How do I treat hypersalivation?

Treatment of Hypersalivation (Excess Salivating)

For chronic severe drooling in neurologically impaired patients (ages 3-16), initiate glycopyrrolate oral solution starting at 0.02 mg/kg three times daily, titrating every 5-7 days up to 0.1 mg/kg three times daily based on response and tolerability. 1

Identify the Underlying Cause First

The treatment approach depends critically on whether hypersalivation results from true overproduction versus impaired clearance:

• Impaired clearance (pseudohypersalivation) is the most common mechanism in neurologically impaired patients and stroke survivors, caused by poor oral/pharyngeal muscle control and dysphagia 2, 3
• True overproduction occurs with cholinergic medications (clozapine, risperidone, bethanecol), organophosphate poisoning, or certain systemic conditions 4, 3
• Gastroesophageal reflux disease can present with increased salivation (water brash) as a subtle manifestation 3

Treatment Algorithm by Severity and Etiology

For Neurologically Impaired Patients with Chronic Severe Drooling

First-line pharmacologic therapy:

• Glycopyrrolate oral solution is FDA-approved for chronic severe drooling in patients aged 3-16 years with neurologic conditions 1
• Start at 0.02 mg/kg orally three times daily 1
• Titrate in increments of 0.02 mg/kg every 5-7 days based on therapeutic response and tolerability 1
• Maximum dose: 0.1 mg/kg three times daily, not exceeding 1.5-3 mg per dose based on weight 1
• Critical timing requirement: Administer at least one hour before or two hours after meals, as high-fat meals reduce bioavailability by 78% 1

Common dose-limiting adverse effects:

• Constipation is the most common reason for discontinuation—assess patients within 4-5 days of initial dosing or after dose increases 1
• Other frequent side effects include dry mouth, vomiting, flushing, and nasal congestion (incidence ≥30%) 1
• Use with caution in patients with renal impairment, as glycopyrrolate is largely renally eliminated 1

Alternative anticholinergic options:

• Scopolamine patches can be effective for controlling drooling 2, 4
• Atropine has been used but may have more central nervous system side effects 4
• Systemic anticholinergics often lead to limiting side effects including urinary retention, constipation, and cognitive impairment 5, 4

For Drug-Induced Hypersalivation

Stepwise management approach:

1. Adjust the causative medication if possible—reduce dose or split daily dosing according to patient response and medical history 4
2. Non-pharmacologic measures: Increase swallowing frequency with sugar-free chewing gum 4
3. Anticholinergic agents are most commonly used for symptomatic treatment, with atropine, glycopyrrolate, and scopolamine being equally described in the literature 4
4. Alternative agents with clinical effectiveness include:
   • Dopamine antagonists (amisulpride) 4
   • Alpha-2-adrenergic agonists (clonidine) 4
   • Terazosin, moclobemide, bupropion, or N-acetylcysteine 4

For Acute Life-Threatening Situations

Organophosphate/carbamate poisoning with hypersalivation:

• Atropine should be given immediately for severe poisoning with bronchorrhea and hypersalivation 6
• Atropine blocks parasympathetic overstimulation, mitigating bronchorrhea and other cholinergic excess symptoms 6
• Decontamination through removal of contaminated clothing and copious irrigation is essential 6

Procedural sedation with ketamine:

• Atropine or glycopyrrolate may be used prophylactically to prevent increased salivation during ketamine administration 6
• This is particularly important when ketamine is used for dissociative sedation/anesthesia 6

Botulinum Toxin Injections

For patients with inadequate response to medications or intolerable side effects:

• Ultrasound-guided botulinum toxin type A injection into the parotid and submandibular glands is safe and effective 2, 5
• Effects typically last at least 2 months, requiring repeat injections 2, 5
• This approach avoids systemic anticholinergic side effects 5
• Particularly useful in patients with progressive neuromuscular diseases and bulbar palsy 5

Surgical Options

Reserved for severe, refractory cases:

• Surgical interventions including salivary gland excision, salivary duct ligation, and duct rerouting provide the most effective and permanent treatment 2
• These procedures can greatly improve quality of life for patients and caregivers when conservative measures fail 2

Critical Clinical Pitfalls to Avoid

Do not overlook underlying causes:

• Always evaluate for esophageal obstruction (foreign body, cancer, stricture), infection, or gastroesophageal reflux disease before attributing hypersalivation solely to neurologic impairment 3
• Rule out heavy metal poisoning, Wilson disease, or infections in appropriate clinical contexts 3

Do not use glycopyrrolate in contraindicated conditions:

• Absolute contraindications include glaucoma, paralytic ileus, unstable cardiovascular status, severe ulcerative colitis, toxic megacolon, and myasthenia gravis 1
• Do not use concomitantly with solid oral potassium chloride formulations, as glycopyrrolate may arrest GI passage 1

Monitor for intestinal complications:

• Assess for constipation or intestinal pseudo-obstruction, which may present as abdominal distention, pain, nausea, or vomiting 1
• If incomplete mechanical intestinal obstruction is suspected (may present paradoxically as diarrhea), discontinue glycopyrrolate and evaluate immediately 1

Avoid high ambient temperatures:

• Anticholinergic medications impair sweating and thermoregulation, increasing risk of heat prostration 1

Multidisciplinary Team Approach

Treatment is best managed by a clinical team including primary care providers, speech pathologists, occupational therapists, dentists, orthodontists, neurologists, and otolaryngologists 2. Speech therapy for swallowing should be initiated when drooling is caused by poor oral or pharyngeal neuromuscular control 5.