Published: 5 December 2024

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Medicines that make you sweat: drug-induced hyperhidrosis

Prescriber Update 45(4): 83–85
December 2024

Two cases of drug-induced hyperhidrosis were recently reported to the New Zealand Pharmacovigilance database. The suspect medicines were methylphenidate and entacapone (report IDs: 155330 and 153818, respectively). Sweating/hyperhidrosis is a known adverse reaction of these medicines and is listed in the respective data sheets.

This article provides an overview of drug-induced hyperhidrosis, associated medicines and mechanisms.

Drug-induced hyperhidrosis

Hyperhidrosis refers to excessive and uncontrollable sweating.¹ Hyperhidrosis can be classified as primary and of unknown cause (idiopathic), or secondary due to an underlying medical condition, medicines or other causes.²

Drug-induced hyperhidrosis is the most common cause of secondary hyperhidrosis. It can affect any part of the body and may be unilateral, asymmetrical or generalised. Untreated hyperhidrosis can lead to skin infections, social embarrassment, decreased self-confidence and emotional distress.³

Mechanism

The thermoregulatory pathway maintains body temperature, and involves the hypothalamus, spinal thermoregulatory centres, sympathetic ganglia and the eccrine-neuroeffector junction. Acetylcholine is an important mediator in the regulation of body temperature and sweating. Medicines that act on these pathways and increase acetylcholine transmission may increase sweating.^3,4

Table 1 provides examples of medicines that can cause hyperhidrosis and the proposed mechanisms.

Table 1: Drug classes/medicines associated with hyperhidrosis and mechanism (list not exhaustive)

Drug classa,b	Examplesc	Mechanisma,b
Acetylcholinesterase inhibitors	Galantamine Rivastigmine	Cholinesterase inhibition leading to increased levels of acetylcholine
Opioids	Codeine Fentanyl Morphine Oxycodone Tramadol	Release of histamine and subsequently acetylcholine
Selective serotonin reuptake inhibitors	Citalopram Escitalopram Fluoxetine Paroxetine	Serotonergic effect on hypothalamus or spinal cord
Serotonin and noradrenaline reuptake inhibitors	Venlafaxine	Serotonergic effect on hypothalamus or spinal cord
Tricyclic antidepressants	Amitriptyline Clomipramine Dosulepin Imipramine	Noradrenaline reuptake inhibition and stimulation of peripheral adrenergic receptors.
Medicines that affect endocrine function Glucocorticoid steroids Thyroid medicines	Dexamethasone Hydrocortisone Prednisone Levothyroxine	Release of various hormones that influence regulatory feedback loops

Sources:

1. Cheshire WP and Fealey RD. 2008. Drug-induced hyperhidrosis and hypohidrosis: incidence, prevention and management. Drug Safety 31(2): 109-26. DOI: 10.2165/00002018-200831020-00002 (accessed 18 September 2024).
2. Ting SO and Oakley A. 2020. Drug-induced hyperhidrosis. In: DermNet April 2020. URL: dermnetnz.org/topics/drug-induced-hyperhidrosis (accessed 18 September 2024).
3. Sweating/hyperhidrosis is listed in the data sheets, available at: medsafe.govt.nz/Medicines/infoSearch.asp

Management

If a patient’s medicine is suspected to cause hyperhidrosis, consider reducing the dose or changing to an extended-release formulation. Pharmacological and non-pharmacological measures (eg, topical antiperspirants) may help to reduce symptom severity.³ If the hyperhidrosis is severe and outweighs the medicine’s therapeutic benefit, discontinue the medicine and swap to an alternative medicine less likely to cause sweating.^2,3

New Zealand case reports

There were 376 cases of hyperhidrosis with medicines (excluding vaccines) reported during the period 1 January 2010 to 30 September 2024. The top five most frequently reported medicines were:

• venlafaxine (49 reports)
• iohexol (13)
• tramadol (12)
• varenicline (9)
• zoledronic acid (9).

References

1. Brackenrich J and Fagg C. 2022. Hyperhidrosis. In: StatPearls 3 October 2022. URL: ncbi.nlm.nih.gov/books/NBK459227 (accessed 18 September 2024).
2. Baumgartner F. 2024. Hyperhidrosis. In: BMJ Best Practice 18 January 2024. URL: bestpractice.bmj.com/topics/en-gb/856 (accessed 30 September 2024).
3. Ting SO and Oakley A. 2020. Drug-induced hyperhidrosis. In: DermNet April 2020. URL: dermnetnz.org/topics/drug-induced-hyperhidrosis (accessed 18 September 2024).
4. Cheshire WP and Fealey RD. 2008. Drug-induced hyperhidrosis and hypohidrosis: incidence, prevention and management. Drug Safety 31(2): 109-26. DOI: 10.2165/00002018-200831020-00002 (accessed 18 September 2024).