Drug Info: A: Anticholinergics/Antispasmodics (Systemic)

Some commonly used brand names are:

In the U.S.—

In Canada—

Other commonly used names are: dicycloverine;glycopyrronium bromide; hyoscine hydrobromide; hyoscinemethobromide; methanthelinium; octatropine

• Anesthesia adjunct --Scopolamine
• Antiarrhythmic --Atropine; Glycopyrrolate;Hyoscyamine ; Scopolamine
• Anticholinergic --Anisotropine; Atropine;Belladonna ; Clidinium; Dicyclomine; Glycopyrrolate;Homatropine; Hyoscyamine ; Mepenzolate; Methantheline;Methscopolamine; Pirenzepine; Propantheline ;Scopolamine
• Antidiarrheal --Glycopyrrolate
• Antidote, to cholinesterase inhibitors--Atropine; Hyoscyamine
• Antidote, to muscarine --Atropine;Hyoscyamine
• Antidote, to organophosphate pesticides--Atropine
• Antidysmenorrheal --Belladonna;Scopolamine
• Antiemetic --Scopolamine
• Antispasmodic, gastrointestinal --Dicyclomine; Scopolamine
• Antispasmodic, urinary tract -- Atropine;Scopolamine
• Antivertigo agent -- Belladonna;Scopolamine
• Cholinergic adjunct, curariform block--Atropine; Glycopyrrolate ; Hyoscyamine

The anticholinergics/antispasmodics are a group ofmedicines that include the natural belladonna alkaloids(atropine, belladonna, hyoscyamine, and scopolamine) andrelated products.

The anticholinergics/antispasmodics are used to relievecramps or spasms of the stomach, intestines, and bladder.Some are used together with antacids or other medicine in thetreatment of peptic ulcer. Others are used to prevent nausea,vomiting, and motion sickness.

Anticholinergics/antispasmodics are also used in certainsurgical and emergency procedures. In surgery, some are givenby injection before anesthesia to help relax you and todecrease secretions, such as saliva. During anesthesia andsurgery, atropine, glycopyrrolate, hyoscyamine, andscopolamine are used to help keep the heartbeat normal.Scopolomine is also used to prevent nausea and vomiting afteranesthesia and surgery. Atropine is also given by injectionto help relax the stomach and intestines for certain types ofexaminations. Some anticholinergics are also used to treatpoisoning caused by medicines such as neostigmine andphysostigmine, certain types of mushrooms, and poisoning by“nerve”' gases or organic phosphorous pesticides(for example, demeton [Systox], diazinon, malathion,parathion, and ronnel [Trolene]). Also, anticholinergics canbe used for painful menstruation, runny nose, and to preventurination during sleep.

These medicines may also be used for other conditions asdetermined by your doctor.

The anticholinergics/antispasmodics are available onlywith your doctor's prescription in the following dosageforms:

• Oral
• Anisotropine
  • Tablets (U.S.)
• Atropine
  • Tablets (U.S.)
  • Soluble tablets (U.S.)
• Belladonna
  • Tincture (U.S.)
• Clidinium
  • Capsules (U.S.)
• Dicyclomine
  • Capsules (U.S. and Canada)
  • Syrup (U.S. and Canada)
  • Tablets (U.S. and Canada)
• Glycopyrrolate
  • Tablets (U.S. and Canada)
• Homatropine
  • Tablets (U.S.)
• Hyoscyamine
  • Extended-release capsules (U.S.)
  • Extended-release tablets (U.S.)
  • Elixir (U.S.)
  • Oral solution (U.S. and Canada)
  • Tablets (U.S. and Canada)
• Mepenzolate
  • Tablets (U.S.)
• Methantheline
  • Tablets (U.S.)
• Methscopolamine
• Pirenzepine
  • Tablets (Canada)
• Propantheline
  • Tablets (U.S. and Canada)
• Scopolamine
  • Tablets (Canada)

• Parenteral
• Atropine
  • Injection (U.S. and Canada)
• Dicyclomine
  • Injection (U.S. )
• Glycopyrrolate
  • Injection (U.S. and Canada)
• Hyoscyamine
  • Injection (U.S. )
• Scopolamine
  • Injection (U.S. and Canada)

• Rectal
• Scopolamine
  • Suppositories (Canada)

• Transdermal
• Scopolamine
  • Transdermal disk (U.S. and Canada)

In deciding to use a medicine, the risks of taking themedicine must be weighed against the good it will do. This isa decision you and your doctor will make. Foranticholinergics/antispasmodics the following should beconsidered:

Allergies—Tell your doctor if you haveever had any unusual or allergic reaction to any of thenatural belladonna alkaloids (atropine, belladonna,hyoscyamine, and scopolamine), or any related products. Also,tell your health care professional if you are allergic to anyother substances, such as foods, preservatives, or dyes.

