From the Guidelines
For clozapine-induced sialorrhea, botulinum toxin (BT) therapy to salivary glands is a suitable medication option, especially for patients with an inadequate response or intolerance to anticholinergic therapy, as suggested by the American College of Chest Physicians clinical practice guideline and expert panel report 1. When considering BT therapy, it is essential to note that the decision to use BT or radiation therapy (RT) first can be based on local expertise, and clinicians should consult individual studies for appropriate doses of BT 1. Some key points to consider when using BT therapy include:
- The certainty of evidence for BT therapy is very low, but it is still a recommended option for patients who do not respond to or cannot tolerate anticholinergic therapy 1.
- BT therapy works by temporarily paralyzing the salivary glands, reducing saliva production and alleviating symptoms of sialorrhea.
- Patients should be monitored for potential side effects and complications of BT therapy, such as dysphagia or bruising at the injection site.
- Non-pharmacological approaches, such as sleeping in a side-lying position and using a towel on the pillow, can also be used in conjunction with BT therapy to manage symptoms. It is crucial to weigh the potential benefits and risks of BT therapy and consider individual patient factors, such as medical history and current medications, when making treatment decisions 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). A suitable medication for clozapine (Clozaril)-induced sialorrhea (drooling) is glycopyrrolate (PO), as it is indicated to reduce chronic severe drooling in patients with neurologic conditions associated with problem drooling.
- 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. 2
From the Research
Suitable Medications for Clozapine-Induced Sialorrhea
- Sublingual atropine sulfate has been shown to reduce nocturnal unstimulated saliva secretion in patients with clozapine-induced hypersalivation, with a significant decrease in saliva secretion compared to placebo 3.
- Glycopyrrolate, an antimuscarinic agent, has been effective in alleviating clozapine-induced sialorrhea in three out of four reported cases, with patients experiencing a decrease in drooling severity and frequency 4.
- Other potential treatment options include:
- Amisulpride, which has been reported to be effective in a single case of clozapine-induced sialorrhea 5.
- Ipatropium bromide, which has shown preliminary promise in reducing hypersalivation in patients who failed to respond to anticholinergic or adrenergic agents 6.
- Pirenzepine, a selective muscarinic receptor antagonist, which has a promising mechanism but is not yet available in the United States 7.
Considerations for Treatment
- Antimuscarinic agents and alpha-receptor agonists are viable options, but must be administered and monitored cautiously in patients with psychiatric disorders 7.
- Treatment options should be carefully evaluated and monitored due to the potential for added side effects and interactions with other medications.