Anticholinergic medications for reducing drooling in children with developmental disability

Abstract

DISDrooling Impact Scale AIM To determine: the effectiveness of three anticholinergic medications in reducing drooling in children with developmental disabilities (such as cerebral palsy, intellectual disability, and autism spectrum disorder), the frequency and nature of side effects, and their impact on treatment discontinuation.METHOD After prescription of benzhexol hydrochloride, glycopyrrolate, or scopolamine patches at a tertiary saliva control clinic, all carers of 110 consecutive, eligible patients were recruited over a 5-year period. They provided data for 52 weeks, or until drug discontinuation, on compliance, drooling, adverse effects, and reasons for cessation. We evaluated and compared best drooling response, side effects, and drug cessation rates using survival analysis, and the effect of baseline variables on the discontinuation rate using proportional hazards regression.RESULTS Among 110 participants (71 males, 39 females; mean age 8y 5mo [SD 4y 3mo], range 1y 11mo-18y 11mo), benzhexol, glycopyrrolate, and scopolamine were prescribed 81, 62, and 17 times respectively, with respective response rates of 85%, 75%, and 65%. Poor head control and poor oromotor function were predictive of poor response. Side effects frequently prompted drug cessation in males more than females (hazard ratio 1.8 [95% confidence interval 1.0-3.2], p=0.048). Glycopyrrolate had the fewest side effects.INTERPRETATION Benzhexol, glycopyrrolate, and scopolamine reduce drooling, but improvement is offset by adverse side effects. Overall, glycopyrrolate performs best.

Salivary gland ablation: introducing an interventional radiology treatment alternative in the management of sialorrhea

“…Behavioral intervention is time-intensive, often yielding only transient improvement [9]. Anticholinergic medications can be effective, but side effects commonly limit their use [10,11]. Surgical intervention for sialorrhea includes rerouting the submandibular gland ducts, ligating the submandibular ducts or parotid ducts, excising the submandibular glands and sublingual glands, and laryngotracheal separation.…”

“…Sialorrhea management usually begins conservatively with postural and behavioral modification and commonly includes anticholinergic medications such as glycopyrrolate, scopolamine and atropine [9]. These medications can be effective but have intolerable side effects for many; urinary retention, constipation and blurred vision are among the most severe [10,11]. When these therapies are ineffective or intolerable, botulinum toxin A (BoNT-A) may be injected into the submandibular and parotid glands to temporarily decrease saliva production.…”

Developing the evidence base for the management of drooling

“…Medications with significant anticholinergic properties are the usual first‐line drug therapy; commonly used preparations include scopolamine/hyoscine patches, benzhexol/trihexyphenidyl, atropine eye drops (administered sublingually), amitriptyline, and glycopyrronium. Choice as to which to use as first‐line therapy varies, but, as described by Reid et al., this appears to have more to do with local practice and formulary restrictions than any evidence as to efficacy. There is a tendency to select the easiest treatment (e.g.…”

“…However, there is increasing evidence that first‐line anticholinergic therapy should be glycopyrronium. In a number of studies, including the current one, glycopyrronium is the most effective anticholinergic treatment and has a much‐reduced side effect profile, in large part because it does not cross the blood–brain barrier …”

“…In a number of studies, including the current one, glycopyrronium is the most effective anticholinergic treatment and has a much-reduced side effect profile, in large part because it does not cross the bloodbrain barrier. 1,3 There have been few attempts to collect systematically prospective outcome data from patients receiving anticholinergic therapy. The choice of a patient reported outcome rather than an objective measure of saliva volume is welcome, as the latter has been shown to not correlate with the burden and impact of saliva related symptoms.…”