Pregnancy—If you are pregnant or ifyou may become pregnant, make sure your doctor knows if yourmedicine contains any of the following:

• Atropine—Atropine has not been shown to causebirth defects or other problems in animals. However, wheninjected into humans during pregnancy, atropine has beenreported to increase the heartbeat of the fetus.
• Belladonna—Studies on effects in pregnancyhave not been done in either humans or animals.
• Clidinium—Clidinium has not been studied inpregnant women. However, clidinium has not been shown tocause birth defects or other problems in animalstudies.
• Dicyclomine—Dicyclomine has been associatedwith a few cases of human birth defects but dicyclomine hasnot been confirmed as the cause.
• Glycopyrrolate—Glycopyrrolate has not beenstudied in pregnant women. However, glycopyrrolate did notcause birth defects in animal studies, but did decrease thechance of becoming pregnant and the newborn's chance ofsurviving after weaning.
• Hyoscyamine—Studies on effects in pregnancyhave not been done in either humans or animals. However,when injected into humans during pregnancy, hyoscyamine hasbeen reported to increase the heartbeat of the fetus.
• Mepenzolate—Mepenzolate has not been studiedin pregnant women. However, studies in animals have notshown that mepenzolate causes birth defects or otherproblems.
• Propantheline—Studies on effects in pregnancyhave not been done in either humans or animals.
• Scopolamine—Studies on effects in pregnancyhave not been done in either humans or animals.

Breast-feeding—Although thesemedicines may pass into the breast milk, they have not beenreported to cause problems in nursing babies. However, theflow of breast milk may be reduced in some patients. The useof dicyclomine in nursing mothers has been reported to causebreathing problems in infants.

Children—Unusual excitement,nervousness, restlessness, or irritability and unusualwarmth, dryness, and flushing of skin are more likely tooccur in children, who are usually more sensitive to theeffects of anticholinergics. Also, when anticholinergics aregiven to children during hot weather, a rapid increase inbody temperature may occur. In infants and children,especially those with spastic paralysis or brain damage, thismedicine may be more likely to cause severe side effects.Shortness of breath or difficulty in breathing has occurredin children taking dicyclomine.

Older adults—Confusion or memory loss;constipation; difficult urination; drowsiness; dryness ofmouth, nose, throat, or skin; and unusual excitement,nervousness, restlessness, or irritability may be more likelyto occur in the elderly, who are usually more sensitive thanyounger adults to the effects of anticholinergics. Also, eyepain may occur, which may be a sign of glaucoma.

Other medicines—Although certainmedicines should not be used together at all, in other casestwo different medicines may be used together even if aninteraction might occur. In these cases, your doctor may wantto change the dose, or other precautions may be necessary.When you are taking anticholinergics/antispasmodics, it isespecially important that your health care professional knowif you are taking any of the following:

• Antacids or
• Diarrhea medicine containing kaolin or attapulgiteor
• Ketoconazole (e.g., Nizoral)—Using thesemedicines with an anticholinergic may lessen the effects ofthe anticholinergic

• Central nervous system (CNS) depressants (medicinesthat cause drowsiness)—Taking scopolamine with CNSdepressants may increase the effects of eithermedicine

• Other anticholinergics (medicine for abdominal orstomach spasms or cramps) or
• Tricyclic antidepressants (amitriptyline [e.g.,Elavil], amoxapine [e.g., Asendin], clomipramine [e.g.,Anafranil], desipramine [e.g., Pertofrane], doxepin [e.g.,Sinequan], imipramine [e.g., Tofranil], nortriptyline[e.g., Aventyl], protriptyline [e.g., Vivactil],trimipramine [e.g., Surmontil])—Takinganticholinergics with tricyclic antidepressants or otheranticholinergics may cause an increase in the effects ofthe anticholinergic

