has not been established. Children
are particularly susceptible to the side effects of
belladonna alkaloids. Transderm Scōp should
not be used in children because it is not known
whether this system will release an amount of
scopolamine that could produce serious
adverse effects in children.
The adverse reactions for Transderm Scōp are
provided separately for patients with motion
sickness and with post-operative nausea and
Motion Sickness: In motion sickness clinical
studies of Transderm Scōp, the most frequent
adverse reaction was dryness of the mouth.
This occurred in about two thirds of patients on
drug. A less frequent adverse drug reaction was
drowsiness, which occurred in less than one
sixth of patients on drug. Transient impairment
of eye accommodation, including blurred vision
and dilation of the pupils, was also observed.
Post-operative Nausea and Vomiting:
In a total
of five clinical studies in which Transderm Scōp
was administered perioperatively to a total of
461 patients and safety was assessed, dry
mouth was the most frequently reported
adverse drug experience, which occurred in
approximately 29% of patients on drug.
Dizziness was reported by approximately 12%
of patients on drug6.
Postmarketing and Other Experience:
to the adverse experiences reported during
clinical testing of Transderm Scōp, the following
are spontaneously reported adverse events
from postmarketing experience. Because the
reports cite events reported spontaneously
from worldwide postmarketing experience, frequency
of events and the role of Transderm
Scōp in their causation cannot be reliably determined:
acute angle-closure (narrow-angle)
glaucoma; confusion; difficulty urinating; dry,
itchy, or conjunctival injection of eyes; restlessness;
hallucinations; memory disturbances;
rashes and erythema; and transient changes in
Drug Withdrawal/Post-Removal Symptoms:
Symptoms such as dizziness, nausea, vomiting,
and headache occur following abrupt discontinuation
of antimuscarinics. Similar symptoms,
including disturbances of equilibrium,
have been reported in some patients following
discontinuation of use of the Transderm Scōp
system.These symptoms usually do not appear
until 24 hours or more after the patch has been
removed. Some symptoms may be related to
adaptation from a motion environment to a
motion-free environment. More serious symptoms
including muscle weakness, bradycardia
and hypotension may occur following discontinuation
of Transderm Scōp.
Because strategies for the management of drug
overdose continually evolve, it is strongly recommended
that a poison control center be contacted
to obtain up-to-date information regarding
the management of Transderm Scōp patch
overdose.The prescriber should be mindful that
antidotes used routinely in the past may no
longer be considered optimal treatment. For
example, physostigmine, used more or less
routinely in the past, is seldom recommended
for the routine management of anticholinergic
Until up-to-date authoritative advice is obtained,
routine supportive measures should be directed
to maintaining adequate respiratory and cardiac
The signs and symptoms of anticholinergic toxicity
include: lethargy, somnolence, coma, confusion,
agitation, hallucinations, convulsion,
visual disturbance, dry flushed skin, dry mouth,
decreased bowel sounds, urinary retention,
tachycardia, hypertension, and supraventricular
Most cases of toxicity involving the use of the
product will resolve with simple removal of the
patch. Serious symptomatic cases of overdosage
involving multiple patch applications
and/or ingestion may be managed by initially
ensuring the patient has an adequate airway,
and supporting respiration and circulation. This
should be rapidly followed by removal of all
patches from the skin and the mouth. If there is
evidence of patch ingestion, gastric lavage,
endoscopic removal of swallowed patches, or
administration of activated charcoal should be
considered, as indicated by the clinical situation.
In any case where there is serious overdosage
or signs of evolving acute toxicity, continuous
monitoring of vital signs and ECG,
establishment of intravenous access, and
administration of oxygen are all recommended.
The symptoms of overdose/toxicity due to
scopolamine should be carefully distinguished
from the occasionally observed syndrome of
withdrawal (see Drug Withdrawal/Post Removal
Symptoms). Although mental confusion and
dizziness may be observed with both acute toxicity
and withdrawal, other characteristic findings
differ: tachyarrhythmias, dry skin, and decreased
bowel sounds suggest anticholinergic toxicity,
while bradycardia, headache, nausea and
abdominal cramps, and sweating suggest postremoval
withdrawal.Obtaining a careful history is
crucial to making the correct diagnosis.
Initiation of Therapy: To prevent the nausea and
vomiting associated with motion sickness, one
Transderm Scōp patch (programmed to deliver
approximately 1.0 mg of scopolamine over 3
days) should be applied to the hairless area
behind one ear at least 4 hours before the
antiemetic effect is required. To prevent post
operative nausea and vomiting, the patch
should be applied the evening before scheduled
surgery. To minimize exposure of the newborn
baby to the drug, apply the patch one hour prior
to cesarean section. Only one patch should be
worn at any time. Do not cut the patch.
Handling: After the patch is applied on dry skin
behind the ear, the hands should be washed
thoroughly with soap and water and dried. Upon
removal, the patch should be discarded. To prevent
any traces of scopolamine from coming
into direct contact with the eyes, the hands and
the application site should be washed thoroughly
with soap and water and dried. (A
patient brochure is available).
Continuation of Therapy:
Should the patch
become displaced, it should be discarded, and
a fresh one placed on the hairless area behind
the other ear. For motion sickness, if therapy is
required for longer than 3 days, the first patch
should be removed and a fresh one placed on
the hairless area behind the other ear. For perioperative
use, the patch should be kept in place
for 24 hours following surgery at which time it
should be removed and discarded.
The Transderm Scōp system is a tan-colored circular
patch, 2.5 cm2, on a clear, oversized, hexagonal
peel strip, which is removed prior to use.
Each Transderm Scōp system contains 1.5 mg
of scopolamine and is programmed to deliver
in-vivo approximately 1.0 mg of scopolamine
over 3 days. Transderm Scōp is available in
packages of four patches. Each patch is foil
wrapped. Patient instructions are included.
1 Package (4 patches) NDC 0067-4345-04
The system should be stored at controlled room
temperature between 20°C-25°C (68°F-77°F).
McEvoy, G.K. (ed.); AHSF Drug Information;
American Society of Hospital Pharmacists,
Bethesda, MD, pp. 608-611 (1990).
Gilman, A.G. et al (ed.);The Pharmacological
Basis of Therapeutics (8th Ed.); Pergamon
Press, New York, NY, pp. 150-165 (1990).
Pharmacokinetic clinical data on file.
Kotelko, D.M. et al; "Transdermal scopolamine
decreases nausea and vomiting following
cesarean section in patients receiving
epidural morphine", Anesthesiology 71(5):
Bailey, P.L. et al; "Transdermal scopolamine
reduces nausea and vomiting after outpatient
laparoscopy", Anesthesiology 72(6):
Clinical safety data on file.
Mfd by: ALZA Corporation
Mountain View, CA 94043
Novartis Consumer Health, Inc.
Parsippany, NJ 07054-0622
42013C (Rev. 2/06)