Use of glycopyrrolate and other anticholinergic medications for sialorrhea in children with cerebral palsy

Facial Edema Induced by Glycopyrrolate in a Patient With Metastatic Tongue Cancer: A Case Report

Glycopyrrolate, an anticholinergic medication, is commonly used for managing excessive secretions in palliative care, especially in patients with advanced head and neck cancers. However, its side effect profile, particularly in complex oncological cases, is not fully understood. This case report presents a 62-year-old male with metastatic squamous cell carcinoma (SCC) of the tongue, who was managed in a palliative care setting. Glycopyrrolate 0.2 mg subcutaneously (SC) or intravenously (IV) every six hours was initiated to control chest secretions. While the patient showed initial symptomatic improvement, he subsequently developed significant and unexpected facial edema extending to both lower eyelids. The edema did not respond to antibiotics or corticosteroids and only improved after discontinuation of glycopyrrolate, suggesting a potential adverse reaction, although the advanced stage of his illness may have also contributed to the development of edema. This case underscores the importance of monitoring for rare adverse effects like facial edema when using glycopyrrolate, particularly in patients with advanced metastatic cancers. Further research is warranted to explore the underlying mechanisms of this reaction and guide safer clinical practice.

The when, why, and how of using glycopyrronium to diminish drooling in children with neurodevelopmental disabilities: Implications for clinical practice

BACKGROUND

Despite the established efficacy of glycopyrronium bromide in reducing drooling among children with neurodevelopmental disabilities, evidence on its impact on the daily lives of children and parents and effectiveness in a real-world setting are scarce, especially among long-term users. This study explored timing and duration of glycopyrronium treatment, effect and impact on daily life, and occurrence of side effects to inform clinical practice.

METHODS

This was a retrospective cohort study at a national referral centre for drooling, including 61 children with nonprogressive neurodevelopmental disabilities, treated with glycopyrronium for anterior and/or posterior drooling between 2011 and 2021. Data were obtained from medical records and supplemented by structured telephone interviews with parents.

RESULTS

Anterior drooling severity decreased in 82% of the included children. Changes in the impact of drooling on burden of care, social interaction, and self-esteem were reported in 55%, 31%, and 36%, respectively. Side effects were noted for 71% of cases, yet only 36% of parents deemed these as outweighing the positive impact of treatment. A substantial majority (77%) of the included children were long-term users (≥6 months). Among these, 38% of parents reported decreasing effectiveness and 27% noticed more prominent side effects over time.

CONCLUSIONS

Glycopyrronium demonstrated potential in mitigating the impact of drooling on daily life, although variations were observed in the specific aspects and extent of improvement. The real-world context of our study provides important insights for refining clinical practices, emphasizing the need for balanced consideration of treatment benefits and potential side effects to facilitate shared decision-making.

Botulinum neurotoxin type A in the interdisciplinary treatment of sialorrhea in adults and children-update and practice recommendations

Sialorrhea is defined as a chronic excessive flow of saliva from the mouth, often with adverse consequences for health and quality of life of patients. In addition to currently used non-drug treatment and systemic drugs, intraglandular Botulinum Neurotoxin A (BoNT/A) injections have been examined in case studies, controlled trials and clinical practice. Two pivotal Phase III trials recently led to market approval in the USA and EU for IncobotulinumtoxinA [Xeomin®, IncoBoNT/A, Clostridium botulinum neurotoxin type A (150 kD), free from complexing proteins, Merz Pharmaceuticals GmbH] for treatment of chronic sialorrhea in adults and pediatric patients. This review provides a multidisciplinary approach to discuss the current state of sialorrhea therapy as well as benefits and current limitations of BoNT/A injections. A consensus regarding treatment recommendations made available to physicians in Germany in 2022 has now been updated here for presentation to an international audience. This review provides a framework including a flow chart for patient selection, recommendations for dosing and the injection process, as well as a discussion of therapeutic goals, long-term benefits and safety aspects. This review is aimed at supporting physicians in developing multidisciplinary and individualized treatment approaches to achieve optimal benefits for patients.

Sanfilippo syndrome: consensus guidelines for clinical care

Sanfilippo syndrome is a group of rare, complex, and progressive neurodegenerative lysosomal storage disorders that is characterized by childhood dementia. The clinical management of patients with progressive neurological decline and multisystem involvement requires a multidisciplinary team with experience in the management of neurodegenerative disorders. Best practice guidelines for the clinical management of patients with these types of rare disorders are critical to ensure prompt diagnosis and initiation of appropriate care. However, there are no published standard global clinical care guidelines for patients with Sanfilippo syndrome. To address this, a literature review was conducted to evaluate the current evidence base and to identify evidence gaps. The findings were reviewed by an international steering committee composed of clinical experts with extensive experience in managing patients with Sanfilippo syndrome. The goal was to create a consensus set of basic clinical guidelines that will be accessible to and informed by clinicians globally, as well as providing a practical resource for families to share with their local care team who may not have experience with this rare disease. This review distills 178 guideline statements into an easily digestible document that provides evidence-based, expert-led recommendations for how to approach common management challenges and appropriate monitoring schedules in the care of patients with Sanfilippo syndrome.

