What medications can increase salivary flow, specifically sialagogues (salivary stimulants)?

From the Guidelines

The most effective medication to increase salivary flow is cevimeline, which has been found to improve ocular irritation symptoms and aqueous tear production with fewer adverse systemic side effects than oral pilocarpine 1.

Medication Options

• Cevimeline is typically prescribed at a dose of 30 mg three times daily, and it works by stimulating muscarinic receptors in salivary glands, directly increasing saliva production.
• Pilocarpine is another option, typically prescribed at 5-10 mg three times daily, but it has more adverse systemic side effects, including excessive sweating, which occurred in over 40% of patients 1.

Important Considerations

• Patients with certain heart conditions, uncontrolled asthma, or narrow-angle glaucoma should avoid prescription sialagogues and consult their healthcare provider before starting treatment.
• Regular dental check-ups are important as dry mouth increases the risk of dental decay.
• Staying well-hydrated, avoiding alcohol and caffeine, and using a humidifier at night can complement medication therapy.

Alternative Options

• For milder cases, over-the-counter options include Biotène products, xylitol-containing lozenges, or sugar-free gum to stimulate natural saliva flow.
• Autologous serum and autologous plasma rich in growth factors drops have been reported to improve ocular irritation symptoms as well as conjunctival and corneal dye staining in patients with Sjögren’s syndrome and GVHD 1.

From the FDA Drug Label

Cevimeline has been shown to improve the symptoms of dry mouth in patients with Sjögren’s Syndrome A 6-week, randomized, double blind, placebo-controlled study was conducted in 75 patients Seventy-six percent of the patients in the 30 mg tid group reported a global improvement in their dry mouth symptoms A 12-week, randomized, double-blind, placebo-controlled study was conducted in 197 patients Statistically significant global improvement in the symptoms of dry mouth (p=0. 0004) was seen for the 30 mg tid group compared to placebo Salivary flow showed statistically significant increases at both doses of cevimeline during the study compared to placebo The 30 mg tid group showed a statistically significant increase in salivary flow from pre-dose to post-dose compared to placebo (p=0.0017)

Cevimeline and pilocarpine are medications that can increase salivary flow.

• Cevimeline has been shown to improve symptoms of dry mouth in patients with Sjögren's Syndrome, with a significant increase in salivary flow at doses of 30 mg tid.
• Pilocarpine also increases salivary flow, with a dose-related increase in unstimulated salivary flow following single oral doses. In a study, pilocarpine increased whole saliva flow and unstimulated parotid flow, with a duration of effect of 3 to 5 hours 2. It is essential to note that the effectiveness of these medications may vary depending on the individual patient and the specific condition being treated. Pilocarpine has been studied in patients with head and neck cancer and Sjögren's Syndrome, with significant increases in salivary flow observed in both populations 2, 2.

From the Research

Medications to Increase Salivary Flow

• Cevimeline is a muscarinic agonist that stimulates salivary secretion in animals and humans, effectively increasing salivary flow rates 3.
• Pilocarpine is another medication that can increase salivary flow and alleviate xerostomia, with studies showing its effectiveness in patients with hemodialysis 4.
• Salagen and Evoxac are FDA-approved salivary stimulants that can be used to treat dry mouth in patients with Sjögren's syndrome, providing an alternative to palliative measures 5.

Treatment Strategies

• Treatment of xerostomia should focus on increasing salivary output, rather than just providing palliative measures 5.
• A combination of pharmacological stimulants and non-pharmacological methods, such as gustatory stimulation with sugar-free gum and candies, can be effective in managing dry mouth 5.
• Clinicians should be aware of the biology of saliva and the best means of providing a continuum of relief for people with xerostomia and hyposalivation 6.

Adverse Effects and Considerations

• Cevimeline and pilocarpine can cause adverse effects such as sweating, gastrointestinal symptoms, and dizziness, but these are generally mild and tolerable 3, 4.
• Patients should be aware of the indications, contraindications, potential adverse effects, and tolerance of salivary stimulants before starting treatment 5.