Our doctors diagnose hyperhidrosis by doing a physical examination and listening to a patients history. One of these includes feeling warm and sweating more than usual. The following suggestions may help control sweating and body odor: 1. Before the procedure, your doctor will numb the underarm area. (2022). Hypoglycemia is the most common side effect of insulin. You can unsubscribe at any time. (2008). Or you may need a test that pinpoints the areas of sweating and evaluates how severe your condition is. Opioids, such as morphine (MS Contin) and oxycodone (OxyContin), are a well-known cause of excessive sweating. Talk with your health care provider if you experience side effects. But other people take them regularly for longer periods of time, like for osteoarthritis (OA). Genetic and Rare Diseases Information Center. This might include certain antidepressants, hormone treatments, and opioids. Some, like apple cider vinegar, also kill bacteria and help control the odor related to excessive sweating in the armpits or feet. Each affected area of your body will need several injections. When suspicious of drug-induced hyperhidrosis, the possible culprit medication should be stopped completely as a trial. Drug-induced hyperhidrosis codes and concepts. People with primary hyperhidrosis rarely sweat during their sleep. Topical glycopoyrronium tosylate for the treatment of primary axillary hyperhidrosis: Results from the ATMOS-1 and ATMOS-2 phase 3 randomized controlled trials. We comply with the HONcode standard for trustworthy health information. Abuse may lead to limited physical dependence or psychological dependence relative to those in schedule 4. Submission of this form is subject to Healthgrades, Help Millions of people find the right doctor and care they need, Get immediate care and visit with providers from the comfort of your home, or anywhere, Urgent care centers can be faster and cheaper for situations that are not life threatening, Doctors and patients discuss the latest medical treatments and health tips, Search prescription drugs for why theyre used, side effects and more. Since there may be other possible reasons for the onset of profuse sweating, consulting a physician helps rule out other health threats and also ensures that the right addiction therapy is administered. Palmar hyperhidrosis. /D&+VF.df5fTe"mosUg_h{.u}}2Z|P7Z=PGagMbRRU7C!82"+)5w%j@Q-at0
*m Botulinum toxin ( Botox injections) Botox injections block the nerves that trigger the sweat glands. Commonly, this can include hot flashes or night sweats. 73 /ColorSpace 5 0 R /BitsPerComponent 8 /Filter /FlateDecode >> Primary hyperhidrosis is usually inherited, which means one of your family members may have had it. Genetic and Rare Diseases Information Center. You may be frustrated or upset by other people's reactions. HPD is a condition New research suggests changes in diet, such as adopting a vegetarian diet, and dietary supplements may reduce the severity of hyperhidrosis. WebNot only does profuse sweating lead to hygiene issues, it can also be a precursor to very serious ailments. other information we have about you. If these symptoms are interfering with your quality of life, talk to your cancer specialist. This procedure involves cutting the sympathetic nerve, which is the nerve that controls the sweat reaction. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. The FDA approved the Brella SweatControl Patch, a single-use disposable patch that can reduce excessive armpit sweating for up to four months. Addictive substances like meth, cocaine, and heroin, usually function Has a currently accepted medical use in treatment in the United States. Bryant Ranch Prepack. Increased sweating should go away after you complete your treatment course. DermNet NZ Editor in Chief: Adjunct A/Prof Amanda Oakley, Dermatologist, Hamilton, New Zealand. Prescription versions are typically taken for up to 4 to 8 weeks. About 10% of Americans are taking an antidepressant, and more than 20% of those people experience secondary hyperhidrosis as a side effect. FAQ's about hyperhidrosis. In fact, some antidepressants and other prescription medications can cause sweating as a side effect. (2017). Nerve entrapment syndromes like carpal tunnel can also cause nerve pain. People with hyperhidrosis report feelings of social isolation and withdrawal from others in order to avoid touching others. l_