Anticholinergic treatment for sialorrhea in children: A systematic review

Background

Sialorrhea in children can be associated with adverse physical and social effects. Treatment using anticholinergic medications has been shown to offer symptomatic relief, but there is no consensus regarding which treatment is the most efficacious.

Objective

To examine the effectiveness of anticholinergic medications for sialorrhea in children.

Methods

A systematic review was carried out in Medline, EMBASE, Cochrane, Scopus, and the Web of Science from inception until April 29, 2020. Studies reporting original data on the efficacy of anticholinergic medications in the management of sialorrhea in children aged 0 to 17 years of age were included. This review adhered to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) standards. Data on study design, setting, population, pharmacologic intervention(s), comparator(s), outcomes, and results were extracted and summarized.

Results

The search strategy identified 2,800 studies of which 27 articles were included in the synthesis, including five randomized controlled trials. Each anticholinergic undergoing experimental study (glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine) showed evidence of efficacy. Adverse side effects were common. Significant heterogeneity exists in the studies' methodology and the variability of outcome measures used between studies precluded a meta-analysis.

Conclusions

Glycopyrrolate, scopolamine/hyoscine, trihexyphenidyl/benzhexol, benztropine, and atropine have all shown efficacy in the treatment of sialorrhea in children. The small number of reports and the variability in study design precluded a meta-analysis. More studies are needed with uniformity in outcome measures to help guide evidence-based decision making. A guidance table is presented.

[Therapy of Sialorrhea with Botulinum Toxin - An Update]

The most important salivary glands are the paired parotid and submandibular glands. Adults produce 1 to 1.5 liters of saliva which are then regularly swallowed. When the act of swallowing is disturbed, salivation occurs. More rarely, the cause can be found in increased saliva production, for example, when caused through medication. Sialorrhea impairs the quality of life substantially and is frequently often socially stigmatizing. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, as well as, in selected cases, radiation and surgical measures. Over the last 20 years, local injection of botulinum toxin has been successfully applied in the treatment of this condition. With approval of incobotulinumtoxinA toxin for children and adults, this procedure will become the therapy of choice for chronic sialorrhea. The results of the phase III registration trials have demonstrated high efficacy and good safety of the injection treatment in both children and adults.

Glycopyrrolate for drooling in children with medical complexity under three years of age

Background

The aim of the study is to determine that Glycopirrolate is safe and effective in decreasing drooling in children with medical complexity under 3 years of age. Medical treatment is based on anticholinergic drugs as transdermal scopolamine, benzotropine and GLY. GLY (Glycopyrronium bromide) is a synthetic quaternary ammonium anticholinergic agent with poor blood–brain barrier penetration and consequently has limited central effects. Actually, the oral GLY formulation was approved by the United States Food and Drug Administration (FDA) to treat drooling in children aged 3–16 years. Five studies reported on GLY use for the treatment of drooling in children with cerebral palsy and other conditions with neurological impairment; four are prospective studies while one a retrospective review.

Methods

this is a case report of eighteen children (sex ratio 11/8, median age 17 months, range 2–36 months) under three years of age, followed by a multidisciplinary team at the Bambino Gesù Children Hospital. The median follow-up was of 31.5 months (range 1–69 months). Response to treatment was assessed according to the Drooling Impact Scale administered at time 0 and after 1 month. All patients have an important neurological impairment: nine patients have a cerebral palsy (Gross Motor Function Classification System class V) and nine a genetic/malformative syndrome. Twelve patients have a tracheostomy and two need mechanical ventilation. Gastrostomy is present in 16 out of 18 patients. All patients received Glycopirrolate. The median starting daily dose was 0.065 mg/kg/die (range 0.02–0.21 mg/kg/die) three times a day. The drooling impact scale was administered at time O and after 1 month.

Results

Four out 18 patients stopped treatment for adverse event, lack of efficacy or parental decision. The mean Drooling Impact Scale at time 0 was 89 (range 81–100) and after 1 month 61(range 43–78); the difference was statistically significant (P < 0.001). The overall response to treatment was 94%.

Conclusions

This is the first study to determine the safety and effectiveness of Glycopyrrolate in decreasing drooling in a specific subset of patients. No major side effects were observed. Further comparative studies are needed to confirm our results.

Medication Order Errors at Hospital Admission Among Children With Medical Complexity

OBJECTIVES

We sought to characterize the nature and prevalence of medication order errors (MOEs) occurring at hospital admission for children with medical complexity (CMC), as well as identify the demographic and clinical risk factors for CMC experiencing MOEs.

