Sialorrhoea (excessive drooling) (1)

Excessive drooling of saliva is common in neurodegenerative disorders such as motor neurone disease (MND), Parkinson’s disease and multiple sclerosis. The cause is usually impaired swallowing of saliva rather than excessive saliva production.
Advice should be given on posture, diet and oral care.
For bed-bound patients, consider regular positional changes by carers/nursing staff with advice from a physiotherapist where necessary.
Referral with consent to a speech and language therapist should be considered for advice on swallowing techniques.
Consider a trial of an antimuscarinic agent for treatment for sialorrhoea:
- †glycopyrronium bromide – oral dose (as oral solution) 200 micrograms every 8 hours, titrated according to response and tolerability to 1mg every 8 hours. May be given via enteral feeding tube.
- †hyoscine hydrobromide 1mg/72 hour transdermal patch. If necessary, use 2 patches concurrently. Oral dose (tablets) 300micrograms up to three times daily.
- †amitripyline 10mg to 25mg at night.
- †atropine 1% eye drops may also be used, 4 drops on the tongue or sublingually, every 4 hours as required.
†Glycopyrronium should be used as first-line treatment in patients who have cognitive impairment, because it has fewer central nervous system side effects.
For subcutaneous administration, glycopyrronium or hysocine (as hysocine butylbromide) are preferred because of the lower incidence of central nervous system effects.
Medication to manage sialorrhoea may exacerbate dry mouth causing thickened secretions which may be more difficult to clear.
Where there is thick, tenacious saliva:
- review all current medicines, especially any treatment for sialorrheoea
- consider treatment with humidification, sodium chloride 0.9% nebulisers and carbocisteine
If treatment for sialorrhoea is not effective or not tolerated, consider referral to a palliative care specialist or the specialist team looking after the patient.