Ro%%Q Ah m7dpy]pEzyU._0 2017;15(1):121. doi:10.1186/s12955-017-0693-x, Hajjar WM, Al-Nassar SA, Al-Sharif HM, et al. Get prescription saving tips and more from GoodRx Health. Dont attempt to do this on your own without their guidance. Behavior medicine consultation is recommended for all patients to improve emotional, social and occupational/academic functioning in youth and adults with hyperhidrosis. Medication side effects, such as sometimes experienced when taking some beta blockers and antidepressants, Pheochromocytoma (a rare adrenal gland tumor). Drug-induced hyperhidrosis is the most common cause of secondary hyperhidrosis. Proton pump inhibitor-induced hyperhidrosis: Important but not recognized. The drug has multiple schedules. Back and Neck Surgery (Except Spinal Fusion), https://www.sweathelp.org/pdf/drugs_2009.pdf, https://www.mayoclinic.org/diseases-conditions/hyperhidrosis/symptoms-causes/syc-20367152, https://www.mayoclinic.org/symptoms/excessive-sweating/basics/causes/sym-20050780, https://www.sweathelp.org/home/types-of-hyperhidrosis.html, https://www.sweathelp.org/where-do-you-sweat/sweaty-armpits/170-media-contacts/307-common-consequence-of-taking-antidepressants-excessive-sweating.html, https://www.mayoclinic.org/drugs-supplements/zolmitriptan-oral-route/side-effects/drg-20066780?p=1, https://www.mayoclinic.org/drugs-supplements/rizatriptan-oral-route/side-effects/drg-20065868?p=1, https://www.mayoclinic.org/diseases-conditions/diabetic-hypoglycemia/symptoms-causes/syc-20371525, https://medlineplus.gov/druginfo/meds/a684058.html, https://medlineplus.gov/druginfo/meds/a684060.html, https://www.breastcancer.org/treatment/hormonal/comp_chart, https://www.breastcancer.org/treatment/side_effects/sweating, https://www.cancer.org/cancer/breast-cancer/treatment/hormone-therapy-for-breast-cancer.html, https://www.addictionsandrecovery.org/withdrawal.htm, https://www.nationalmssociety.org/Treating-MS/Medications/Pamelor-Aventyl, https://www.ninds.nih.gov/Disorders/All-Disorders/Paresthesia-Information-Page. By brand name, the SSRIs that cause: The SNRIs that cause sweating are Cymbalta and Effexor. Drug interactions may also cause sweating for some patients; always ask your doctor before taking even an over-the-counter medication. Prescribing Information, Brand name: Tramadol (Qdolo, ConZip) is another opioid pain reliever that can cause sweating. You'll soon start receiving the latest Mayo Clinic health information you requested in your inbox. Hyperhidrosis can be primary, which happens early in life, or secondary, which is caused by systemic or neurological diseases, or as a side effect of medications. Make your tax-deductible gift and be a part of the cutting-edge research and care that's changing medicine. Excessive Sweating (Hyperhidrosis) is a condition in which the body produces more sweat than is required to regulate body temperature. Practice relaxation techniques. Have your symptoms caused you to avoid social situations or activities? excessive sweating thats occurred for at least six months without an apparent reason; Common drugs/medications known to cause diaphoresis listed by For many people, prednisone is only taken for a short period of time. Is excessive sweating a sign of heart disease? Specialised antiperspirant 2. 2018. Available for Android and iOS devices. This should go away after the medication is out of your system, which can vary across triptans. Vapometer: This device measures transepidermal water loss and measures the amount of sweat that the hands, underarms, feet and scalp make. )|;Q.F lN3sWm#5xM?j)q'QjC30#f" d7c"EB7X3vuP13c?p1+a|gh5Z&U)tUC?-yRNpQy#I"r5#Uy Qsm{:u67ZNJHMBHR(cuC6c R'|cJuE9b*}C2oJB/!^Fx!)t
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^4 These side effects may be temporary, lasting a few days to weeks. Aluminum chloride or aluminum chloride hexahydrate are the most common of these creams. Prednisone, NSAIDs, and Viagra can also make you sweat. He or she can recommend a solution, either a different antidepressant or a medication to deal with hyperhidrosis. Botulinum toxin injection (onabotulinumtoxinA) is considered first- or second-line A physical examination can help exclude other causes. Sweating could, therefore, be one of the minor effects of a major physiological change occurring in the body, possibly a result of the consumption of drugs. To retain the effect, you'll likely need repeat treatments about every six months. Some people experience increased sweating after taking these medications. The Food and Drug Administration (FDA) 2018; doi:10.1016/j.jaad.2018.07.002. If your sweating is accompanied by other symptoms, like shaky hands or a fast heartbeat, contact your healthcare provider right away. Does Detoxing from Alcohol Mean I Can Never Drink Again? International Hyperhidrosis Society. Drugs used to treat hyperhidrosis include: Prescription antiperspirant. Data sources include IBM Watson Micromedex (updated 2 Apr 2023), Cerner Multum (updated 17 Apr 2023), ASHP (updated 10 