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Amin SN, Patterson KT, Cvancara DJ, Dahl JP. Pediatric Salivary Gland Pathology. Oral Maxillofac Surg Clin North Am 2024; 36:317-332. [PMID: 38724422 DOI: 10.1016/j.coms.2024.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2024]
Abstract
Benign and malignant salivary gland disorders are uncommon in the pediatric population; however, these can be frequently seen in pediatric otolaryngology or oral and maxillofacial surgery practices. The astute clinician should be aware of the clinical presentation, diagnosis, and management options for common inflammatory, infectious, benign, and malignant disorders of salivary glands.
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Affiliation(s)
- Shaunak N Amin
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Box 356515 Health Sciences Building, Suite BB1165, Seattle, WA 98195-65, USA
| | - Kristopher T Patterson
- School of Medicine, University of Washington, Box 356515 Health Sciences Building, Suite BB1165, Seattle, WA 98195-65, USA
| | - David J Cvancara
- School of Medicine, University of Washington, Box 356515 Health Sciences Building, Suite BB1165, Seattle, WA 98195-65, USA
| | - John P Dahl
- Department of Otolaryngology-Head and Neck Surgery, University of Washington, Seattle, WA, USA; Division of Pediatric Otolaryngology-Head and Neck Surgery, Seattle Children's Hospital, Seattle, WA, USA.
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Parrot M, Yathavan B, Averin O, Hoggard L, Rower JE, Voight M, Greene D, Tarrell A, Whelan A, Ghandehari H, Murphy N, Yellepeddi V. Clinical pharmacokinetics of atropine oral gel formulation in healthy volunteers. Clin Transl Sci 2024; 17:e13753. [PMID: 38465519 PMCID: PMC10926053 DOI: 10.1111/cts.13753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 02/01/2024] [Accepted: 02/14/2024] [Indexed: 03/12/2024] Open
Abstract
Sialorrhea or drooling is a common problem in children and adults with neurodevelopmental disorders. It can negatively impact the quality of life due to its physical and psychological manifestations. Providers commonly prescribe atropine eye drops for topical administration to the oral mucosa, as an off-label treatment to manage sialorrhea. However, the off-label use of atropine eye drops can be associated with medication and dosing errors and systemic side effects. To address these limitations of treatment, we developed a mucoadhesive topical oral gel formulation of atropine as an alternative route to off-label administration of atropine eye drops. In this clinical pharmacokinetic (PK) study, we evaluated the safety and PK of atropine gel (0.01% w/w) formulation after single-dose administration to the oral mucosa in 10 healthy volunteers. The PK data showed that after topical administration to the oral mucosa, atropine followed a two-compartment PK profile. The maximum plasma concentration and area under the curve extrapolated to infinite time were 0.14 ng/mL and 0.74 h·ng·mL-1 , respectively. The absorption rate constant calculated by the compartmental analysis was 0.4 h-1 . Safety parameters, such as heart rate, blood pressure, and oxygen saturation, did not significantly change before and after administration of the gel formulation, and no adverse events were observed in all participants who received atropine gel. These data indicate that atropine gel formulation has a satisfactory PK profile, is well-tolerated at the dose studied, and can be further considered for clinical development as a drug product to treat sialorrhea.
