Table 1.
Comparison of pharmacological treatment classes commonly used in the management of sialorrhoea in MND, PD and stroke.
| Treatments | Licensed to treat sialorrhoea in adults? | Common or licensed dosage useda | Frequency of administration | Method of administration | Location of treatment delivery | Approximate annual cost of treatmentb | Main side effectsc | |
|---|---|---|---|---|---|---|---|---|
| Anticholinergic drugs | Hyoscine hydrobromide | No |
Hyoscine hydrobromide (1.5 mg patch):
1 patch every 72 h; if concerned about side effects start with ¼ or ½ patch; can be increased to 1½–2 patches if necessary Hyoscine hydrobromide (orally/via enteral feeding): 300 μg OD, increased every 2–3 days to 300 μg TDS Hyoscine butylbromide (subcutaneously): Subcutaneous injection: 20 mg every 4 h as required, increased as needed up to 20 mg every hour Subcutaneous infusion: 20–120 mg per 24 h |
2–3 times per day | Skin patches, oral tablets, or parenteral administration (subcutaneous injection or infusion)52 | Home | Skin patches: £195.20–£1561.56 [¼ patch (1.5 mg) –2 patches (1.5 mg) every 72 h] Not applicable Solution for injection: £637.73–£2550.91 (20 mg every 4 h to hourly) Not applicable |
Dry mouth, drowsiness, blurred vision, tachycardia, arrhythmias, flushing, constipation, urine retention, dizziness, skin reactions, confusion, hallucinations, irritation of the eyelids, dilated pupils, increased body temperature, increased fluid pressure inside the eye, and nausea53–57 |
| Atropine sulphate | No |
Atropine 1% eye drops (sublingual
administration):
1–2 drops OD; increased by 1 drop every 2 days, up to 2 drops QDS (as required and tolerated) |
3–6 times per day | Eye drops given sublingually52 | Home |
£480.08–£960.16
(1–2 mg OD) |
Dry mouth, drowsiness, blurred vision, tachycardia, arrhythmias, flushing, constipation, urine retention, hypotension, hallucinations, seizures, heart palpitations, difficulty swallowing and talking, nausea, vomiting, and confusion/delirium53,54,58,59 | |
| Glycopyrronium bromide | No | 200–500 μg TDS, increased in increments, as required and tolerated, up to 2 mg TDS | 2–3 times per day | Oral tablets or solution | Home | £986.44–£9864.40 (200 μg–2 mg TDS)d | Dry mouth, drowsiness, blurred vision, tachycardia, arrhythmias, flushing, constipation, urine retention vomiting, nasal congestion, headache, decreased sweating, dizziness, pupillary dilatation, and mental status changes53,54,60 | |
| Botulinum toxin injections | Serotype A | Yes, in the UK and the US (incobotulinumtoxinA only)e |
IncobotulinumtoxinA: 100 units (5 units/0.1 ml) per treatment session, given as 2 injections each into the parotid (30 units per side) and submandibular glands (20 units per side)61 | Every 16 weeks62 | Injection into the salivary glands | Clinical care setting |
£422.18
(100 units of incobotulinumtoxinA every 16 weeks) |
Pain at needle site, dry mouth, dysphagia, paraesthesia, viscous saliva, chewing weakness, tooth extraction, diarrhoea, hypertension, and respiratory infections61–63 |
| Serotype B | Yes, in the US | RimabotulinumtoxinB (NeuroBloc® or MyoBloc®, Sloan Pharma Sarl, Bertrange, Luxembourg): 1500–3500 units administered as 500–1500 units to per parotid gland and 250 units per submandibular gland64 | Every 12 weeks | Injection into the salivary glands | Clinical care setting |
£481.87
(1500 units every 12 weeks) £642.50 (3500 units every 12 weeks) |
Pain at needle site, dry mouth, viscous saliva, chewing weakness, dysphagia, dyspepsia, dental caries and respiratory infections64–66 | |
Dosages for licensed preparations within the treatment class are included for the treatment of sialorrhoea in adults, where no treatments are licensed within the treatment class, typical dosages (off label) used by clinicians are shown.
Costs reflect the UK NHS indicative price in the online British National Formulary 2019 (prices correct at the time of publication); annual costs have been calculated using the licensed dosage or the typical dosages used by clinicians.
Reported side effects associated with these pharmacological treatments.
Costs are derived from the British National Formulary for Children 2019 as the oral solution of glycopyrronium is currently only licensed for use in children.
Alternative BoNT-A products are available but as they are currently unlicensed, there is no confirmed posology available at present.
BoNT-A, botulinum toxin type A; MND, motor neuron disease; NHS, National Health Serveice; OD: once a day; PD, Parkinson’s disease; QDS: four times a day; TDS: three times a day.