Apr 2023) and others. Keratoderma palmoplantaris transgrediens. Secondary hyperhidrosis occurs due to an underlying medical condition, such as: Symptoms can vary in severity among people and even in the same person. If youre experiencing sweating while taking diabetes medications, this could be a sign that your blood glucose is too low (called hypoglycemia). While it is normal for one to sweat when the weather is sunny and the climate is warm, there are certain conditions that can make one sweat profusely, even when the surrounding environment shouldnt cause such a response. Drug-induced hyperhidrosis is diagnosed clinically. Last updated on Aug 25, 2022. You experience night sweats for no apparent reason. Evaporation of this sweat from the skin provides a cooling effect. Hytrin, Drug class: C4>J
s Apocrine glands: these are present from birth but only mature at puberty and start manufacturing sweat at that time. As when taken for depression, these medications can cause secondary hyperhidrosis. skeletal muscle relaxants, For professionals: Excessive sweating can disrupt daily activities and cause social anxiety or embarrassment. Excessive sweating is one of the many side effects of analgesic pain medications. Keep in mind: Opioids carry a risk of dependence. By signing up, I agree to GoodRx's Terms and Privacy Policy, and to receive marketing messages from GoodRx. If a cause isn't found, treatment focuses on controlling heavy sweating. These oral medications can be a good option for patients who sweat in The result is low blood sugar. Sweathelp.org. Ami T. Allscripts EPSi. Talk to your healthcare provider about your options. You may experience these side effects when starting treatment. Note that this may not provide an exact translation in all languages, Home Botulinum toxin injections. A guarantee that you will never pay more for residential treatment than you would by approaching a particular addictions treatment centre directly. Applied daily, usually at night, and then covered to encourage absorption, these creams can be very effective. Plantar sweating as an indicator of lower risk of compensatory sweating after thoracic sympathectomy. There are no specific characteristics that increase the risk of a person getting drug-induced hyperhidrosis. health information, we will treat all of that information as protected health Diarrhea. Galadari H, et al. Terms of use. Symptoms may include: Antiperspirants usually contain an aluminum salt which at concentrations >20% cause a long-lasting closure and shrinkage of the sweat gland. Psoriatic Arthritis Rash: Identification and Treatment. irritability. Abuse may lead to severe psychological or physical dependence. National Institute of Neurological Disorders and Stroke. While sweating tends to reduce at night in patients with primary hyperhidrosis, it can occur during sleep in drug-induced hyperhidrosis. tricyclic antidepressants, Brand name: Hyperhidrosis. Measuring the amount of sweat gives your doctor an objective way to compare the amount of sweat before and after treatment. There are different treatments for hyperhidrosis, depending on the severity of the condition. According to Oks, some medications have sweating as a possible side effect. Author: Dr Selene Ting, Medical Registrar, Waitakere Hospital, Auckland, New Zealand. But some prescription and over-the-counter (OTC) medications can also cause sweating as a side effect. Avoid foods and drinks that can raise your body temperature and make you sweat, especially late in the day or close to bedtime. Breastcancer.org. For example, low blood glucose (sugar), a thyroid problem, or an infection could be the cause. Hyperhidrosis is excessive sweating, which means sweating more than normal. Practicing relaxation techniques like meditation, deep breathing, or yoga can help reduce stress and improve sleep quality. A topical NSAID, like diclofenac gel (Voltaren gel), may be an option if you have a condition like OA. So, sweating may be less of a concern. dosage, side effects, Drug class: Health Qual Life Outcomes. Hyperhidrosis occurs from over-stimulation of our sweat glands, mostly our eccrine sweat glands. endstream All rights reserved. National Multiple Sclerosis Society. 