Pilocarpine is an orally available cholinergic agonist that is used to treat symptoms of dry mouth in patients with keratoconjunctivitis sicca (Sjögren syndrome). Pilocarpine has not been linked to serum enzyme elevations during therapy or to instances of clinically apparent liver injury.
Pilocarpine (pye" loe kar' peen) is a cholinergic agonist that stimulates muscarinic receptors, resulting in an increase in parasympathetic activity. Engagement of the cholinergic receptors causes increased secretion from exocrine glands, including sweat, salivary, lacrimal, gastric, pancreatic and intestinal glands, as well as increased tone and motility of smooth muscle cells in the eye, respiratory and gastrointestinal tract. Use of daily oral doses of pilocarpine has been shown to improve symptoms of dry mouth and increase salivary flow in patients with Sjögren syndrome and with xerostomia due to local irradiation therapy. Pilocarpine for oral use was approved for use in the United States in the 1990s and is currently available in generic forms as tablets of 5 mg. The typical dose is 5 mg 2 to 4 times daily. Side effects are usually mild and largely attributable to cholinergic stimulation including increased sweating, rhinitis, nausea, diarrhea, headaches, dizziness, visual disturbances and fatigue.
In clinical trials of pilocarpine, serum enzyme elevations were uncommon and no more frequent than with placebo. Despite, wide scale use, there have been no published reports of acute liver injury attributable to pilocarpine.
Mechanism of Injury
The mechanism by which pilocarpine might cause serum aminotransferase elevations is not known. Pilocarpine is metabolized in parasympathetic synaptic clefts and in plasma and has little hepatic metabolism.
Drug Class: Sjögren Syndrome Agents, Cholinergic Agents
Other Drugs in the Class: Cevimeline
REPRESENTATIVE TRADE NAMES
Pilocarpine – Generic
Sjögren Syndrome Agents
Product labeling at DailyMed, National Library of Medicine, NIH
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References updated: 25 May 2015
Zimmerman HJ. Hepatotoxicity: the adverse effects of drugs and other chemicals on the liver. 2nd ed. Philadelphia: Lippincott, 1999. (Extensive review of hepatotoxicity published in 1999; cholinergic agents and pilocarpine are not discussed).
Kaplowitz N, DeLeve LD, eds. Drug-induced liver disease. 3rd ed. Amsterdam: Elsevier, 2013. (Textbook of hepatotoxicity published in 2013; cholinergic agents and pilocarpine are not discussed).
Brown JH, Laiken N. Muscarinic receptor agonists and antagonists. In, Brunton LL, Chabner BA, Knollman BC, eds. Goodman & Gilman's the pharmacological basis of therapeutics. 12th ed. New York: McGraw-Hill, 2011, pp. 219-37. (Textbook of pharmacology and therapeutics).
Fox PC, van der Ven PF, Baum BJ, Mandel ID. Pilocarpine for the treatment of xerostomia associated with salivary gland dysfunction. Oral Surg Oral Med Oral Pathol 1986; 61: 243-8. PubMed Citation (Pilot study of single doses of pilocarpine or placebo in 6 patients with Sjögren syndrome demonstrated an increase in salivary flow and decrease in sensation of dry mouth).
Rieke JW, Hafermann MD, Johnson JT, LeVeque FG, Iwamoto R, Steiger BW, Muscoplat C, Gallagher SC. Oral pilocarpine for radiation-induced xerostomia: integrated efficacy and safety results from two prospective randomized clinical trials. Int J Radiat Oncol Biol Phys 1995; 31: 661-9. PubMed Citation (Among 369 patients with xerostomia following cancer radiotherapy who were treated with pilocarpine [2.5-10 mg every 8 hours] or placebo for 12 weeks, there were no serious drug related adverse events at any dose).