• Potassium chloride (e.g., Kay Ciel)—Using thismedicine with an anticholinergic may make gastrointestinalproblems caused by potassium worse

• Bleeding problems (severe)—These medicines mayincrease heart rate, which would make bleeding problemsworse

• Brain damage (in children)—May increase the CNSeffects of this medicine

• Colitis (severe) or
• Dryness of mouth (severe and continuing) or
• Enlarged prostate or
• Fever or
• Glaucoma or
• Heart disease or
• Hernia (hiatal) or
• High blood pressure (hypertension) or
• Intestinal blockage or other intestinal problems or
• Lung disease (chronic) or
• Myasthenia gravis or
• Toxemia of pregnancy or
• Urinary tract blockage or difficult urination—Thesemedicines may make these conditions worse

• Down's syndrome—These medicines may cause anincrease in pupil dilation and heart rate

• Kidney disease or
• Liver disease—Higher blood levels may occur andcause an increase in side effects

• Overactive thyroid—These medicines may furtherincrease heart rate

• Spastic paralysis (in children)—This condition mayincrease the effects of the anticholinergic

Take this medicine only as directed. Do not takemore of it, do not take it more often, and do not take it fora longer time than your doctor ordered. To do so may increasethe chance of side effects.

Dosing—

The dose of the anticholinergic/antispasmodic will bedifferent for different patients. Follow your doctor's orders or the directions on thelabel. The following information includes only theaverage doses of your medicine. If your dose is different, do not change it unlessyour doctor tells you to do so.

The number of capsules or tablets or teaspoonfuls ofsolution or syrup that you take depends on the strength ofthe medicine. Also, the number of doses you take each day, the time allowedbetween doses, and the length of time you take the medicinedepends on the medical problem for which you are taking thismedicine.

• For anisotropine
• For oral dosage forms (tablets):
  • To treat duodenal or stomach ulcers:
    • Older adults, adults, and teenagers—50milligrams (mg) three times a day. Your doctor maychange the dose if needed.
    • Children—Dose must be determined by yourdoctor.

• For atropine
• For oral dosage form (tablets):
  • To treat duodenal or stomach ulcers, intestineproblems, or urinary problems:
    • Older adults, adults, and teenagers—300 to1200 micrograms (mcg) every four to six hours.
    • Children—Dose is based on body weight. Theusual dose is 10 mcg per kilogram (kg) (4.5 mcg perpound) of body weight every four to six hours. However,the dose will not be more than 400 mcg every four tosix hours.
• For injectable dosage form:
  • To treat duodenal or stomach ulcers or intestineproblems:
    • Older adults, adults, and teenagers—400 to600 mcg injected into a muscle, vein, or under the skinevery four to six hours.
    • Children—The dose is based on body weight.The usual dose is 10 mcg per kilogram (kg) (4.5 mcg perpound) of body weight injected under the skin everyfour to six hours. However, the dose will not be morethan 400 mcg every four to six hours.
  • To treat heart problems:
    • Older adults, adults, and teenagers—400 to1000 mcg injected into a vein every one to two hours asneeded. The total dose will not be more than 2 mg.
    • Children—The dose is based on body weight.The usual dose is 10 to 30 mcg per kilogram (kg) (4.5to 13.6 mcg per pound) of body weight injected underthe skin.

• For belladonna
• For oral dosage form (oral solution):
  • To treat duodenal or stomach ulcers or intestineproblems:
    • Older adults, adults, and teenagers—180 to300 micrograms (mcg) three or four times a day. Thedose should be taken 30 to 60 minutes before meals andat bedtime. Your doctor may change the dose ifneeded.
    • Children—The dose is based on body weight.The usual dose is 9 mcg per kilogram (kg) (4 mcg perpound) of body weight three or four times a day.

• For clidinium
• For oral dosage form (capsules):
  • To treat duodenal or stomach ulcers:
    • Older adults, adults, and teenagers—2.5 to 5milligrams (mg) three or four times a day. The doseshould be taken before meals and at bedtime. Yourdoctor may change the dose if needed.
    • Children—Dose must be determined by yourdoctor.