METHODS

Prospective cohort study of 1233 hospitalizations for CMC from November 1, 2015, to October 31, 2016, at 2 children's hospitals. Medication order errors at admission were identified prospectively by nurse practitioners and a pharmacist through direct patient care. The primary outcome was presence of at least one MOE at hospital admission. Statistical methods used included χ2 test, Fisher exact tests, and generalized linear mixed models.

RESULTS

Overall, 6.1% (n = 75) of hospitalizations had ≥1 MOE occurring at admission, representing 112 total identified MOEs. The most common MOEs were incorrect dose (41.1%) and omitted medication (34.8%). Baclofen and clobazam were the medications most commonly associated with MOEs. In bivariable analyses, MOEs at admission varied significantly by age, assistance with medical technology, and numbers of complex chronic conditions and medications (P < 0.05). In multivariable analysis, patients receiving baclofen had the highest adjusted odds of MOEs at admission (odds ratio, 2.2 [95% confidence interval, 1.2-3.8]).

CONCLUSIONS

Results from this study suggest that MOEs are common for CMC at hospital admission. Children receiving baclofen are at significant risk of experiencing MOEs, even when orders for baclofen are correct. Several limitations of this study suggest possible undercounting of MOEs during the study period. Further investigation of medication reconciliation processes for CMC receiving multiple chronic, home medications is needed to develop effective strategies for reducing MOEs in this vulnerable population.

Cumulative Efficacy of Longitudinal Repeat Salivary Gland OnabotulinumtoxinA Injection: A Retrospective Study

AIM

We hypothesized that repeat onabotulinumtoxinA (BTX-A) injections to salivary glands would have a cumulative effect on drooling, leading to prolonged efficacy duration.

METHODS

We retrospectively reviewed medical records and conducted a telephone survey of individuals treated with BTX-A to the salivary glands to investigate ongoing efficacy or adverse effects. Outcome measures were duration of decrease in drooling and adverse events. The main independent variable was the number of injections. We identified 52 consecutive individuals (26 females) with cerebral palsy with an average age of 9 yrs, 3 mos ± 5 yrs 2 mos, who had received BTX-A for sialorrhea.

RESULTS

Linear regression analysis showed that each additional injection resulted in the duration of efficacy being 0.68 mos longer (P < 0.001, R2 = 0.47). Age, sex, Gross Motor Function Classification System level, presence of tube feeding, presence of tracheostomy, gastroesophageal reflex, seizures, and concurrent intramuscular injections seizures were not significant contributors to the association between injection number and efficacy duration (F (6, 45) = 1.01, P = 0.431).

INTERPRETATION

There may be a cumulative effect of BTX-A injections to the salivary glands, resulting in longer periods of efficacy with consecutive injection.

Exploring treatments for drooling in children with neurological disorders

Introduction: Drooling represents a major problem in the every-day life of pediatric patients with neurological disorders. The significant burden, both physical and socio-psychological, of the disorder requires adequate clinical evaluation and proper management. However, treating drooling remains a challenge for clinicians. This is a review of the most up-to-date therapeutic options for the treatment of drooling in the pediatric population, hence both conservative, pharmacological, and surgical approaches are discussed. Areas covered: Randomized clinical trials (RCTs), structured reviews, and case reports are included. Special focus is paid on the methods used to evaluate the efficacy and safety outcomes in the selected RCTs, trying to promote the use of more validated scales to assess drooling in the future. Expert opinion: The lack of reliable metrics to assess efficacy and safety outcomes in drooling limits researchers from identifying the best patient-suitable treatment. The relatively small number of clinical trials carried out over the last two decades is also due to the difficulty in assessing drooling using subjective scales. A key enabler for new efficient therapies stands in the introduction of accurate and robust metrics to measure treatment effectiveness on drooling.

Secretion Management in Tracheostomized Infants using Unconventional Approaches and Outcomes: A Case Series

OBJECTIVE

This study aimed to increase the understanding of secretion management in infants with tracheostomies. In this case series, we describe objective evidence for an unconventional approach in infants refractory to conventional management techniques.

STUDY DESIGN

Case study of two NICU infants utilizing high-resolution manometry was undertaken using personalized oral stimulation protocols with fruity foods.

RESULTS

Oral stimulation improved infant swallowing to clear secretions and reduce the need for suctioning.

CONCLUSION

Innovative oral stimulation protocols are needed to improve swallowing in high-risk infants.

