A wonderful patient asked about Pilocarpine HCL tablets.
Many eyeMDs do not routinely prescribe pilocarpine HCL for dry eyes given is side effect profile. Still it appears to work in increasing tears from the lacrimal gland. There is no data I could find to say it improved meibomian gland oil expression or production, but still looking. Also I could not find any data to say it helps the goblet cells produce more mucin.
Here is more information below.
Side effects include:
Sweating, nausea, runny nose, chills, flushing, frequent urge to urinate, dizziness, weakness, diarrhea, blurred vision, and even increase the risk for retinal detachment, which is very rare. If someone has a family history of retinal detachment, thought, I would not recommend using oral pilocarpine.
Also would be very careful if someone has any of these issues below.
- Asthma, bronchitis, or other breathing problems, or
- Gallbladder problems or
- Glaucoma, angle closure, or
- Heart or blood vessel disease or
- Iritis (inflammation of the iris [colored part] of the eye) or
- Kidney problems or
- Mental problems or
- Peptic ulcer disease, acute—Pilocarpine may make the condition worse
- Retinal detachment, tendency for, or
- Retinal disease—Pilocarpine may increase the risk of a detached retina
Still there are a few studies showing Pilocarpine HCL 5mg 2x/day for 3 months helps dry eye symptoms.
The study by Shih, et.al, below is a review of pilocarpine and other dry eye medications.
Here are some key points: Full open access article is below.
1. The Journal of Inflammation has an impact factor of about 1.78 which is low.
2. Their conclusions:
–oral pilocarpine, cevimeline, lactoferrin, a traditional Chinese medicine (TCM) herb and linoleic acid/ gamma linoleic acid (5/13 systemic modalities) were found to be more effective than placebo or artificial tear in the treatment of dry eye. [22, 23, 25, 26, 27, 28]
3. Studies with oral pilocarpine and doxycycline recruited only female participants. [24, 25]
4. Pilocarpine is a muscarinic agonist that stimulates secretion of saliva, aqueous tear from lacrimal glands, conjunctival epithelium and mucin from goblet cells.  Administration of 5 mg of pilocarpine twice daily, for 12 weeks improved dry eye symptoms and Rose Bengal dye staining compared to the combination of artificial tears and inferior puncta occlusion.  The investigators did not clarify whether other medications such as systemic immunosuppressant were used or if a washout period was implemented.
5. Cevimeline is a parasympathomimetic drug that acts like pilocarpine, except that it has a longer serum half-life.  Two RCTs [22, 28] showed that treatment with cevimeline compared to placebo improved symptoms (Visual analog scale) and signs (Schirmer I) of dry eye. Oral cevimeline (15 mg) thrice daily is superior to placebo in terms of symptoms and signs of dry eye. There is some controversy as to whether a higher dosage of 30 mg thrice daily would provide further benefit. Although Petrone et al. is a randomized study, participants who received 15 mg had more severe dry eyes than those with 30 mg. Due to the differential severity at baseline, the interpretation of results is more difficult. In these studies the rationale for the dosages used was not explained, and especially, why doses lower than 15 mg were not considered.
6. pilocarpine has been found to be associated with the following adverse effects: 4/85 (4.7%) of patients reported mild headache, nausea, vomiting and sweating, though none discontinued treatment.  27/60 (45%) of patients experienced gastrointestinal symptoms from oral cevimeline.  In another study, 162/197 (82.2%) of such patients experienced headache, increased sweating, abdominal pain or nausea, though the intensity of these effects was mild. 
Systematic review of randomized controlled trials in the treatment of dry eye disease in Sjogren syndrome.
Successful Treatment of Dry Mouth and Dry Eye Symptoms in Sjögren’s Syndrome Patients With Oral Pilocarpine: A Randomized, Placebo-Controlled, Dose-Adjustment Study.
Systematic review of randomized controlled trials in the treatment of dry eye disease in Sjogren syndrome
Topical or ophthalmic interventions
Availability of data and material
Ethics approval and consent to participate:
|BCL||Bandage contact lens|
|BCVA||Best corrected visual acuity|
|CFS||Corneal fluorescein staining|
|NSAIDs||Non-steroidal anti-inflammatory drugs|
|OSDI||Ocular Surface Disease Index|
|RCT||Randomized controlled trials|
|TBUT||Tear breakup time|
|TMR||Tear meniscus radius|
|TCM||Traditional Chinese medicine|
|TNF||Tumor necrosis factor alpha|
|CONSORT||Consolidated Standards of Reporting Trials|
|ACR||American College of Rheumatology|
|EULAR||European League Against Rheumatism|
|AECG||American European Consensus Group|