• For dicyclomine
• For oral dosage forms (capsules, extended-releasetablets, syrup, tablets):
  • To treat intestine problems:
    • Older adults, adults, and teenagers—10 to 20milligrams (mg) three or four times a day. Some peoplemay take 30 mg two times a day. Your doctor may changethe dose if needed. Your dose will not be more than 160mg a day.
    • Children 2 years of age and older—5 to 10 mgthree or four times a day. Your doctor may change thedose if needed.
    • Children 6 months to 2 years of age—5 to 10mg of the syrup three or four times a day. Your doctormay change the dose if needed.
    • Children up to 6 months of age—Use is notrecommended.
• For injectable dosage form:
  • To treat intestine problems:
    • Older adults, adults, and teenagers—20 mginjected into a muscle every four to six hours. Yourdoctor may change the dose if needed.
    • Children—Dose must be determined by yourdoctor.

• For glycopyrrolate
• For oral dosage form (tablets):
  • To treat duodenal or stomach ulcers:
    • Older adults, adults, and teenagers—To start,1 to 2 milligrams (mg) two or three times a day. Somepeople may also take 2 mg at bedtime. Your doctor maychange the dose if needed. However, your dose will notbe more than 8 mg a day.
    • Children—Dose must be determined by yourdoctor.
• For injectable dosage form:
  • To treat duodenal or stomach ulcers:
    • Older adults, adults, and teenagers—100 to200 micrograms (mcg) injected into a muscle or vein.The dose may be repeated every four hours up to fourtimes a day.
    • Children—Dose must be determined by yourdoctor.

• For homatropine
• For oral dosage form:
  • To treat duodenal or stomach ulcers:
    • Older adults, adults, and teenagers—5 to 10milligrams (mg) three or four times a day. Your doctormay change the dose if needed.
    • Children—Dose must be determined by yourdoctor.

• For hyoscyamine
• For oral dosage forms (capsules, elixir, oral solution,tablets):
  • To treat duodenal or stomach ulcers, intestineproblems, or urinary problems:
    • Older adults, adults, and teenagers—125 to500 micrograms (mcg) four to six times a day. Somepeople may take 375 mcg two times a day. The tabletsshould be taken 30 to 60 minutes before meals. Yourdoctor may change the dose if needed.
    • Children—Dose is based on body weight. Theusual dose is 12.5 to 187 mcg every four hours ifneeded.
• For injectable dosage form:
  • To treat duodenal or stomach ulcers or intestineproblems:
    • Older adults, adults, and teenagers—250 to500 mcg injected into a muscle, vein, or under the skinevery four to six hours.
    • Children—Dose must be determined by yourdoctor.

• For mepenzolate
• For oral dosage form (tablets):
  • To treat duodenal or stomach ulcers or intestineproblems:
    • Older adults, adults, and teenagers—25 to 50milligrams (mg) four times a day, with meals and atbedtime. Your doctor may change the dose ifneeded.
    • Children—Dose must be determined by yourdoctor.

• For methantheline
• For oral dosage form (tablets):
  • To treat intestine or stomach ulcers, intestineproblems, or urinary problems:
    • Older adults, adults, and teenagers—50 to 100milligrams (mg) every six hours. Your doctor may changethe dose if needed.
    • Children 1 year of age and older—12.5 to 50mg four times a day. Your doctor may change the dose ifneeded.
    • Children 1 month to 1 year of age—12.5 mgfour times a day. Your doctor may change the dose ifneeded.
    • Children up to 1 month of age—12.5 mg twotimes a day. Your doctor may change the dose ifneeded.

• For methscopolamine
• For oral dosage form (tablets):
  • To treat duodenal or stomach ulcers or intestineproblems:
    • Older adults, adults, and teenagers—2.5 to 5milligrams (mg) four times a day, one-half hour beforemeals and at bedtime. Your doctor may change the doseif needed.
    • Children—Dose is based on body weight. Theusual dose is 200 micrograms (mcg) per kilogram (kg)(90.9 mcg per pound) of body weight four times a day.The dose should be taken before meals and atbedtime.

• For pirenzepine
• For oral dosage form (tablets):
  • To treat duodenal or stomach ulcers or intestineproblems:
    • Older adults, adults, and teenagers—50milligrams (mg) two times a day, in the morning and atbedtime. Your doctor may change the dose ifneeded.
    • Children—Dose must be determined by yourdoctor.