Evaluation and Management of Respiratory Illness in Children With Cerebral Palsy

Cerebral palsy (CP) is the most common cause of disability in childhood. Respiratory illness is the most common cause of mortality, morbidity, and poor quality of life in the most severely affected children. Respiratory illness is caused by multiple and combined factors. This review describes these factors and discusses assessments and treatments. Oropharyngeal dysphagia causes pulmonary aspiration of food, drink, and saliva. Speech pathology assessments evaluate safety and adequacy of nutritional intake. Management is holistic and may include dental care, and interventions to improve nutritional intake, and ease, and efficiency of feeding. Behavioral, medical, and surgical approaches to drooling aim to reduce salivary aspiration. Gastrointestinal dysfunction, leading to aspiration from reflux, should be assessed objectively, and may be managed by lifestyle changes, medications, or surgical interventions. The motor disorder that defines cerebral palsy may impair fitness, breathing mechanics, effective coughing, and cause scoliosis in individuals with severe impairments; therefore, interventions should maximize physical, musculoskeletal functions. Airway clearance techniques help to clear secretions. Upper airway obstruction may be treated with medications and/or surgery. Malnutrition leads to poor general health and susceptibility to infection, and improved nutritional intake may improve not only respiratory health but also constipation, gastroesophageal reflux, and participation in activities. There is some evidence that children with CP carry pathogenic bacteria. Prophylactic antibiotics may be considered for children with recurrent exacerbations. Uncontrolled seizures place children with CP at risk of respiratory illness by increasing their risk of salivary aspiration; therefore optimal control of epilepsy may reduce respiratory illness. Respiratory illnesses in children with CP are sometimes diagnosed as asthma; a short trial of asthma medications may be considered, but should be discontinued if ineffective. Overall, management of respiratory illness in children with CP is complex and needs well-coordinated multidisciplinary teams who communicate clearly with families. Regular immunizations, including annual influenza vaccination, should be encouraged, as well as good oral hygiene. Treatments should aim to improve quality of life for children and families and reduce burden of care for carers.

Anticholinergic medications for reducing drooling in children with developmental disability

AIM

To determine: the effectiveness of three anticholinergic medications in reducing drooling in children with developmental disabilities (such as cerebral palsy, intellectual disability, and autism spectrum disorder), the frequency and nature of side effects, and their impact on treatment discontinuation.

METHOD

After prescription of benzhexol hydrochloride, glycopyrrolate, or scopolamine patches at a tertiary saliva control clinic, all carers of 110 consecutive, eligible patients were recruited over a 5-year period. They provided data for 52 weeks, or until drug discontinuation, on compliance, drooling, adverse effects, and reasons for cessation. We evaluated and compared best drooling response, side effects, and drug cessation rates using survival analysis, and the effect of baseline variables on the discontinuation rate using proportional hazards regression.

RESULTS

Among 110 participants (71 males, 39 females; mean age 8y 5mo [SD 4y 3mo], range 1y 11mo-18y 11mo), benzhexol, glycopyrrolate, and scopolamine were prescribed 81, 62, and 17 times respectively, with respective response rates of 85%, 75%, and 65%. Poor head control and poor oromotor function were predictive of poor response. Side effects frequently prompted drug cessation in males more than females (hazard ratio 1.8 [95% confidence interval 1.0-3.2], p=0.048). Glycopyrrolate had the fewest side effects.

INTERPRETATION

Benzhexol, glycopyrrolate, and scopolamine reduce drooling, but improvement is offset by adverse side effects. Overall, glycopyrrolate performs best.

WHAT THIS PAPER ADDS

In drooling, glycopyrrolate produced the greatest improvement with fewer side effects compared with benzhexol and scopolamine. Poor head control and poor oromotor function were associated with poor response. Medication side effects were common and often led to treatment discontinuation. Behavioural issues instigated cessation of benzhexol more often in males than females.

Therapy of Sialorrhea with Botulinum Neurotoxin

Botulinum neurotoxin (BoNT) is considered the treatment of choice for various symptoms and diseases such as focal dystonia and focal spasticity. The effects of BoNT on the salivary glands have also been known for years, but their use was limited because of a lack of approval studies. Now the indication of sialorrhea is approved in some countries for incobotulinumtoxinA, such as the USA and Europe, and therapy could also become the treatment of choice. According to the pivotal study, a dose of 100 units of incobotulinumtoxinA, which is divided into the parotid and submandibular glands, is recommended. RimabotulinumtoxinB is approved in the USA only. To define the value of this therapy, we must consider anatomy, physiology, and available therapies. Therapy includes conservative measures such as functional dysphagia therapy, oral or transdermal application of anticholinergics, and, in selected cases, radiotherapy and surgical procedures. A combination of different approaches is optional. On the basis of the evidence and clinical experience, BoNT injections will be the first line of pharmacotherapy for chronic sialorrhea.