2020. WebGeneralized hyperhidrosis is excessive sweating that happens due to another medical problem. Nicolas, S., et al. (2007). Pamelor Aventyl. WebOther drugs are reported to have caused excessive sweating. Selective serotonin reuptake inhibitors (SSRs), like escitalopram (Lexapro), sertraline (Zoloft), and paroxetine (Paxil), can cause excessive sweating. You may start by seeing your primary care provider. Advertising revenue supports our not-for-profit mission. AHFS DI Monograph, Drug class: (2016). These are usually applied at night for a set period for the best results. << /ProcSet [ /PDF /Text /ImageB /ImageC /ImageI ] /ColorSpace << /Cs1 The safety, tolerability, and risks associated with the use of newer generation antidepressant drugs: A critical review of the literature. This product can cause skin and eye irritation. Although topical and oral medications are the first steps of treatment for the physical symptoms of hyperhidrosis, behavior medicine techniques may provide relief from stress, anxiety and other negative emotional reactions which can be experienced with this condition. Excessive sweating, formally called hyperhidrosis, occurs when your sweat glands produce extra perspiration unnecessarilythat is, when your body doesnt need to cool itself, and you arent in a stressful situation. Psoriasis Diet: Foods to Eat or Limit, Effectiveness, and More. Viagra (sildenafil) can commonly cause flushing. Different classes of medications can influence the sweating response by acting centrally in the brain and the peripheral nervous system [2,5,6]. include protected health information. Certain hormone therapy medications for breast cancer, like tamoxifen (Soltamox), can cause night sweats. Your health care provider may prescribe an antiperspirant with aluminum chloride (Drysol, Xerac AC). International Hyperhidrosis Society. Other medical problems may include menopause, Dont stop taking an opioid abruptly on your own, especially if youve been taking an opioid medication for a long period of time. doi:10.3238/arztebl.2009.0032, www.mycarpe.com/sweatopedia/the-most-common-medicines-that-cause-hyperhidrosis, www.aad.org/public/diseases/a-z/hyperhidrosis-causes, www.uspharmacist.com/article/dont-sweat-it-an-overview-of-hyperhidrosis, www.medicinenet.com/hyperhidrosis/article.htm, Drug-induced hyperhidrosis and hypohidrosis. Drug-induced hyperhidrosis. side effects, Generic name:onabotulinumtoxinA systemic, Drug class: About 4.8% of Americans suffer from excessive sweating, according to a study in the Archives of Dermatological Research. 9th ed. If you are experiencing serious medical symptoms, seek emergency treatment immediately. Dizziness can be a side effect of certain medications such as anti-seizure drugs, antidepressants, sedatives and tranquilizers. MedlinePlus. 2020 [cited 26 February 2020]. Excessive sweating is when you sweat more than you might expect based on the surrounding temperature or your activity level or stress. Excessive sweating: Wear breathable, moisture-wicking underwear and pants to help absorb moisture and prevent visible sweat patches. Medically reviewed by Drugs.com. Has a currently accepted medical use in treatment in the United States or a currently accepted medical use with severe restrictions. THIS TOOL DOES NOT PROVIDE MEDICAL ADVICE. Nonsteroidal anti-inflammatory drugs (NSAIDs), like ibuprofen (Advil, Motrin) and aspirin, can sometimes cause sweating as a side effect. Examples include antidepressants like Lexapro, Zoloft, and Wellbutrin. mild allergic reaction *. https://www.aad.org/public/diseases/a-z/hyperhidrosis-overview. CnxZ4P9Rja~%P$_Op\cU1eq'-=\T3, /F3.0 10 0 R >> /XObject << /Im1 8 0 R >> >> Other factors that can contribute to increased sweating include a family history of increased sweating, and underlying medical conditions such as obesity, diabetes, hyperthyroidism, menopause, or cancer [4,5]. }`
0 Iontophoresis: During this treatment, you sit with your hands, feet, or both in a shallow tray of water for about 20 to 30 minutes, while a low electrical current travels through the water. Use of this website and any information contained herein is governed by the Healthgrades User Agreement. These may include reducing your dosage, changing your medication, or having you stop it altogether. Theres a higher risk of serotonin syndrome if youre taking multiple medications that affect serotonin levels. Some medications are known to cause excessive sweating , including night sweats. ES can occur in unexpected circumstances, such as a cooler environment, or without any apparent trigger. Removal of the sweat glands by thermolysis, surgery, or other procedures. They can discuss adjusting your current medications or adding a new medication. Avoid tight-fitting clothing that can trap heat and moisture, exacerbating the problem. Mast cells release histamine, which can result in skin warmth and sweating. Examples of medications that can cause excessive sweating include prednisone (Rayos) and escitalopram (Lexapro). A possible side effect is short-term muscle weakness in the treated area. Psychotherapy and Psychosomatics. They should go away when your Viagra dose leaves your body. Patients