Warning - This article discusses the use of an anticholinergic drug. When treating those with Alzheimer's disease or Progressive Supranuclear Palsy (PSP) extreme caution should be shown since while the drug may appear to help the condition it is meant to treat, it can also block the action of the neurotransmitter acetylcholine which in these diseases may already be insufficient in quantity. This may lead to an overall long-term worsening of the disease -- especially how the disease affects the patient's memory.
Sialorrhea, or excessive drooling, is a problem for a considerable number of persons with cerebral palsy, intellectual disability, and other neurological conditions.[1] Unable to manage their oral secretions, affected persons are at increased risk of aspiration, skin maceration, and infection. Care may be compromised since the frequent suctioning and cleaning required to maintain proper hygiene can become very burdensome. Drooling also impedes social integration. Isolation is unfortunately common as saliva soils furniture, carpets, toys, and the clothing of peers, siblings, parents, and caregivers.[2] This article reviews the use of atropine sulfate to reduce salivation and help relieve the medical and social problems of drooling.
Saliva is produced by both the major and minor salivary glands. There are three pairs of major salivary glands: the parotid, submandibular, and sublingual glands. These glands produce approximately 1.5 liters of saliva daily: 70% is from the submandibular glands, 25% is from the parotid glands, and 5% is from the sublingual glands. Minor salivary glands located on the palate, buccal mucosa, and tongue also produce modest amounts of saliva.[3]
The secretory innervation of the salivary glands is primarily under the control of the parasympathetic nervous system.[4] Stimulation of the parasympathetic system causes profuse secretion of watery saliva.[5] Some persons are unable to swallow their saliva fast enough to prevent drooling. Excessive drooling is a distressing condition that can create significant hygienic and psychosocial problems.
Several factors predispose the development of sialorrhea. Incompetent control of orofacial, head, and neck musculature is common in patients with cerebral palsy cerebrovascular accidents, head injuries, mental retardation, motor neuron diseases, Parkinson's disease, and other neurologic disorders.
Nasal obstruction with mouth breathing, improper head posture, and severe dental malocclusion may also contribute to sialorrhea.[6] Adverse drug reactions involving tranquilizers, anticonvulsants, and anticholinesterases can aggravate sialorrhea by causing hypersecretion of saliva.[7]
Thorough dental and medical evaluations are important to determine the causes of sialorrhea. Is it because of increased production of saliva; inability to control mouth, lips, or throat muscles; physical abnormalities that impede the transport of saliva, or mental functioning below that required to learn to swallow?[8] Detailed evaluations can help answer this question. Counting the number of bibs or shirts soiled each day provides a subjective estimate of the severity of the condition. Physical findings such as skin maceration on the neck, chest, and hands due to dampness and constant wiping confirm initial impressions of severity and indicate the need for treatment.
The goal of treatment is to reduce drooling but maintain a moist, healthy oral cavity. To completely eliminate drooling risks the significant complication of xerostomia.[9] Available therapies include the use of anticholinergic drugs, speech therapy, prosthetic devices, behavioral therapy, biofeedback, radiation therapy, and a variety of surgical procedures. No single therapy has been documented to resolve sialorrhea satisfactorily in all patients. Rather, a combination of therapies that includes surgery is often required.[10]
The anticholinergic drug, atropine sulfate, has been shown to reduce by more than 50% of base line levels the amount of resting secretion, intraoral accumulation, and pharyngeal-laryngeal pooling of saliva.[11] The drug is a competitive antagonist of the muscarinic actions of acetylcholine. It does not prevent the release of acetylcholine but antagonizes the effect of this neurotransmitter on the effector cells.