Pharmacology, toxicology and clinical safety of glycopyrrolate

The clinical use of the anticholinergic glycopyrrolate dates back to the early 1960s when it was first approved in the U.S. Since then, oral and inhalation formulations have been developed as therapeutic agents inhibiting the muscarinic acetylcholine receptor in various indications including chronic obstructive pulmonary disease (COPD), excessive salivation, and peptic ulcers. More recently, topical formulations of glycopyrrolate (GPB, also known as glycopyrronium bromide) have gained interest as a treatment option for excessive sweating (hyperhidrosis). The U.S. Food and Drug Administration (FDA) approved the first topical glycopyrronium product for the treatment of hyperhidrosis in 2018. Glycopyrrolate, as a quaternary amine, shows minimal penetration of the blood brain barrier which limits CNS side effects. In addition, lack of phototoxicity, genotoxicity and carcinogenicity makes it suitable for chronic indications. The information on the nonclinical and clinical safety profile of glycopyrronium supporting various therapeutically approved uses has been obtained from published literature, our own data as well as summary documents issued by regulatory bodies. Collectively, these data support the conclusion that the benefits of glycopyrronium generally outweigh the risks in chronic use indications that require muscarinic receptor antagonism to provide therapeutic effects.

Safety of combined salivary gland and multilevel intramuscular onabotulinumtoxinA injections with and without ethanol in pediatric patients with cerebral palsy: A retrospective study

OBJECTIVE

To evaluate the safety of combining salivary gland onabotulinumtoxinA (BTX-A) injections for sialorrhea with intramuscular BTX-A injections for spasticity in the same procedure.

DESIGN

A retrospective cohort study in a tertiary hospital center. Patients selected were younger than 20 years, diagnosed with cerebral palsy, and received their first salivary gland BTX-A injection between March 2011 and July 2015. Chart review and telephone interviews were performed. The primary outcome measure was the rate of adverse events after combined BTX-A injections into salivary glands and muscles. The secondary outcome measure was the efficacy of injections, as reported by patients.

RESULTS

Twenty-five of the 52 selected patients received salivary gland BTX-A injections only, and 27 received concurrent salivary gland and multi-level intramuscular chemodenervation with BTX-A with or without alcohol. The rate of adverse events was < 10% in both groups; 4% in "Salivary Only Group" and 7% in the "Salivary + Multilevel Intramuscular Chemodenervation with BTX-A group (with or without alcohol)". Both approaches were equally effective in meeting their goals of salivary injections (> 50% improvement for at least two months). In the "salivary only" and in the "salivary + multi-level intramuscular" group, 76 and 85% of the patients reached their goals respectively.

CONCLUSIONS

Combining BTX-A injections for sialorrhea with multilevel intramuscular BTX-A injections (with or without alcohol) appears to be safe and effective and allows treatment of patients for both conditions simultaneously.

Botulinum Toxin Injection to the Salivary Glands for the Treatment of Sialorrhea with Chronic Aspiration

Objectives

Chronic aspiration of salivary secretions can cause major pulmonary morbidity in neurologically impaired patients. Many treatments are proposed to address these problems, some with significant side effects. Botulinum toxin type A injection into the salivary glands is known to reduce salivary flow without major complications. Few reports exist regarding the use of this treatment in the prevention of recurrent aspiration pneumonia. We studied the effects of this treatment for patients with recurrent aspiration pneumonia.

Methods

We performed a chart review of 12 patients, ranging in age from 7 months to 37 years, treated with botulinum toxin injections at a single tertiary care institution. A caregiver telephone questionnaire was also administered. The numbers of pulmonary infections and hospitalizations before and after the initiation of treatment were compared.

Results

Nine of 12 patients reported improvement in the numbers of hospitalizations and pulmonary infections following botulinum toxin injections. Reduction in the use of anticholinergic medication and reduced pulmonary toilet requirements were also noted. There were no complications of treatment.

Conclusions

Botulinum toxin injection into the salivary glands can be effective in reducing pulmonary morbidity in many neurologically impaired patients. This relatively simple technique offers an alternative to the use of anticholinergic medication and may obviate the need for more invasive surgical treatment in certain patients.

Gastrointestinal Dysfunctions in Parkinson's Disease: Symptoms and Treatments

A diagnosis of Parkinson's disease is classically established after the manifestation of motor symptoms such as rigidity, bradykinesia, and tremor. However, a growing body of evidence supports the hypothesis that nonmotor symptoms, especially gastrointestinal dysfunctions, could be considered as early biomarkers since they are ubiquitously found among confirmed patients and occur much earlier than their motor manifestations. According to Braak's hypothesis, the disease is postulated to originate in the intestine and then spread to the brain via the vagus nerve, a phenomenon that would involve other neuronal types than the well-established dopaminergic population. It has therefore been proposed that peripheral nondopaminergic impairments might precede the alteration of dopaminergic neurons in the central nervous system and, ultimately, the emergence of motor symptoms. Considering the growing interest in the gut-brain axis in Parkinson's disease, this review aims at providing a comprehensive picture of the multiple gastrointestinal features of the disease, along with the therapeutic approaches used to reduce their burden. Moreover, we highlight the importance of gastrointestinal symptoms with respect to the patients' responses towards medical treatments and discuss the various possible adverse interactions that can potentially occur, which are still poorly understood.

