From the Guidelines
To reduce saliva in palliative care, anticholinergic medications, such as glycopyrrolate, are the most effective option, as recommended by the most recent and highest quality study 1.
Common Drugs Used
The following are some of the common drugs used to reduce saliva in palliative care:
- Glycopyrrolate (0.2-0.4mg orally or subcutaneously every 4-6 hours)
- Hyoscine butylbromide (Buscopan, 10-20mg orally, subcutaneously or IV every 4-6 hours)
- Hyoscine hydrobromide (scopolamine) as patches (1-3 patches applied behind the ear every 72 hours) or as subcutaneous injections (0.2-0.4mg every 4-6 hours)
- Atropine drops (1% solution, 1-2 drops sublingually every 4-6 hours)
Administration and Monitoring
When administering these drugs, it is essential to monitor for common anticholinergic side effects, including dry mouth, blurred vision, urinary retention, and constipation 2. In patients with dementia or the elderly, it is recommended to start with lower doses to minimize confusion and other central nervous system effects.
Alternative Options
Other options, such as botulinum toxin (BT) therapy and radiation therapy (RT), may also be considered, but the evidence for these treatments is limited, and they should be reserved for experienced centers 1.
Key Considerations
The goal of treatment is to improve the patient's quality of life by reducing saliva and minimizing the risk of aspiration and pneumonia. The choice of medication and dosage should be individualized based on the patient's specific needs and medical history. Regular monitoring and adjustment of treatment are crucial to ensure optimal outcomes.
From the FDA Drug Label
Glycopyrrolate is a competitive inhibitor of acetylcholine receptors that are located on certain peripheral tissues, including salivary glands. Glycopyrrolate indirectly reduces the rate of salivation by preventing the stimulation of these receptors. Glycopyrrolate inhibits the action of acetylcholine on salivary glands thereby reducing the extent of salivation. Glycopyrrolate oral solution is used to reduce saliva in patients with neurologic conditions associated with problem drooling.
- Common drugs used for palliative care to reduce saliva include glycopyrrolate. The use of glycopyrrolate to reduce saliva is supported by its mechanism of action as a competitive inhibitor of acetylcholine receptors on salivary glands 3.
From the Research
Reducing Saliva in Palliative Care
- Sialorrhea, or excessive saliva production, is a common problem in patients with amyotrophic lateral sclerosis (ALS) and other conditions, and can be managed with various treatments 4, 5.
- Anticholinergic drugs, such as atropine, glycopyrrolate, amitriptyline, hyoscyamine, and transdermal scopolamine, are often used to reduce saliva production, but their effectiveness in patients with ALS is not well established 4.
- Other treatment options for sialorrhea include botulinum toxin injections, radiotherapy, and surgery, which may be considered when anticholinergic drugs are not effective 4, 5, 6.
Common Drugs Used to Reduce Saliva
- Hyoscine hydrobromide and glycopyrrolate are two anticholinergic drugs that have been compared in studies for their effectiveness in reducing death rattle, a symptom related to excessive saliva production 7, 8.
- A study found that hyoscine hydrobromide was more effective than glycopyrrolate in reducing death rattle at 30 minutes after administration, but there was no significant difference in improvement at 1 hour or at the last recorded score before death 8.
- Another study found that botulinum toxin B injections may produce participant-reported improvement in sialorrhea, and may reduce saliva production, but the evidence is of low certainty 6.
- Dextromethorphan with quinidine (DMQ) has also been shown to produce a participant-reported improvement in sialorrhea, with moderate-certainty evidence 6.
Treatment Options for Sialorrhea
- Botulinum toxin injections, radiotherapy, and surgery are treatment options for sialorrhea that may be considered when anticholinergic drugs are not effective 4, 5, 6.
- The choice of treatment for sialorrhea depends on the individual patient's needs and circumstances, and should be based on the best available evidence 5, 6.
- Further research is needed to establish the effectiveness of different treatments for sialorrhea, and to develop better measures for assessing the symptom and its impact on patients 6.