What medications are used to manage drooling?

Medications for Managing Drooling

Anticholinergic medications are the first-line pharmacological treatment for chronic severe drooling, with glycopyrrolate being the most effective and FDA-approved option for patients with neurological conditions. 1

First-Line Pharmacological Options

Glycopyrrolate

• FDA-approved for chronic severe drooling in patients aged 3-16 years with neurological conditions (e.g., cerebral palsy) 1
• Dosing regimen:
  • Initial dose: 0.02 mg/kg three times daily
  • Titrate in increments of 0.02 mg/kg every 5-7 days based on response and side effects
  • Maximum recommended dose: 0.1 mg/kg three times daily (not to exceed 1.5-3 mg per dose based on weight)
  • Administer at least one hour before or two hours after meals 1
• Efficacy: Effectively decreases but rarely abolishes drooling in patients with cerebral palsy and related neurodevelopmental disabilities 2
• Common side effects: Dry mouth, vomiting, constipation, flushing, and nasal congestion (incidence ≥30%) 1

Other Anticholinergics

• Scopolamine (transdermal): Alternative option for drooling management 3
• Atropine-related oral anticholinergics: Used to reduce cholinergic tone systemically 4
• Sublingual ipratropium spray: Provides more localized reduction of cholinergic tone 4

Second-Line and Adjunctive Options

Botulinum Toxin Injections

• Indication: Refractory cases not responding to anticholinergic medications 4
• Administration: Injected into the parotid and submandibular glands 3
• Efficacy: Safe and effective in controlling drooling, but effects fade after several months requiring repeat injections 3

Other Pharmacological Approaches

• Clonidine patch: Works by increasing adrenergic tone 4
• TRPV1 agonists (e.g., capsaicinoids, piperine): May improve swallowing function by decreasing the latency of the swallow reflex 5
• Dopaminergic agents (e.g., levodopa, amantadine, cabergoline): May be used in patients with swallowing dysfunction due to neurological conditions like Parkinson's disease or post-stroke 5

Treatment Algorithm Based on Patient Characteristics

For Patients with Neurological Conditions (e.g., cerebral palsy, Parkinson's disease)

1. Start with glycopyrrolate:

   • Begin at 0.02 mg/kg three times daily
   • Titrate up as needed and tolerated
   • Monitor for anticholinergic side effects

2. If inadequate response or intolerable side effects:

   • Consider scopolamine transdermal patch or sublingual ipratropium spray
   • For Parkinson's patients: Consider optimizing dopaminergic therapy

3. For refractory cases:

   • Consider botulinum toxin injections into salivary glands
   • Consider surgical options for permanent management in severe cases

For Patients with Swallowing Dysfunction

1. Prior to medication: Perform instrumental swallow evaluation 5
2. If delayed swallow reflex is identified:
   • Consider TRPV1 agonists or dopaminergic agents as adjuncts to behavioral swallow therapy 5
   • Add glycopyrrolate if significant drooling persists

Monitoring and Precautions

• Constipation: Assess patients for constipation, particularly within 4-5 days of initial dosing or after a dose increase 1
• Heat sensitivity: Advise patients to avoid high temperatures to reduce the risk of heat prostration 1
• Drug interactions: Monitor for interactions with digoxin, amantadine, atenolol, metformin, haloperidol, and levodopa 1
• Renal impairment: Use glycopyrrolate with caution in patients with renal impairment 1

Clinical Pearls

• The effective dose of glycopyrrolate can vary widely between patients (0.01 to 0.82 mg/kg per day), requiring individualized titration 2
• Approximately 65% of patients continue glycopyrrolate therapy due to perceived benefit, despite side effects 2
• Treatment decisions should be based on a careful risk-benefit analysis due to limited evidence regarding clinical endpoints 5
• Drooling management is best approached by a multidisciplinary team including primary care providers, speech pathologists, occupational therapists, dentists, neurologists, and otolaryngologists 3

Remember that while medications can significantly reduce drooling, they rarely eliminate it completely. The goal of treatment should be to reduce drooling to a manageable level that improves quality of life and prevents complications such as skin irritation, dehydration, and social stigmatization.