What medications reduce salivary load, also known as sialorrhea (excessive salivation)?

From the Guidelines

Anticholinergic medications, such as glycopyrrolate or scopolamine, are the first-line therapy for reducing salivary load in patients with sialorrhea, as they have been suggested by the American College of Chest Physicians clinical practice guideline and expert panel report 1. To manage excessive salivation, the following medications can be considered:

• Anticholinergics like glycopyrrolate (1-2 mg orally two to three times daily) and scopolamine (transdermal patch 1.5 mg every 72 hours) are effective options, as they work by blocking acetylcholine receptors in salivary glands, inhibiting the neural signals that stimulate saliva production 1.
• Tricyclic antidepressants such as amitriptyline (10-25 mg at bedtime) can also decrease saliva production.
• For short-term use, antihistamines like diphenhydramine (25-50 mg every 6-8 hours) are effective.
• Botulinum toxin injections into salivary glands provide longer-lasting effects (typically 3-6 months) but require specialist administration, and can be considered for patients who have an inadequate response or are intolerant of the side effects of anticholinergic therapy 1. It is essential to start with lower doses and monitor for side effects, which may include dry mouth, blurred vision, constipation, and urinary retention. Elderly patients and those with glaucoma, prostatic hypertrophy, or cognitive impairment should use these medications cautiously. Non-pharmacological approaches like proper positioning, regular oral suctioning, and speech therapy techniques can complement medication therapy for managing excessive salivation.

From the FDA Drug Label

Scopolamine can inhibit the secretion of saliva and sweat, decrease gastrointestinal secretions and motility, cause drowsiness, dilate the pupils, increase heart rate, and depress motor function. Glycopyrrolate injection is not recommended for the treatment of peptic ulcer in pediatric patients

• Medications that reduce salivary load (sialorrhea):
  • Scopolamine
  • Glycopyrrolate These medications have anticholinergic properties that can help reduce salivary secretions. 2 3

From the Research

Medications for Reducing Salivary Load

The following medications have been identified as potential treatments for reducing salivary load, also known as sialorrhea:

• Anticholinergic drugs, such as:
  • Atropine 4, 5, 6
  • Glycopyrrolate 4, 5, 7, 6
  • Scopolamine 4, 5, 8, 6
  • Hyoscyamine 4
• Botulinum toxin injections into the parotid and submandibular glands 5, 7, 8
• Dextromethorphan with quinidine (DMQ) 8
• Dopamine antagonists, such as amisulpride 6
• Alpha-2-adrenergic agonists, such as clonidine 6
• Other agents, such as terazosine, moclobemide, bupropion, and N-acetylcysteine 6

Treatment Approaches

Treatment approaches for sialorrhea may involve:

• Non-drug related management, such as increasing the frequency of swallowing with chewing gum 6
• Adjusting the dosage of the drug causing sialorrhea 6
• Adding a symptomatic treatment, such as an anticholinergic agent 6
• Using botulinum toxin injections or other medications, such as DMQ or dopamine antagonists 5, 7, 8, 6