Glycopyrrolate for Drooling Management
Glycopyrrolate oral solution is indicated for chronic severe drooling, with a recommended starting dose of 0.02 mg/kg three times daily, titrated up to a maximum of 0.1 mg/kg three times daily (not exceeding 1.5-3 mg per dose based on weight). 1
Dosage and Administration
Pediatric Patients (3-16 years)
- Initial dose: 0.02 mg/kg orally three times daily
- Titration: Increase in increments of 0.02 mg/kg every 5-7 days based on therapeutic response and adverse reactions
- Maximum dose: 0.1 mg/kg three times daily (not exceeding 1.5-3 mg per dose based on weight)
- Administration timing: At least 1 hour before or 2 hours after meals (high-fat food reduces bioavailability) 1
Weight-Based Dosing Guide
| Weight (kg) | Level 1 (~0.02 mg/kg) | Level 5 (~0.1 mg/kg) |
|---|---|---|
| 13-17 kg | 0.3 mg (1.5 mL) | 1.5 mg (7.5 mL) |
| 18-22 kg | 0.4 mg (2 mL) | 2.0 mg (10 mL) |
| 23-27 kg | 0.5 mg (2.5 mL) | 2.5 mg (12.5 mL) |
| 28-32 kg | 0.6 mg (3 mL) | 3.0 mg (15 mL) |
| ≥33 kg | 0.7-1.0 mg | 3.0 mg (15 mL) |
Adults
While not FDA-approved for adults, case reports suggest effectiveness for clozapine-induced sialorrhea with similar dosing principles 2.
Monitoring and Management
Efficacy Assessment
- Evaluate response after 1 month of treatment
- Studies show significant improvement in drooling scores with proper dosing 3
- Response rates of approximately 90% have been reported 4
Side Effect Management
Monitor for common adverse effects (incidence ≥30%):
- Dry mouth (10.9%)
- Vomiting (17.5%)
- Constipation (20.4%)
- Flushing (10.9%)
- Nasal congestion (10.9%) 3
Special Considerations
- Assess for constipation within 4-5 days of initial dosing or after dose increases 1
- Use with caution in patients with renal impairment 1
- Avoid high ambient temperatures to reduce risk of heat prostration 1
- Consider anticholinergic burden, especially in elderly patients or those with cognitive impairment 5
Alternative Options
If glycopyrrolate is ineffective or poorly tolerated:
- Other anticholinergics: scopolamine (transdermal or oral), hyoscyamine 5
- Botulinum toxin injections to salivary glands (second-line therapy) 5
Clinical Pearls
Measure doses with an accurate measuring device (special marked dose measuring cup or oral syringe) 1
Glycopyrrolate decreases but rarely abolishes drooling completely 4
Contraindicated in:
- Glaucoma
- Paralytic ileus
- Unstable cardiovascular status
- Severe ulcerative colitis
- Myasthenia gravis
- Concomitant use of solid oral potassium chloride 1
Drug interactions to monitor:
- Digoxin (increased serum levels)
- Amantadine (increased glycopyrrolate effects)
- Atenolol or metformin (increased serum levels)
- Haloperidol or levodopa (decreased serum levels) 1
Glycopyrrolate has been used off-label in children under 3 years with a median starting dose of 0.065 mg/kg/day, though FDA approval is only for ages 3-16 years 6