Vivino FB, Al-Hashimi I, Khan Z, LeVeque FG, Salisbury PL 3rd, Tran-Johnson TK, Muscoplat CC, et al. Pilocarpine tablets for the treatment of dry mouth and dry eye symptoms in patients with Sjögren syndrome: a randomized, placebo-controlled, fixed-dose, multicenter trial. P92-01 Study Group. Arch Intern Med 1999; 159: 174-81. PubMed Citation (Among 373 patients with Sjögren syndrome who were treated with pilocarpine [2.5 or 5 mg 4 times daily] or placebo for 12 weeks, none had serious drug related adverse events; liver function tests were monitored, but there was no mention of ALT elevations or hepatotoxicity).
Wu CH, Hsieh SC, Lee KL, Li KJ, Lu MC, Yu CL. Pilocarpine hydrochloride for the treatment of xerostomia in patients with Sjögren syndrome in Taiwan.a double-blind, placebo-controlled trial. J Formos Med Assoc 2006; 105: 796-803. PubMed Citation (Among 44 patients with Sjögren syndrome treated with pilocarpine [5 mg 4 times daily] or placebo for 12 weeks, the most common side effect was excessive sweating [22%] and there were no serious adverse events or "significant alterations in ...hepatic profiles").
Fox RI. Sjogren's syndrome: evolving therapies. Expert Opin Investig Drugs 2003; 12: 247-54. PubMed Citation (Review of standard and experimental therapies of Sjögren syndrome mentions pilocarpine and cevimeline, but does not discuss its adverse side effects).
Papas AS, Sherrer YS, Charney M, Golden HE, Medsger TA Jr, Walsh BT, Trivedi M, et al. Successful treatment of dry mouth and dry eye symptoms in Sjögren syndrome patients with oral pilocarpine: a randomized, placebo-controlled, dose-adjustment study. J Clin Rheumatol 2004; 10: 169-77. PubMed Citation (Among 250 patients with Sjögren syndrome treated with pilocarpine [20 to 30 mg daily] or placebo for 12 weeks, there were no serious drug related adverse events or significant changes in laboratory results in comparison to placebo).
Berk L. Systemic pilocarpine for treatment of xerostomia. Expert Opin Drug Metab Toxicol 2008 4: 1333-40. PubMed Citation (Review of 6 controlled trials of pilocarpine for radiation induced xerostomia; among 261 patients treated long term, side effects included sweating [55%], urinary frequency [11%], rhinitis [10%], headache [8%], increased lacrimation [8%] and diarrhea [6%], with no mention of ALT elevations or clinically apparent liver injury).
Ramos-Casals M, Tzioufas AG, Stone JH, Sisó Bosch X. Treatment of primary Sjögren syndrome: a systematic review. JAMA 2010; 304: 452-60. PubMed Citation (Review of 3 controlled trials of pilocarpine in 673 patients with Sjögren syndrome found improvements in symptoms of dry mouth and dry eyes with a dose of 5 mg every 6 hours, but also a higher rate of excessive sweating, urinary frequency and nausea; no mention of ALT elevations or clinically apparent liver injury).
Reuben A, Koch DG, Lee WM; Acute Liver Failure Study Group. Drug-induced acute liver failure: results of a U.S. multicenter, prospective study. Hepatology 2010; 52: 2065-76. PubMed Citation (Among 1198 patients with acute liver failure enrolled in a US prospective study between 1998 and 2007, 133 were attributed to drug induced liver injury, but none were linked to pilocarpine or other cholinergic agents).
Chalasani N, Bonkovsky HL, Fontana R, Lee W, Stolz A, Talwalkar J, Reddy KR, et al.; United States Drug Induced Liver Injury Network. Features and outcomes of 899 patients with drug-induced liver injury: the DILIN prospective study. Gastroenterology 2015; 148: 1340-1352.e7. PubMed Citation (Among 899 cases of drug induced liver injury enrolled in a US prospective study between 2004 and 2013, no cases were attributed to pilocarpine or other cholinergic agents).
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