Can Ingrezza (valbenazine) be used to treat drooling?

Ingrezza (Valbenazine) for Treating Drooling

Ingrezza (valbenazine) is not recommended for treating drooling as it lacks FDA approval and clinical evidence for this indication. While Ingrezza is approved for treating tardive dyskinesia, there is no evidence supporting its use for sialorrhea (drooling) 1.

Understanding Drooling and Its Management

Drooling (sialorrhea) occurs due to two primary mechanisms:

• Increased saliva production that exceeds swallowing capacity
• Impaired swallowing function with normal or reduced saliva production

Pharmacological Options for Drooling

The most evidence-supported medications for drooling include:

1. Anticholinergic medications - First-line pharmacological treatment:

   • Atropine (sublingual)
   • Glycopyrrolate
   • Scopolamine (transdermal)
   • Ipratropium (sublingual spray)

2. Adrenergic medications:

   • Clonidine patch

3. Advanced interventions for refractory cases:

   • Botulinum toxin injections into salivary glands
   • Surgical interventions for severe cases

Why Ingrezza Is Not Appropriate for Drooling

Ingrezza (valbenazine) is a vesicular monoamine transporter 2 (VMAT2) inhibitor specifically approved for tardive dyskinesia 1. It works by regulating dopamine release in the brain, which helps control involuntary movements. However:

• No clinical studies demonstrate efficacy for drooling
• The mechanism of action does not target the pathways involved in saliva production or swallowing function
• Pharmacological treatment of drooling should focus on medications that either reduce saliva production (anticholinergics) or improve swallowing function 2

Evidence-Based Approach to Drooling Management

For patients with drooling, the following algorithm is recommended:

1. Identify the cause:

   • Neurological disorders (Parkinson's disease, stroke, cerebral palsy)
   • Medication-induced (clozapine, direct/indirect cholinergic agonists) 2
   • Anatomical abnormalities affecting swallowing

2. First-line treatment:

   • Anticholinergic medications to reduce saliva production
   • Behavioral or oral motor therapies to improve swallowing function 3

3. For refractory cases:

   • Botulinum toxin injections into salivary glands
   • Surgical interventions (duct ligation, gland excision)

Important Considerations

• Anticholinergic medications can cause significant side effects including confusion, urinary retention, constipation, and blurred vision, particularly in elderly patients 4
• Treatment decisions should be based on the severity of drooling and its impact on quality of life 5
• Pharmacological treatments for drooling often provide only symptomatic relief and may not address the underlying cause 2

Conclusion on Ingrezza for Drooling

Based on the available evidence, Ingrezza (valbenazine) should not be used for treating drooling. Instead, established treatments targeting the mechanisms of drooling should be employed, starting with anticholinergic medications for excessive saliva production or therapies to improve swallowing function for neurogenic drooling.