Salivary botulinum toxin injection may reduce aspiration pneumonia in neurologically impaired children

OBJECTIVES

Neurologically impaired children often drool and aspirate saliva leading to recurrent aspiration pneumonia and frequent hospitalizations. Salivary botulinum toxin injection is known to reduce sialorrhea. This study evaluates whether this intervention affects the frequency and duration of respiratory infections including aspiration pneumonia and hospitalizations in neurologically impaired children.

METHODS

Retrospective review of patients treated with salivary botulinum toxin at a tertiary care pediatric hospital from January 2009 to December 2013. Each patient was their own control and 180 day pre-injection and post-injection time periods were compared. Outcomes evaluated included: number of hospital days, intensive care unit days, days of antibiotic treatment, chest X-rays, and infiltrates on chest X-ray.

RESULTS

13 patients accumulated 539 hospital days. All children were gastrostomy tube dependent. 54% were tracheostomy tube dependent. Amongst all patients, the total hospital days decreased from 385 to 154 (P=0.02), the mean days treated with antibiotics decreased from 214 to 47 (P=0.02), and the number of chest X-ray confirmed infiltrates decreased from 20 to 6 (P=0.02) after injection.

CONCLUSION

In this review, there was a decrease in hospitalized days, antibiotic usage, and chest X-ray infiltrates after the salivary botulinum toxin injection. A prospective study is needed to evaluate whether this treatment can prevent aspiration pneumonia in neurologically impaired children.

The Experience of Treating Drooling with Repeated Botulinum Toxin Injections

Botulinum toxin A (BTX-A) injections to the salivary glands are effective in the treatment of drooling, and complications are rare. However, there are only a few previous reports on the long-term use of BTX-A injections. This study retrospectively analyzes our experience of treating drooling with repeated BTX-A injections in patients with neurodegenerative diseases. All patients who received repeated BTX-A injections to the submandibular glands at Tampere University Hospital in 2004-2013 were included in the analysis. Six patients, aged from 6 to 21 years, were included in the study, and a total of 41 bilateral BTX-A injections were administered to their submandibular glands. The average number of injections per patient was 6 (range: 3-11). The average interval between the injections was 9.8 months (range: 4-18), and 95% (39/41) of the injections were performed with good response. The complication rate of the BTX-A injections was 2.4% (1/41), since one of the patients had swallowing problems after an injection. BTX-A injections to the submandibular glands are effective and have a low morbidity rate, and repeated injections can be recommended as long-term treatment of drooling.

Glycopyrrolate and theophylline for the treatment of severe pallid breath-holding spells

Severe pallid breath-holding spells (BHSs) are based on parasympathetic hyperactivity, leading to cardiac asystole, pallor, brain ischemia, loss of consciousness, and reflex anoxic seizures. In recent years, an increasing number of patients with severe pallid BHSs have been successfully treated with pacemaker implantation. We present the case of a 13-month-old girl suffering from repeated severe pallid BHSs, causing asystole, loss of consciousness, and generalized anoxic seizures. She underwent treatment with oral glycopyrrolate, an anticholinergic drug, and an oral retard preparation of theophylline. The aim of the treatment was to decrease cardiac inhibition with glycopyrrolate and to bring about a positive chronotropic effect with theophylline. In our case, the combined therapy was effective in suppressing syncope and reflex anoxic seizures associated with BHSs This avoided the need for ventricular pacemaker implantation.

Anticholinergics in palliative medicine: an update

Anticholinergics, or antimuscarinic drugs, are drugs that competitively inhibit the action of acetylcholine at muscarinic receptors, leading to a blockade of the actions of the parasympathetic nervous system at sites where overactivity can lead to increased symptom burden. Successful blockade of the parasympathetic nervous system ultimately leads to decreased production of secretions in the salivary, bronchial, and gastrointestinal tracts. These effects are often used for several symptoms that originate due to parasympathetic nervous system overactivity, such as the "death rattle" and malignant bowel obstruction. Anticholinergic agents are divided into either tertiary amines or quaternary ammonium compounds, which differ in their ability to cross into the central nervous system. Quaternary compounds do not cross into the central nervous system and have a different adverse effect profile than the tertiary amines. The purpose of this review is to highlight anticholinergic agents, their pharmacology, and an evidence-based assessment of their role in palliative care.

