From the Guidelines
The most effective treatment option for managing sialorrhea is a therapeutic trial of an anticholinergic medication as first-line therapy, with continued use only if benefits are perceived to outweigh potential side effects, as suggested by the American College of Chest Physicians clinical practice guideline and expert panel report 1.
Treatment Options
Treatment options for managing sialorrhea include both non-pharmacological and pharmacological approaches. Non-pharmacological methods should be tried first, including:
- Behavioral modification techniques
- Speech therapy
- Positioning adjustments to improve swallowing and oral control
- Oral motor exercises to strengthen muscles involved in saliva control For pharmacological management, anticholinergic medications are commonly used, including:
- Glycopyrrolate (1-2mg three times daily), which reduces saliva production but may cause side effects like dry mouth, constipation, and urinary retention
- Scopolamine patches (1.5mg applied behind the ear every 72 hours) offer another option
Additional Treatment Options
Botulinum toxin injections into the salivary glands (typically 15-75 units per gland) provide temporary relief lasting 3-6 months by blocking acetylcholine release, and can be considered for patients with inadequate response or intolerance to anticholinergic therapy 1. For severe cases unresponsive to other treatments, surgical options include:
- Salivary gland removal
- Duct ligation
- Duct relocation Treatment selection depends on the underlying cause of sialorrhea, patient age, comorbidities, and the severity of symptoms, as well as the potential benefits and risks of each treatment option, as discussed in the American College of Chest Physicians clinical practice guideline and expert panel report 1.
From the FDA Drug Label
GLYCOPYRROLATE ORAL SOLUTION 1MG/5ML is an anticholinergic indicated to reduce chronic severe drooling in patients aged 3-16 years with neurologic conditions associated with problem drooling (e.g., cerebral palsy). The treatment option for managing sialorrhea is Glycopyrrolate oral solution, which is indicated to reduce chronic severe drooling in patients aged 3-16 years with neurologic conditions associated with problem drooling (e.g., cerebral palsy) 2.
- The recommended dosage is 0.02 mg/kg three times daily, titrated in increments of 0.02 mg/kg every 5-7 days, based on therapeutic response and adverse reactions.
- The maximum recommended dose is 0.1 mg/kg three times daily, not to exceed 1.5-3 mg per dose based upon weight.
From the Research
Treatment Options for Sialorrhea
- Medical management: Anticholinergic drugs such as atropine, glycopyrrolate, amitriptyline, hyoscyamine, and transdermal scopolamine are often used to treat sialorrhea, although their effectiveness in patients with amyotrophic lateral sclerosis (ALS) is limited 3.
- Botulinum toxin injections: Botulinum toxin injections into the salivary glands have been shown to be effective in treating sialorrhea, with a clear-cut benefit in 89% of injections 4. Both abobotulinumtoxinA and rimabotulinumtoxinB have been found to be safe and effective, with a mean benefit duration of 87 days 4.
- Radiation therapy: Radiation therapy in the salivary glands can be considered when anticholinergic drugs are not effective 3.
- Surgical options: Surgical therapies, such as saliva surgery, may represent a valid option for treatment of sialorrhea, especially in cases where other treatments are not effective 3, 5.
- Behavioral intervention: Behavioral intervention, such as oral appliances and oral motor exercises, can be effective in managing sialorrhea 5.
- Anticholinergic medications: Anticholinergic medications, such as glycopyrrolate, have been found to be effective in controlling sialorrhea, although they can have adverse effects 6.
Specific Patient Populations
- Children with developmental disabilities: Glycopyrrolate has been found to be effective in controlling sialorrhea in children with developmental disabilities, although approximately 20% of children may experience substantial adverse effects 6.
- Patients with ALS: Botulinum toxin injections have been found to be effective in treating sialorrhea in patients with ALS, although the benefit duration may be shorter compared to patients with Parkinson's disease 4.
- Patients with Parkinson's disease: Botulinum toxin injections have been found to be effective in treating sialorrhea in patients with Parkinson's disease, with a longer benefit duration compared to patients with ALS 4.