• For propantheline
• For oral dosage form (tablets):
  • To treat duodenal or stomach ulcers:
    • Older adults, adults, and teenagers—7.5 to 15milligrams (mg) three times a day, one-half hour beforemeals, and 30 mg at bedtime. Your doctor may change thedose if needed.
    • Children—Dose is based on body weight. Theusual dose is 375 micrograms (mcg) per kilogram (kg)(170 mcg per pound) of body weight four times a day.Your doctor may change the dose if needed.

• For scopolamine
• For oral dosage form (tablets):
  • To treat urinary problems or intestine problems orpainful menstruation:
    • Older adults, adults, and teenagers—10 to 20milligrams (mg) three or four times a day. Your doctormay change the dose if needed.
    • Children—Dose must be determined by yourdoctor.
• For injectable dosage form:
  • To treat urinary problems or intestine problems:
    • Older adults, adults, and teenagers—10 to 20mg three or four times a day. Your doctor may changethe dose if needed.
    • Children—Dose must be determined by yourdoctor.
• For rectal dosage form (suppository):
  • To treat urinary problems or intestine problems orpainful menstruation:
    • Older adults, adults, and teenagers—Insertone 10 mg suppository rectally three or four times aday. Your doctor may change the dose if needed.
    • Children—Dose must be determined by yourdoctor.
• For transdermal dosage form (patch):
  • To treat motion sickness:
    • Older adults, adults, and teenagers—Apply one1.0 milligram (mg) patch behind ear at least four hoursbefore antinausea effect is needed.
    • Children—Use is not recommended.
  • To treat nausea and vomiting after surgery
    • Older adults, adults and teenagers—Apply one1.0 mg patch behind the ear the evening before surgeryto prevent nausea and vomiting after surgery
    • Children—Use is not recommended.

Missed dose—

If you miss a dose of this medicine, take it as soon aspossible. However, if it is almost time for your next dose,skip the missed dose and go back to your regular dosingschedule. Do not double doses.

For patients taking any of these medicines by mouth :

• Take this medicine 30 minutes to 1 hour before mealsunless otherwise directed by your doctor.

To use the rectal suppository form of scopolamine:

• If the suppository is too soft to insert, chill it inthe refrigerator for 30 minutes or run cold water over itbefore removing the foil wrapper.
• To insert the suppository: First remove the foilwrapper and moisten the suppository with cold water. Liedown on your side and use your finger to push thesuppository well up into the rectum.

To use the transdermal disk form of scopolamine:

• This medicine usually comes with patient directions.Read them carefully before using this medicine.
• Wash and dry your hands thoroughly before and afterhandling.
• Apply the disk to the hairless area of skin behind theear. Do not place over any cuts or irritations.

Storage—

To store this medicine:

• Keep out of the reach of children. Overdose isespecially dangerous in young children.
• Store away from heat and direct light.
• Do not store the capsule or tablet form of thismedicine in the bathroom, near the kitchen sink, or inother damp places. Heat or moisture may cause the medicineto break down.
• Keep the liquid form of this medicine tightly closedand keep it from freezing. Do not refrigerate the syrupform of this medicine.
• Do not keep outdated medicine or medicine no longerneeded. Be sure that any discarded medicine is out of thereach of children.

If you think you or someone else may have taken anoverdose, get emergency help at once. Taking an overdoseof any of the belladonna alkaloids or taking scopolamine withalcohol or other CNS depressants may lead to unconsciousnessand possibly death. Some signs of overdose are clumsiness orunsteadiness; dizziness; severe drowsiness; fever;hallucinations (seeing, hearing, or feeling things that arenot there); confusion; shortness of breath or troubledbreathing; slurred speech; unusual excitement, nervousness,restlessness, or irritability; fast heartbeat; and unusualwarmth, dryness, and flushing of skin.

These medicines may make you sweat less, causing your bodytemperature to increase. Use extra care not to become overheated during exerciseor hot weather while you are taking this medicine, sinceoverheating may result in heat stroke. Also, hot baths orsaunas may make you dizzy or faint while you are taking thismedicine.

Check with your doctor before you stop using thismedicine . Your doctor may want you to reduce graduallythe amount you are using before stopping completely. Stoppingthis medicine may cause withdrawal side effects such asvomiting, sweating, and dizziness.