diagnosed with hyperhidrosis may experience increased stress associated with excessive sweating. constipation *. ! Acetylcholinesterase inhibitors, such as donepezil or benztropine. Your healthcare provider can help you discontinue it slowly and safely to avoid or minimize withdrawal symptoms. These include topical anesthesia, ice and massage (vibration anesthesia). In some cases, they may add a medication to help keep your sweating under control. endobj Most people don't feel much pain during the procedure. Hyperhidrosis. Medications in the triptan family, such as zolmitriptan, rizatriptan and others, include the side effect of hyperhidrosis. Late dumping syndrome starts 1 to 3 hours after you eat a high-sugar meal. Consider these nine foods to help keep your skin looking youthful and radiant. It is easy to become suddenly delirious when they begin to sweat profusely after consuming the drug. We offer a free callback service 24/7. 2 0 obj It can begin at any age, and affect people of all races [4]. irritability. Then wash the product off when you get up, taking care to not get any in your eyes. endobj Although the exact cause is unknown, experts believe it may be due to overactivity of the hypothalamus (the area of the brain that maintains body temperature) which stimulates our nervous system to release sweat from eccrine sweat glands. You can buy the device if you have a prescription from your health care provider. Have your symptoms been continuous or occasional? In: Triage Protocols for Aging Adults. And for some people, they may improve over time. Has a potential for abuse less than those in schedules 1 and 2. WebThese medications are called anticholinergics, which mean they cause a drying reaction in the body. The content on Healthgrades does not provide medical advice. Smith CC, et al. Primary hyperhidrosis may be at least partly hereditary. WebHyperhidrosis describes sweating in excess of normal body temperature regulation. We can also measure the level of sweating in two different ways: Starch Iodine Test: This is a test that turns the sweat brown and is used to detect excessive sweating (hyperhidrosis). Some of these might include: Some cancers are known to cause night sweats, so if you only sweat at night, see your doctor as soon as possible to rule out a serious disease. What, if anything, seems to improve your symptoms? Activity is based on recent site visitor activity relative to other medications in the list. Hypercare, Excessive sweating, or hyperhidrosis (hi-pur-hi-DROE-sis), can affect your entire body or just certain areas, such as your palms, soles, underarms or face. According to the International Hyperhidrosis Society, many common antidepressants list excessive sweating as a side effect 13. Your skin will be iced or Hyperhidrosis is another name for excessive or uncontrollable sweating. (n.d.). Finding useful information and resources about addiction or alcoholism can be a minefield. If the excess sweating is due to an underlying medical condition, it's called secondary hyperhidrosis. One of these conditions is addiction. This disease involves the excessive buildup of fluid in your inner ear. They work by controlling your sweat glands. How it works: These individually wrapped cloths contain an active ingredient, glypyrronium tosylate, that can reduce underarm sweating. Once you start seeing results from using it daily for a few days, you can scale back to once or twice a week to maintain the effect. Johns Hopkins Medical, The Center for Sweat Disorders. While rare, this is a serious condition caused by high serotonin levels in the brain. Drug-induced hyperhidrosis may lead to social embarrassment, lowered self-confidence, and emotional stress [1,7]. These treatments are likely to cause night sweats, even when your room is cool, and sometimes cause hot flashes because they mimic the symptoms of menopause. There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use in pregnant women despite potential risks. Antipsychotics, such as haloperidol and clozapine. Excessive Sweating (Hyperhidrosis) is a condition in which the body produces more sweat than is required to regulate body temperature. WebSmall injections of botulinum toxin (like Botox) in your armpits can temporarily block sweating. 