Am Fam Physician. 2005 May 15;71(10) Online.
to the editor: In their article, “Sialorrhea: A Management Challenge,”1 the authors advocate the use of glycopyrrolate tablets and scopolamine (Transderm Scop) topical patches for the treatment of sialorrhea. I propose that physicians also should consider two alternatives: low-dose atropine sulfate tablets and scopolamine hydrobromide tablets.
One study2 documented that oral administration of atropine reduced the amount of resting secretion, intraoral accumulation, and pharyngeal-laryngeal pooling of saliva by more than 50 percent of baseline levels, with negligible side effects. Another study3 demonstrated depression of salivation up to 80 percent in healthy adult patients taking oral atropine.
Atropine tablets reduce salivation in infants, children, and adults. The medication may be administered every four to six hours as needed. The average wholesale price of atropine tablets is approximately one third of the price of glycopyrrolate tablets.4
Scopolamine tablets may be administered every eight hours as needed. This medication warrants consideration as a substitute for the scopolamine patch because of its dosing flexibility, faster onset of action, shorter duration of action, and significantly lower cost.4,5
1. Hockstein NG, Samadi DS, Gendron K, Handler SD. Sialorrhea: a management challenge. Am Fam Physician 2004;69:2628-34.
2. Dworkin JP, Nadal JC. Nonsurgical treatment of drooling in a patient with closed head injury and severe dysarthria. Dysphagia 1991;6:40-9.
3. Murrin KR. A study of oral atropine in healthy adult subjects. Br J Anaesth 1973;45:475-80.
4. 2003 Drug Topics. Red Book. Montvale, NJ: Medical Economics Data, 2003.
5. Sherman CR. Motion sickness: review of causes and preventive strategies. J Travel Med 2002;9:251-6.
in reply: We appreciate Dr. Sherman’s insights into additional medical treatment options for sialorrhea and agree that a variety of preparations of anticholinergic medications may offer promising results. Unfortunately, study of the use of low-dose atropine sulfate tablets or scopolamine hydrobromide tablets for the treatment of sialorrhea is limited, especially in children.
Although oral anticholinergic medications are consistently reliable in their reduction of sialorrhea, side effect profiles frequently result in discontinuation of their use.1,2 A retrospective review and a prospective randomized trial of the use of transdermal scopolamine for the treatment of drooling demonstrate high efficacy and low toxicity.3,4
Dr. Sherman references a case report5 of the use of atropine to control sialorrhea in a patient with a closed head injury. The toxicities frequently associated with systemic anticholinergics may not have been apparent in this patient because of his underlying mental status. Dr. Sherman further indicates that oral atropine was demonstrated to reduce salivation by up to 80 percent in healthy adults; the applicability of this data to patients with pathologic sialorrhea has not been elucidated.6
Although there is potentially a variety of cost-effective, efficacious medications in the treatment of sialorrhea, further study is indicated.
1. Blasco PA, Stansbury JC. Glycopyrolate treatment of chronic drooling. Arch Pediatr Adolesc Med 1996;150:932-5.
2. Mier RJ, Bachrach SJ, Lakin RC, Barker T, Childs J, Moran M. Treatment of sialorrhea with glycopyrrolate: a double-blind, dose-ranging study. Arch Pediatr Adolesc Med 2000;154:1214-18.
3. Talmi YP, Finkelstein Y, Zohar Y. Reduction of salivary flow with transdermal scopolamine: a four-year experience. Otolaryngol Head Neck Surg 1990;103:615-8.
4. Lewis DW, Fontana C, Mehallick LK, Everett Y. Transdermal scopolamine for reduction of drooling in developmentally delayed children. Dev Med Child Neurol 1994;36:484-6.
5. Dworkin JP, Nadal JC. Nonsurgical treatment of drooling in a patient with closed head injury and severe dysarthria. Dysphagia 1991;6:40-9.
6. Murrin KR. A study of oral atropine in healthy adult subjects. Br J Anaesth 1973;45:475-80.
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