From the Guidelines
The approach to excessive salivation should begin with a trial of anticholinergic agents, which are relatively inexpensive and readily available, as recommended by the American College of Chest Physicians clinical practice guideline and expert panel report 1. The first-line pharmacological treatments include anticholinergic medications such as glycopyrrolate (1-2mg orally three times daily), scopolamine transdermal patches (1.5mg patch applied behind the ear every 72 hours), or atropine drops (1-2 drops of 1% solution sublingually 3-4 times daily) 1. For patients with neurological conditions, botulinum toxin injections into the salivary glands can provide relief for 3-6 months, as suggested by the American College of Chest Physicians clinical practice guideline and expert panel report 1. Some key points to consider when treating excessive salivation include:
- Anticholinergic medications can have side effects such as dry mouth, blurred vision, urinary retention, and constipation, so starting with lower doses in elderly patients and monitoring closely is essential 1.
- Botulinum toxin therapy can provide long-lasting relief, but the certainty of the evidence is limited by the unblinded observational design of the studies and the subjective improvement assessment bias 1.
- Radiation therapy may be considered for patients with significant debility resulting from sialorrhea, but the balance of benefits and risks is unclear, and the harm may outweigh the benefits for some patients 1. Non-pharmacological approaches, such as behavioral modification techniques, speech therapy, and proper positioning of the head to improve swallowing, can also be effective in managing excessive salivation. It is essential to weigh the benefits and risks of each treatment option and consider the individual patient's needs and circumstances when making a decision. The American College of Chest Physicians clinical practice guideline and expert panel report provides a comprehensive review of the evidence and recommendations for managing sialorrhea in patients with neuromuscular weakness 1.
From the FDA Drug Label
Glycopyrrolate inhibits the action of acetylcholine on salivary glands thereby reducing the extent of salivation. Glycopyrrolate is a competitive inhibitor of acetylcholine receptors that are located on certain peripheral tissues, including salivary glands. Glycopyrrolate indirectly reduces the rate of salivation by preventing the stimulation of these receptors. The approach to excessive salivation is to use glycopyrrolate oral solution, which is an anticholinergic drug that reduces salivation by inhibiting the action of acetylcholine on salivary glands.
- The drug works by competitively inhibiting acetylcholine receptors on peripheral tissues, including salivary glands.
- It indirectly reduces the rate of salivation by preventing the stimulation of these receptors. 2
From the Research
Approach to Excessive Salivation
Excessive salivation, also known as sialorrhea or hypersalivation, is a condition characterized by an overproduction of saliva. This can be caused by various factors, including:
- Dysfunction in salivary production or oropharyngeal clearance 3
- Neurologic dysfunction, leading to dysphagia 3, 4
- Insufficient oro-motor function or decreased central control and coordination 4
Treatment Options
Several treatment options are available to manage excessive salivation, including:
- Non-pharmacologic treatments, such as swallowing therapy programs 4
- Pharmacologic treatments, such as glycopyrrolate fluid solution (Sialanar®) for pediatric cases 4 and clozapine for certain movement disorders 5, 6, 7
- Surgical treatment, which should be reserved for isolated cases 4
- Radiotherapeutic treatment, which can be safe and effective when using modern 3D techniques to minimize tissue damage 4
- Injection of botulinum toxin into the salivary glands, which has shown safe and effective results with long-lasting saliva reduction 4
Specific Considerations
In some cases, excessive salivation may be related to underlying conditions, such as Parkinson's disease or other movement disorders. In these cases, treatment with clozapine may be effective in managing symptoms, including psychosis and tremor 5, 6, 7. However, careful consideration of the potential risks and benefits of clozapine treatment is necessary, as well as close monitoring for adverse effects.