Glycopyrrolate oral solution: for chronic, severe drooling in pediatric patients with neurologic conditions

Chronic drooling (sialorrhea) is a common dysfunction in children with neurologic disorders such as cerebral palsy. Glycopyrrolate oral solution, an anticholinergic agent, is the first drug treatment approved in the US for drooling in children with neurologic conditions. This article reviews the clinical efficacy and tolerability of glycopyrrolate oral solution in pediatric patients with neurologic conditions and provides an overview of the pharmacological properties of the drug. In a phase III, randomized, double-blind, multicenter trial, children (aged 3-16 years; n = 36) with problem drooling associated with neurologic conditions and receiving glycopyrrolate oral solution had a significantly (p < 0.01) greater modified Teacher's Drooling Scale (mTDS) response rate at 8 weeks (primary endpoint) than those receiving placebo (73.7% vs 17.6%). At 24 weeks in an additional, noncomparative, phase III study, 52.3% of glycopyrrolate oral solution recipients (aged 3-18 years; n = 137) had an mTDS response (primary endpoint); the response rate was consistently above 50% at all 4-weekly timepoints, aside from the first assessment at week 4 (40.3%). In general, glycopyrrolate oral solution was well tolerated in clinical trials. The majority of adverse events were within expectations as characteristic anticholinergic outcomes.

Dysphagia and aspiration in children

Aspiration is a significant cause of respiratory morbidity and sometimes mortality in children. It occurs when airway protective reflexes fail, especially, when dysphagia is also present. Clinical symptoms and physical findings of aspiration can be nonspecific. Advances in technology can lead to early diagnosis of dysphagia and aspiration, and, new therapeutic advances can significantly improve outcome and prognosis. This report first reviews the anatomy and physiology involved in the normal process of swallowing. Next, the protective reflexes that help to prevent aspiration are discussed followed by the pathophysiologic events that occur after an aspiration event. Various disease processes that can result in dysphagia and aspiration in children are discussed. Finally, the various methods for diagnosis and treatment of dysphagia in children are reviewed.

Glycopyrrolate for chronic drooling in children

BACKGROUND

Sialorrhea, or drooling, is seen in the pediatric population, especially in patients with cerebral palsy and other neurodevelopmental disabilities. If medication use is warranted, anticholinergic agents are the drug of choice; however, adverse effects limit their use. Glycopyrrolate, a synthetic anticholinergic that acts at peripheral muscarinic receptors, has been used off-label for excessive drooling in children with neurodevelopmental disabilities for years. Product formulations restricted the use of glycopyrrolate. However, an oral solution was approved by the US Food and Drug Administration for children ages 3 to 16 years with neurologic disorders for chronic severe drooling in 2010; it became available for use in 2011.

OBJECTIVE

This article provides an overview of the pharmacology, clinical efficacy, and tolerability of glycopyrrolate when used for sialorrhea in children.

METHODS

To evaluate the efficacy and safety profile of glycopyrrolate for the treatment of sialorrhea in children, a comprehensive search was performed of the MEDLINE database (1966-February 25, 2012) and International Pharmaceutical Abstracts as well as references from additional review articles identified. Searches were conducted using the terms glycopyrrolate, sialorrhea, drooling, secretion, and pediatrics. The terms drug-induced and Parkinson disease-associated sialorrhea were excluded from the search. The pharmaceutical manufacturer of the oral solution was contacted for medical and study information.

RESULTS

Oral bioavailability of glycopyrrolate varies widely, with a median of 3.3%. Mean C(max) in children was determined to be 0.37 μg/mL, and mean T(max) was 3.1 hours. The clearance in children ranges from 0.6 to 1.43 L/kg/h. The t(½) ranges from 22 to 130 minutes and 19 to 99 minutes in infants and children, respectively. Six studies describing the use of glycopyrrolate for drooling in children were identified. A double-blind, crossover trial of 27 patients (age range, 4-19 years) demonstrated a reduced mean drooling score (modified Teacher's Drooling Scale [1 = never drools to 9 = clothing, hands, and objects frequently become wet]) for glycopyrrolate (mean highest tolerated dose, 0.11 mg/kg) compared with placebo of 1.85 versus 6.33 (P < 0.001). In a parallel study of 36 patients (age range, 3-16 years), 14 of 20 patients randomized to receive glycopyrrolate solution showed improvement in the mean modified Teacher's Drooling Scale score compared with only 3 patients receiving placebo (-3.5 vs -0.1, respectively). Glycopyrrolate was initiated at 0.02 mg/kg per dose orally TID (Max dose: 3 mg) and titrated over a 4-week period. Adverse effects identified in studies include dry mouth (9%-41%), constipation (9%-39%), and behavioral changes (18%-36%).

CONCLUSIONS

Glycopyrrolate is effective in decreasing sialorrhea in children with cerebral palsy or other neurodevelopmental disabilities. Adverse effects did occur, more frequently at higher doses, and should be monitored.

