Management of Drooling in Parkinson’s disease

• Background
• Non-Pharmacological Options
• Pharmacological Treatment Options

Background

Saliva plays a vital role in facilitating swallowing, speaking and maintaining oral health. Inability to control oral secretions is known formally as ‘sialorrhea’ and informally as ‘drooling’. It leads to excessive saliva accumulation - it is not an issue with overproduction of saliva.

In Parkinson’s disease, this may be due oro-facial rigidity, lingual bradykinesia and aspects of oro-pharyngeal dysphagia.  Drooling can have a distressing impact and lead to reduced social interactions through embarrassment, oral odour as well as clinical issues such as skin breakdown, aspiration and infection.

Early intervention, even when symptoms are not unduly bothersome should be considered to prevent potential complications. Severity should be assessed, and the need for treatment to be established.

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Non-Pharmacological Options

On the recommendation of Speech and Language Therapist (SLT)

• Attention to posture (e.g. raising eye level of reading material/computer screens, activities that require leaning forward)
• Support collars
• Boiled sweets/chewing gum (if eating IDDSI Level 7 Regular foods - use with caution as can also exacerbate the accumulation and production)
• Frequently sipping drinks  
• Swallow prompts (e.g. apps (https://speechtools.co/swallow-prompt), timers, verbal reminder from a companion)
• Sage (tea, tincture, capsules)
• Dark grape juice
• Suction
• Surgical intervention (including radiotherapy and salivary gland removal)
• Avoiding acidic foods/fruits
• Avoiding alcohol

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Pharmacological Treatment Options

Factors to consider prior to initiating pharmacological therapy include:

• past medical history - some therapies are contraindicated or advised to use with caution in certain conditions (e.g. glaucoma, urinary retention, cardiovascular disorders, dementia)  
• current medication and allergy status - patients already taking medicines with anti-muscarinic effects. Where clinically appropriate consider titrating the dose of existing therapy before initiating any of the following options
• consider how long pharmacological therapy is needed. E.g. if short-term consider oral or sublingual treatment options
• as always involve patient in the decision-making

For all therapies, use the minimum effective dose to manage symptoms and monitor closely for reduce potential for anti-cholinergic (e.g. dry mouth, blurred vision, confusion, constipation, urinary retention). Patients started on an individual therapy should have a review of efficacy/adverse effects at 5 to 7 days after a dose change, or at a frequency decided on an individual basis.

Xeomin (Clostridium Botulinum neurotoxin type A)
Licensed for symptomatic treatment of chronic sialorrhea due to neurological disorders
Not interchangeable with other Botulinum toxin type A preparations

For further information refer to the Summary of Product Characteristics:
https://www.medicines.org.uk/emc/search?q=%22Xeomin%22   

Administration:

• reconstitute with sodium chloride 0.9 % solution for injection in accordance with good clinical practice guidelines
• repeat doses a minimum of every 16 weeks
• may be considered first line in long term patients or where multiple daily dosing could be a problem/patient unable to administer the dose of liquid/drops.

Atropine 1% drops sublingually

• The only available preparation is in the form of eye drops - please take care when prescribing and educating patient/carer., as this is an un-licensed use of a licensed medicine.
• Administer: sublingually (under the tongue – note this is an unlicensed use)
• Starting dose: 1 drop twice a day  (increasing to 1 drop four times a day - liaise with pharmacy)
• Patients may experience a bitter taste and patients with limited dexterity may struggle with self-administration
• Caution if patient has any cardiac co-morbidities, as systemic absorption may occur.
• For further information refer to the Summary of Product Characteristics: https://www.medicines.org.uk/emc/product/3297/smpc

Glycopyrronium bromide

• Has a long duration of action and less likely to cause central or cardiac –related adverse effects
• Glycopyrronium bromide 400micorgrams/mL  (Sialanar®) oral solution, for use in patients with dysphagia and/or an enteral tube in situ.
• For further information refer to the Summary of Product Characteristics:
  https://www.medicines.org.uk/emc/product/2301
• Still monitor closely for anticholinergic effects but does not cross the blood brain barrier, so less likely to cause central nervous system anti-muscarinic effects.

Palliative / EOL
See LTHT guidance - A Guide to Symptom Management in Palliative Care:
http://nww.lhp.leedsth.nhs.uk/common/guidelines/other_versions/405.pdf