1998-2023 Mayo Foundation for Medical Education and Research (MFMER). StatPearls. Similar to certain antidepressants, triptans also carry a risk of serotonin syndrome. Addictive substances like meth, cocaine, and heroin, usually function by dilating the blood vessels in order to drastically increase the rate of blood flow. Das, S. (2022). dizziness. For example, trazodone is an antidepressant that may be less likely to cause sweating. << /Length 4 0 R /Filter /FlateDecode >> Then your underarm skin is lifted into the system and microwave energy is directed to the sweat glands. In some cases, you may experience night sweats as a side effect of a medication that youre taking. Dermatology Made Easybook. Third Party materials included herein protected under copyright law. Qbrexza. Talk with your doctor about ways to mitigate hyperhidrosis and other withdrawal symptoms. Mayo Clinic. sense of panic. Certain treatments, such as raloxifene and toremifene, may cause hyperhidrosis as a side effect. My sweating is intolerable and always interferes with my daily activities. I would also like to sign up for a free GoodRx account, Written by Brian Leonard, PharmD, BCACP, BCGP, Written by Divya Bhaskar, PharmD Candidate, Written by Rachel Feaster, PharmD, BCOP, BCPS, Written by Nicole E. Cieri-Hutcherson, PharmD, BCPS, NCMP. x_]GADPh)R( Excessive sweating may also be a side effect of chemotherapy as well as removal of the ovaries. Copyright 2023 Leaf Group Ltd., all rights reserved. Topical glycopyrrolate is first-line treatment for craniofacial sweating. (n.d.). OTC pain relievers, like ibuprofen (Motrin, Advil), are also a potential culprit. WebDrugs that induce hyperhidrosis, or sweating in excess of that needed to maintain thermoregulation, can cause patient discomfort and embarrassment, and include There are two different types of In particular, blood pressure lowering medications may cause faintness if they lower your Symptoms include sweating, shaky hands, and a fast heartbeat. https://www.uptodate.com/content/search. Your healthcare provider may need to adjust your medications if this is happening regularly. Gawkrodger DJ, et al. Leuprolide (Lupron Depot, Eligard, Camcevi) is an injectable medication used to treat prostate cancer. anticholinergic antiparkinson agents, Brand names: In this case, let your healthcare provider know if sweating becomes a problem. You may also need a physical exam or tests to further evaluate the cause of your symptoms. These injections cause a very reliable temporary decrease in sweating, typically lasting from three to six months. HPD is a condition that causes ES. Avoid foods and drinks that can raise your body temperature and make you sweat, especially late in the day or close to bedtime. Check your blood glucose levels if you notice abnormal sweating or more sweating than usual. While excessive sweating may be a side effect of hormonal imbalances, certain drugs given to patients to balance hormones may also increase sweating. These include: Nevirapine, Efavirenz, AZT (treatment of AIDS) Acyclovir, Ribavirin, Foscarnet (antivirals) Ciprofloxacin, Ceftriaxone, Gatifloxacin, Moxifloxacin, Telithromycin (antibiotics) Clozapine, haloperidol (psychosis) Varenicline (smoking cessation) https://www.sweathelp.org. Flushing. National Organization of Rare Disorders. A temporal relationship between initiation of a certain medication and onset of symptoms with no other apparent cause of secondary hyperhidrosis is suggestive of drug-induced hyperhidrosis [7]. Sweating may not be a major issue in this situation. DermNet does not provide an online consultation service. Xerac AC, Drug class: You may then be referred to a specialist in diagnosing and treating conditions of the hair and skin (dermatologist). If you think you may have a medical emergency, immediately call your doctor or dial 911. %PDF-1.3 Your health care provider might offer one or more of the methods used to numb skin. Talk with your health care provider about ways to reduce side effects. Try adding the following power foods to your diet to help keep your skin, hair and nails at their bestand keep your body in beautiful health along the way. They produce a milky type sweat and sweat production is increased during times of heightened emotional state (stress or fear). Botulinum toxin injections. Hyperhidrosis is excessive sweating that occurs on the: The body uses sweat as a form of temperature control, in order to cool itself. Treatment approaches and outcomes associated with the use of abobotulinumtoxinA for the treatment of hyperhidrosis: A systematic review. In addition to treating depression, the drugs desipramine, nortriptyline and protriptyline, along with some other antidepressants, also are used to treat nerve pain. Expanded Access is a potential pathway for a patient with a serious or immediately life-threatening disease or condition to gain access to an investigational medical product (drug, biologic, or medical device) for treatment outside of clinical trials when no comparable or satisfactory alternative therapy options are available.
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