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Affiliation(s)
- Madison Parrot
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Molecular Pharmaceutics, Utah Center for Nanomedicine, College of PharmacyUniversity of UtahSalt Lake CityUtahUSA
| | - Bhuvanesh Yathavan
- Department of Molecular Pharmaceutics, Utah Center for Nanomedicine, College of PharmacyUniversity of UtahSalt Lake CityUtahUSA
| | - Olga Averin
- Department of Pharmacology and Toxicology and Center for Human ToxicologyUniversity of UtahSalt Lake CityUtahUSA
| | - Logan Hoggard
- Department of Pharmacology and Toxicology and Center for Human ToxicologyUniversity of UtahSalt Lake CityUtahUSA
| | - Joseph E. Rower
- Department of Pharmacology and Toxicology and Center for Human ToxicologyUniversity of UtahSalt Lake CityUtahUSA
| | - Michael Voight
- Investigational Drug Service, Pharmacy Services, University of Utah HospitalSalt Lake CityUtahUSA
| | - Danielle Greene
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Ariel Tarrell
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Aviva Whelan
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUtahUSA
| | - Hamidreza Ghandehari
- Department of Molecular Pharmaceutics, Utah Center for Nanomedicine, College of PharmacyUniversity of UtahSalt Lake CityUtahUSA
| | - Nancy Murphy
- Division of Complex Care, Department of PediatricsUniversity of Utah HealthSalt Lake CityUtahUSA
| | - Venkata Yellepeddi
- Division of Clinical Pharmacology, Department of Pediatrics, Spencer Fox Eccles School of MedicineUniversity of UtahSalt Lake CityUtahUSA
- Department of Molecular Pharmaceutics, Utah Center for Nanomedicine, College of PharmacyUniversity of UtahSalt Lake CityUtahUSA
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Bradford CV, Parman AM, Johnson PN, Miller JL. Pharmacologic Management of Sialorrhea in Neonatal and Pediatric Patients. J Pediatr Pharmacol Ther 2024; 29:6-21. [PMID: 38332959 PMCID: PMC10849690 DOI: 10.5863/1551-6776-29.1.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/10/2023] [Indexed: 02/10/2024]
Abstract
Sialorrhea, defined as an excess flow of saliva or excessive secretions, is common in patients with cerebral palsy and other neurologic disorders and is associated with clinical complications such as increased risk of local skin reactions, infections, aspiration, pneumonia, and dehydration. Upon failure of non-pharmacologic measures, clinicians have several noninvasive pharmacologic options available to manage sialorrhea. This review of the literature provides detailed descriptions of medications used, efficacy, safety, and practical considerations for use of non-injectable pharmacologic agents. The literature search included published -human studies in the English language in PubMed and Google Scholar from 1997 to 2022. Relevant citations within articles were also screened. A total of 15 studies representing 719 pediatric patients were included. Glycopyrrolate, atropine, scopolamine, and trihexyphenidyl all have a potential role for sialorrhea management in children; however, glycopyrrolate remains the most studied option with 374 (n = 52.0%) of the 719 patients included in the systematic review receiving this medication. Overall, glycopyrrolate showed similar efficacy but higher tolerability than its comparators in 2 comparative studies and is often considered the first-line agent. Patient-specific (age, route of administration) and medication-specific (dosage formulation, medication strength) considerations must be weighed when initiating a new therapy or switching to another medication upon treatment failure. Owing to the high propensity of adverse events with all agents, clinicians should consider initiating doses at the lower end of the dosage range, as previous studies have noted a dose-dependent relationship.
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Affiliation(s)
- Caitlyn V. Bradford
- Department of Pharmacy Practice (CVB), Philadelphia College of Pharmacy at Saint Joseph’s University, Philadelphia, PA
| | - Avery M. Parman
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Peter N. Johnson
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
| | - Jamie L. Miller
- Department of Pharmacy, Clinical and Administrative Sciences (AMP, JLM, PNJ), University of Oklahoma College of Pharmacy, Oklahoma City, OK
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Petkus KD, Noritz G, Glader L. Examining the Role of Sublingual Atropine for the Treatment of Sialorrhea in Patients with Neurodevelopmental Disabilities: A Retrospective Review. J Clin Med 2023; 12:5238. [PMID: 37629280 PMCID: PMC10455410 DOI: 10.3390/jcm12165238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/04/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Sialorrhea is common in children with neurodevelopmental disabilities (NDD) and is reported in >40% of children with cerebral palsy (CP). It causes a range of complications, including significant respiratory morbidity. This single-center retrospective chart review aims to document sublingual atropine (SLA) utilization to guide further study in establishing its role in secretion management for children with NDD. A chart review was completed for patients with NDD ≤ 22 years of age treated with SLA at a free-standing children's hospital between 1 January 2016 and 1 June 2021. Descriptive statistics were generated to summarize findings. In total, 190 patients were identified, of which 178 met inclusion criteria. The average starting dose for SLA was 1.5 mg/day, or 0.09 mg/kg/day when adjusted for patient weight. Eighty-nine (50%) patients were prescribed SLA first line for secretion management while 85 (48%) patients tried glycopyrrolate prior to SLA. SLA was used after salivary Botox, ablation, and/or surgery in 16 (9%) patients. This study investigates SLA as a potential pharmacologic agent to treat sialorrhea in children with NDD. We identify a range of prescribing patterns regarding dosing, schedule, and place in therapy, highlighting the need for further evidence to support and guide its safe and efficacious use.
