The aim of this study is to explore the off-label use of atropine, administered sublingually, for the management of clozapine-induced sialorrhea in a patient who showed inadequate response to commonly used agents. The investigation stems from a clinical scenario where traditional approaches failed, prompting an exploration of alternative and cost-effective options to alleviate sialorrhea associated with clozapine therapy in a patient of lower socio-economic status.

Mr. A, a 29-year-old with bipolar affective disorder, experienced persistent sialorrhea during clozapine treatment, resistant to trials with trihexyphenidyl and glycopyrrolate. Following a brief discontinuation of clozapine, the patient relapsed into a manic episode, leading to hospitalization. Despite the re-initiation of clozapine, sialorrhea reoccurred. Various doses and combinations of trihexyphenidyl and glycopyrrolate were ineffective, with affordability issues limiting the latter. As sialorrhea persisted, clozapine dose reduction was necessary. Attempts with different antipsychotics were made, and valproate sodium was increased, but sialorrhea remained problematic.

Given the patient's unique case and previous medication failures, an off-label use of atropine via a sublingual route was done after obtaining informed consent. Quantitative measurement of sialorrhea was conducted using a sialometry machine. The patient underwent a trial with sublingual atropine drops, and the salivary rate significantly decreased, indicating a potential efficacy in managing clozapine-induced sialorrhea.

The discussion encompasses the challenges faced in managing clozapine-induced sialorrhea in the presented case. Traditional agents, including glycopyrrolate and trihexyphenidyl, proved ineffective or were hindered by affordability issues. The subsequent reduction of clozapine dose compromised overall treatment efficacy. The introduction of atropine eye drops via sublingual administration emerged as a novel approach, demonstrating a reduction in salivary rate without notable adverse effects except elevated heart rate 2 hours after administration of atropine. The unique pharmacological properties of atropine, despite being an off-label use, provided a potential avenue for addressing persistent sialorrhea.

In conclusion, the off-label use of atropine via the sublingual route showed promise in alleviating clozapine-induced sialorrhea in this particular case. Despite demonstrable efficacy in pre and post-sialometry, the clinical challenges and practical considerations associated with atropine's use in this context raise concerns. The case underscores the need for alternative strategies in managing medication-induced side effects, especially when standard interventions fail. Further research is warranted to explore the broader applicability and safety of this approach in a larger cohort.

To study the implications of proposed changes in guidelines in ICD-11 in Alcohol and Opioid Use Disorder patients. To evaluate the concordance of ICD-11 with ICD-10 and DSM-5. To compare endorsement of various criteria for dependence between ICD 11 and other systems. To examine the agreement between ICD-11 and other systems with regard to the severity of dependence. To compare the application of WHO ASSIST in screening across systems.

A cross-sectional study among newly registered, adult male patients attending NDDTC OPD, or community clinics and using the substance in the last week. N = 200 (100 each of Alcohol and opioids). Instruments: Semi-structured proforma, CIDI 3, ASI-lite, WHO-ASSIST, AUDIT. Items of CIDI were used to make the diagnosis according to various systems. The diagnostic agreement was assessed by Kappa. Endorsement frequencies of the criteria were compared across diagnostic systems. Scores of scales across systems were compared using Two Independent sample t-test.

The highest prevalence of Dependence was found using ICD-11. Almost perfect agreement between ICD-11 and ICD-10 for both Use Disorder and Dependence for all substances (kappa >0.8) except Inhalants. Agreement for AUD, CUD, and IUD between ICD-11 and DSM-5 was substantial but less than almost perfect. Similar findings for ICD-11 Dependence and DSM-5 Moderate-Severe Use Disorder in Benzodiazepines and Inhalants (kappa ranging from 0.693–0.790). High endorsement frequencies of Salience for Alcohol and Opioids, and Craving and Tolerance for all substances (ICD Dependence); Inability to cut down or control, Craving, and Tolerance (DSM-5 UD). Mean scores of AUDIT and ASSIST were generally lower in participants who received the diagnosis according to ICD-11 (sig. difference for CUD and Cannabis Dependence).

There are significant implications of the changes in ICD-11, and further testing of the impact of these changes needs to be done.