What medications are used to treat excessive salivation (sialorrhea)?

Medications for Excessive Salivation (Sialorrhea)

Anticholinergic medications are the first-line pharmacological treatment for excessive salivation, with botulinum toxin injections recommended as second-line therapy when anticholinergics are ineffective or poorly tolerated. 1

First-Line Pharmacological Options

Anticholinergic Medications

These medications work by competitively inhibiting acetylcholine receptors on salivary glands, reducing saliva production:

1. Glycopyrrolate (oral solution)

   • Mechanism: Competitive inhibitor of acetylcholine receptors on salivary glands 2
   • Dosing: Available as 1 mg/5 mL oral solution
   • Administration: Should be taken at least one hour before or two hours after meals (high-fat meals reduce bioavailability by approximately 74%) 2
   • Particularly studied in pediatric patients aged 3-16 years with neurologic conditions 2
   • Caution in patients with:
     • Renal impairment (drug is largely renally eliminated)
     • Impaired gastric emptying
     • History of urinary retention
     • Not recommended in narrow-angle glaucoma unless approved by ophthalmologist 1

2. Scopolamine (transdermal)

   • Available as transdermal patch delivering approximately 1 mg over 3 days 3
   • Mechanism: Blocks cholinergic transmission, inhibiting saliva secretion 3
   • Common side effects: Dry mouth, drowsiness, dilated pupils, increased heart rate 3

3. Atropine (sublingual drops) 1

4. Amitriptyline

   • May be beneficial particularly for patients with neurological disorders 1, 4

Second-Line Therapy

Botulinum Toxin Injections

When anticholinergic medications are ineffective or poorly tolerated:

• IncobotulinumtoxinA (Xeomin) - FDA-approved at 100 Units dose 1
• Administered into parotid and submandibular salivary glands in a 3:2 dose ratio 1
• Benefits:
  • Relatively simple injection procedure
  • Effects last weeks to months
  • Long-term data supports safety and efficacy over 64 weeks 1
• Side effects:
  • Mild to moderate dry mouth (2.7-11.1%)
  • Dysphagia (0-4.2%) 1, 5
• No tachyphylaxis or need for repeated therapeutic sessions 4

Special Considerations

Patient Selection

• Careful assessment of risk-benefit balance is essential, particularly in:
  • Elderly patients
  • Patients with cognitive impairment 1
  • Patients with neurological disorders (Parkinson's disease, ALS, cerebral palsy, stroke) 4

Monitoring

• Regular screening for dysphagia, especially in patients with neurological disorders 1
• Monitor for signs of aspiration (sialorrhea increases risk of aspiration pneumonia) 1
• Evaluate treatment response regularly and adjust as necessary 1

Complications of Untreated Sialorrhea

• Aspiration pneumonia (leading cause of death in patients with neurological disorders)
• Perioral chapping
• Dehydration
• Odor
• Social stigmatization 1

Third-Line Options

For severe, refractory cases:

• Radiation therapy to salivary glands (reserved for use in experienced centers due to risk of irreversible dryness) 1
• Surgical options may be considered for long-term management 4

Practical Management Tips

• Improve hydration but limit caffeine intake 1
• Avoid crunchy, spicy, acidic, or hot food/drink 1
• Encourage increased frequency of swallowing with chewing gum 1
• Consider referral to specialists (dentistry or otolaryngology) for severe cases 1

Remember that sialorrhea management should prioritize reduction of aspiration risk and improvement in quality of life, with medication selection based on patient-specific factors including age, comorbidities, and underlying cause of hypersalivation.