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Affiliation(s)
- Kayla Durkin Petkus
- Division of Complex Care, Nationwide Children’s Hospital, Columbus, OH 43205, USA; (G.N.); (L.G.)
- Department of Pharmacy, Nationwide Children’s Hospital, Columbus, OH 43205, USA
| | - Garey Noritz
- Division of Complex Care, Nationwide Children’s Hospital, Columbus, OH 43205, USA; (G.N.); (L.G.)
| | - Laurie Glader
- Division of Complex Care, Nationwide Children’s Hospital, Columbus, OH 43205, USA; (G.N.); (L.G.)
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Michelon H, Larabi IA, Lemoine J, Alvarez JC, Genevée A, Lillo-Lelouet A, Azouvi P, Lefèvre-Dognin C, Paquereau J. Atropine-induced toxicity after off-label sublingual administration of eyedrop for sialorrhoea treatment in neurological disabled patients. Br J Clin Pharmacol 2021; 87:3364-3369. [PMID: 33521988 DOI: 10.1111/bcp.14757] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 01/12/2021] [Accepted: 01/20/2021] [Indexed: 11/28/2022] Open
Abstract
Sialorrhea is a troublesome and disabling symptom defined by the unintentional loss of saliva from the mouth, usually associated with swallowing disorders. Today there is no consensus about the management of sialorrhoea, but off-label use of ophthalmic atropine eyedrop administered sublingually may offer benefits, despite limited safety data. We report 2 cases of atropine overdose after sublingual administration illustrating that atropine can expose to severe adverse effects when administered sublingually. The noncompartmental pharmacokinetic study of atropine performed in 1 patient highlighted that systemic absorption of sublingual atropine was effective (Cmax [1 h] = 2.2 ng mL-1 ; approximately) after a single dose of 1 mg.
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Affiliation(s)
- Hugues Michelon
- Service de Pharmacie, Hôpital Sainte-Périne, APHP. Université Paris-Saclay, Paris, France.,Service de Pharmacie, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France
| | - Islam Amine Larabi
- Service de Pharmacologie - Toxicologie, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France
| | - Jérôme Lemoine
- Unité de Soins de Rééducation Post-Réanimation, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France
| | - Jean-Claude Alvarez
- Service de Pharmacologie - Toxicologie, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France
| | - Anne Genevée
- Unité de Soins de Rééducation Post-Réanimation, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France
| | - Agnès Lillo-Lelouet
- Centre Régional de Pharmacovigilance de Paris, Hôpital Européen Georges Pompidou, AP-HP.Centre - Université de Paris, Paris, France
| | - Philippe Azouvi
- Unité de Soins de Rééducation Post-Réanimation, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France
| | - Clémence Lefèvre-Dognin
- Unité de Soins de Rééducation Post-Réanimation, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France.,Unité de Soins Prolongés Complexes, Hôpital Sainte-Périne, APHP. Université Paris-Saclay, Paris, France
| | - Julie Paquereau
- Unité de Soins de Rééducation Post-Réanimation, Hôpital Raymond Poincaré, APHP. Université Paris-Saclay, Garches, France
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