This action results in drying of the mouth through reduction of salivary gland secretions.[12] Atropine-induced inhibition of salivation occurs within 30 minutes to one hour. Inhibition peaks within two hours after oral administration but can persist for up to four hours. The usual oral dose for adults is 0.4 mg every 4 to 6 hours. In children, the suggested dose is 0.01 mg/kg, but generally not exceeding 0.4 mg every 4 to 6 hours.[13]
The drug is well absorbed from the small intestine. Following oral administration of a single radiolabeled 2 mg dose in healthy fasting adults, about 90% of the dose was absorbed. Peak plasma concentrations occur within one hour. The plasma half-life for atropine sulfate is about 2.5 hours. The drug is metabolized by the liver and excreted by the kidney.(14)
Salivary secretions are generally inhibited at doses lower than those required to affect other organs.[15,16] Nevertheless, one must be aware of a variety of potential adverse effects. These include vasodilation; drying of the mouth; inhibition of contractions of the gastrointestinal tract, ureter, and bladder; reduction of bronchial, gastric, and sweat gland secretions. In addition, the drug may cause dilation of the pupils (mydriasis); paralysis of accommodation (cycloplegia); and in patients with narrow angle glaucoma, increase intraocular pressure.[17]
Atropine sulfate can also affect the heart by altering its rate. Rate often decreases by about 4 to 8 beats per minute after ingestion of an average clinical dose (0.4 mg). There are no accompanying changes in blood pressure or cardiac output. Larger doses, however, cause progressively increasing tachycardia by blocking vagal effects on the SA nodal pacemaker.[18] Because of these potential side effects, atropine sulfate is contraindicated in patients with asthma, glaucoma, or synechia (adhesions) between the iris and lens of the eye.[19]
Prudent drug therapy necessitates prescribing the lowest effective dose to minimize the risk of adverse reactions. Atropine sulfate may be perscribed as a component of a comprehensive treatment plan that incorporates several specialties. The drug's relatively short half-life adds significant flexibility to the treatment plan. Doses can be customized to reflect the varying needs of each patient at different times throughout the day. Doses may also be titrated easily to respond to gradual changes in disease severity that occur over longer periods of time. Used in this manner, atropine sulfate can be very useful in treatment intended to maintain consistent control of salivation.
In summary, sialorrhea is a frequent problem in persons with neurologic disabilities that impair orofacial control. Serious medical and psychosocial problems may result. Used in combination with other treatment modalities, drug therapy with atropine sulfate may help provide consistent control of salivation to improve hygiene and self-esteem.
Low dose atropine sulfate (SAL-TROPINE 0.4 mg tablets) was recently documented to be an effective conservative treatment for drooling.
In addition to stigmatizing social effects, drooling can macerate the skin around the mouth and chin, cause foul odors, and soil clothing and furnature. Severe droolers are at risk for laryngeal irritation, aspiration pneumonia, and depletion of body fluids.
Treatment should substantially reduce the effects of drooling without adding new clinically significant symptoms.
Atropine sulfate was recently reported "unequivocally beneficial" because it reduced by more than 50% of baseline levels the amount of resting secretion, intraoral accumulation, and pharyngeal-laryngeal pooling of saliva. Reported side effects were "negligible" because therapy was initiated with conservative doses and gradually increased as tolerated to prevent complaints of excessive intraoral dryness.
Reduced secretion afforded easier and more successful attempts at swallowing residual saliva.
Atropine sulfate is available as SAL-TROPINE 0.4 mg tablets. Please review the prescribing information which includes dosage guidelines for infants, children, and adults. Tablets are soluble and have no taste to facilitate administration to small children. Doses are adjusted according to weight and can be administered every 4 to 6 hours or as needed.
SAL-TROPINE is available by prescription through pharmacies nationwide. A trial regimen with gradual dosage increments as needed and tolerated warrants consideration as part of a comprehensive treatment plan. Please consider SAL-TROPINE as your means to control drooling.
Please print these pages, including the Prescribing Information, to share with your physician when considering a prescription for SAL-TROPINE.
SAL-TROPINE: Doses Adjusted According to Weight. Every 4 to 6 Hours As Needed.
By Prescription Only
Please see Prescribing Information for complete warnings, precautions, and indications for use.
Review Article: Drug Therapy with Atropine Sulfate for the Treatment of Sialorrhea
Other Reference: Dysphagia 6: 40-49 (1991).