Anticholinergics may cause some people to have blurredvision. Make sure your vision is clear before you drive or doanything else that could be dangerous if you are not able tosee well. These medicines may also cause your eyes tobecome more sensitive to light than they are normally.Wearing sunglasses may help lessen the discomfort from brightlight.

These medicines, especially in high doses, may cause somepeople to become dizzy or drowsy. Make sure you know how you react to this medicine beforeyou drive, use machines, or do anything else that could bedangerous if you are dizzy or are not alert.

Dizziness, lightheadedness, or fainting may occur,especially when you get up from a lying or sitting position.Getting up slowly may help lessen this problem.

These medicines may cause dryness of the mouth, nose, andthroat. For temporary relief of mouth dryness, use sugarlesscandy or gum, melt bits of ice in your mouth, or use a salivasubstitute. However, if your mouth continues to feel dry formore than 2 weeks, check with your medical doctor or dentist.Continuing dryness of the mouth may increase the chance ofdental disease, including tooth decay, gum disease, andfungus infections.

For patients taking scopolamine:

• This medicine will add to the effects of alcohol andother CNS depressants (medicines that slow down the nervoussystem, possibly causing drowsiness). Some examples of CNSdepressants are antihistamines or medicine for hay fever,other allergies, or colds; sedatives, tranquilizers, orsleeping medicine; prescription pain medicine or narcotics;barbiturates; medicine for seizures; muscle relaxants; oranesthetics, including some dental anesthetics. Check with your doctor before taking any of the abovewhile you are using this medicine.

For patients taking any of these medicines by mouth :

• Do not take this medicine within 2 or 3 hours of takingantacids or medicine for diarrhea. Taking antacids orantidiarrhea medicines and this medicine too close togethermay prevent this medicine from working properly.

Along with its needed effects, a medicine may cause someunwanted effects. Although not all of these side effects mayoccur, if they do occur they may need medical attention.

Check with your doctor as soon as possible if any of thefollowing side effects occur:

• Rare
  • Confusion (especially in the elderly); dizziness,lightheadedness (continuing), or fainting; eye pain; skinrash or hives
  
  

• Symptoms of overdose
  • Blurred vision (continuing) or changes in nearvision; clumsiness or unsteadiness; confusion ;convulsions (seizures); difficulty in breathing, muscleweakness (severe), or tiredness (severe); dizziness;drowsiness (severe); dryness of mouth, nose, or throat(severe); fast heartbeat; fever; hallucinations (seeing,hearing, or feeling things that are not there); slurredspeech; unusual excitement, nervousness, restlessness, orirritability; unusual warmth, dryness, and flushing ofskin
  
  

Other side effects may occur that usually do not needmedical attention. These side effects may go away duringtreatment as your body adjusts to the medicine. However, checkwith your doctor if any of the following side effects continueor are bothersome:

• More common
  • Constipation (less common with hyoscyamine);decreased sweating; dryness of mouth, nose, throat, orskin
  
  

• Less common or rare
  • Bloated feeling; blurred vision; decreased flow ofbreast milk; difficult urination; difficulty inswallowing; drowsiness (more common with high doses ofany of these medicines and with usual doses ofscopolamine when given by mouth or by injection); falsesense of well-being (for scopolamine only); headache;increased sensitivity of eyes to light; lightheadedness(with injection); loss of memory; nausea or vomiting;redness or other signs of irritation at place ofinjection; trouble in sleeping (for scopolamine only);unusual tiredness or weakness
  
  

• After you stop using scopolamine, your body may need timeto adjust. The length of time this takes depends on theamount of scopolamine you were using and how long you usedit. During this period of time check with your doctor if younotice any of the following side effects:

• Anxiety; irritability; nightmares; trouble insleeping

• While using the disk or even after removing it, your eyesmay become more sensitive to light than usual. You may alsonotice the pupil in one eye is larger than the other. Checkwith your doctor if this side effect continues or isbothersome

Other side effects not listed above may also occur in somepatients. If you notice any other effects, check with yourdoctor.

Once a medicine has been approved for marketing for acertain use, experience may show that it is also useful forother medical problems. Although these uses are not includedin product labeling, anticholinergics/antispasmodics are usedin certain patients with the following medicalconditions:

• Diarrhea
• Excessive watering of mouth
• Asthma treatment (atropine)

Other than the above information, there is no additionalinformation relating to proper use, precautions, or sideeffects for these uses.