Evaluation of glycopyrrolate in the treatment of chronic drooling

Abstract

Drooling is a major problem for children and adults with cerebral palsy and other neurological conditions. Medication is a major treatment option for these individuals. The focus of this review is to review glycopyrrolate, one of the frequently used medications for poor saliva control. Glycopyrrolate is a quaternary ammonium compound structurally related to atropine. The pharmacology, mode of action and pharmocokinetics are discussed, efficacy studies are reviewed, and safety and tolerability are described. Mention is made of the limited amount of information that is available on patient satisfaction and quality of life. Glycopyrrolate has an important place in the treatment of chronic drooling and possible uses for this medication are described. Further research would be helpful comparing glycopyrrolate with other anticholinergic medication and alternative treatments for drooling including botulinum toxins and surgical procedures. Keywords: dribbling, poor saliva control, cerebral palsy, Parkinson Disease Management issues for chronic severe droolingDrooling, sometimes known as dribbling or poor saliva control, is a distressing problem. Drooling may be odorous; the secretions can cause chronic irritation of the facial skin; dehydration can occur if severe; and excessive drooling may damage clothing, books, and computer equipment. The care required for the individual increases the demands on family members.1 Poor saliva control may result in loss of self esteem. It is a major factor in impeding the successful integration of children and young adults into school, the community, and later the workplace. For adults with neurological conditions such as Parkinson Disease, the impact can be distressing, and individuals that drool have more difficulties with eating, speaking, and with social interactions than individuals with the same condition that do not drool. 2Many factors influence salivary flow including emotional state, environmental temperature, state of hydration, and the presence of food in the mouth. Quantification of salivary flow rate or drooling is challenging. Therefore, few studies documenting prevalence of the condition are available. Drooling has been reported as occurring in between 10% and 78% of children with cerebral palsy, and in 38% of a recent population-based cohort of 385 children from the Victorian Cerebral Palsy Register (manuscript in preparation). It also occurs in many individuals with intellectual disability and in other more unusual neurological and head and neck conditions. 3 For those attending special education settings, the number may be higher and was reported to be present in 58% of children with cerebral palsy. 4 Poor saliva control also occurs in acquired neurological conditions including Parkinson Disease, where it is estimated

Saliva management options for difficult-to-wean people with tracheostomy following severe acquired brain injury (ABI): A review of the literature

“…For example, clonazepam, clobazam, clozapine, cholinesterase inhibitors and topiramate may increase saliva production [60,64]. Studies exploring pharmaceutical options for the management of saliva are summarized in Table II.…”

“…It has been used and studied extensively as a premedication to anaesthesia to reduce oral and airway secretions [60,64]. More recently it has been trialled in various studies for sialorrhoea, particularly in children with cerebral palsy.…”

“…More recently it has been trialled in various studies for sialorrhoea, particularly in children with cerebral palsy. Only one study is a randomized control trial [64], with a high dropout rate of 30% [61].…”

“…Reported side-effects of botulinum toxin injections have been reported which include pain, swelling and bleeding [64]. Additionally, dysphagia, altered speech and thickened saliva have been found [14,79,83].…”

Glycopyrrolate in comparison to hyoscine hydrobromide and placebo in the treatment of hypersalivation induced by clozapine (GOTHIC1): study protocol for a randomised controlled feasibility study

“…Glycopyrrolate is an anti-muscarinic with weak blood-brain-barrier penetration [11] and is used widely in the UK as a pre-anaesthetic agent because of its ability to decrease salivary production and gastric acid. It is commonly prescribed by paediatricians in the treatment of drooling in children with neurodevelopmental disorders [12].…”