Safety and efficacy of glycopyrrolate oral solution for management of pathologic drooling in pediatric patients with cerebral palsy and other neurologic conditions

Background

The purpose of this study was to assess the safety and efficacy of oral glycopyrrolate solution 1 mg/5 mL for 24 weeks in pediatric patients with chronic moderate-to- severe drooling associated with cerebral palsy and other neurologic conditions.

Methods

In this multicenter, open-label, 24-week study, males and females aged 3–18 years weighing at least 27 lb received oral glycopyrrolate solution, starting at 0.02 mg/kg three times daily and titrated in increments of 0.02 mg/kg every 5–7 days for 4 weeks to an optimal maintenance dose or a maximum dose of 0.1 mg/kg, but not exceeding 3 mg three times daily. Safety was assessed by description and tabulation of all adverse events. The primary efficacy endpoint was response, defined as at least a three-point change from baseline to week 24 on the modified Teacher’s Drooling Scale.

Results

Of 137 intent-to-treat participants, 10 (7.3%) received the maximum dose of 0.1 mg/kg three times daily; 122 (89%) had at least one treatment-emergent adverse event, 47% related to oral glycopyrrolate solution, with most being mild-to-moderate in intensity. The most commonly reported treatment-emergent adverse events were constipation (20.4%), vomiting (17.5%), diarrhea (17.5%), pyrexia (14.6%), dry mouth (10.9%), flushing (10.9%), and nasal congestion (10.9%). Nineteen patients (13.9%) discontinued treatment due to an adverse event, but no adverse event was specifically associated with discontinuation. Two patients had clinically significant toxicity grade shifts, one each in platelet count and calcium concentration. No deaths occurred on treatment; deaths of three patients (multisystem organ failure, anoxic encephalopathy, and aspiration pneumonia) within 30 days of their last dose were not considered to be treatment-related. At 24 weeks, 52.3% (95% confidence interval 43.7–60.9) of patients were responders, with at least a three-point decrease in modified Teacher’s Drooling Scale from baseline, with 83.5% of parents/caregivers and 85.8% of investigators rating oral glycopyrrolate solution as being worthwhile.

Conclusion

Oral glycopyrrolate solution 1 mg/5 mL for chronic moderate-to-severe drooling associated with cerebral palsy or other neurologic conditions was well tolerated over 24 weeks by pediatric patients aged 3–18 years.

Randomized Phase III evaluation of the efficacy and safety of a novel glycopyrrolate oral solution for the management of chronic severe drooling in children with cerebral palsy or other neurologic conditions

AIM

To evaluate the efficacy of glycopyrrolate oral solution (1 mg/5 mL) in managing problem drooling associated with cerebral palsy and other neurologic conditions.

METHOD

Thirty-eight patients aged 3-23 years weighing at least 27 lb (12.2 kg) with severe drooling (clothing damp 5-7 days/week) were randomized to glycopyrrolate (n = 20), 0.02-0.1 mg/kg three times a day, or matching placebo (n = 18). Primary efficacy endpoint was responder rate, defined as percentage showing ≥3-point change on the modified Teacher's Drooling Scale (mTDS).

RESULTS

Responder rate was significantly higher for the glycopyrrolate (14/19; 73.7%) than for the placebo (3/17; 17.6%) group (P = 0.0011), with improvements starting 2 weeks after treatment initiation. Mean improvements in mTDS at week 8 were significantly greater in the glycopyrrolate than in the placebo group (3.94 ± 1.95 vs 0.71 ± 2.14 points; P < 0.0001). In addition, 84% of physicians and 100% of parents/caregivers regarded glycopyrrolate as worthwhile compared with 41% and 56%, respectively, for placebo (P ≤ 0.014). Most frequently reported treatment-emergent adverse events (glycopyrrolate vs placebo) were dry mouth, constipation, and vomiting.

INTERPRETATION

Children aged 3-16 years with problem drooling due to neurologic conditions showed a significantly better response, as assessed by mTDS, to glycopyrrolate than to placebo. CLINICALTRIALS.GOV IDENTIFIER: NCT00425087.

Effect of botulinum toxin type a on morphology of salivary glands in patients with cerebral palsy

Objective

To investigate the effect of botulinum toxin type A (BTXA) on drooling and the morphologic change of the salivary gland in patients with cerebral palsy.

Method

Eight cerebral palsy patients suffering from severe drooling participated in this study. BTXA was injected into both submandibular and parotid glands under intravenous sedation and with ultrasound guidance (1 unit/gland/kg: maximum 100 units) in an outpatient or inpatient procedure. The severity of drooling was measured before injection and 3 weeks after injection using the Teacher Drooling Scale, the Drooling Score-severity, frequency and the Visual Analog Scale. To investigate the morphologic change of the salivary glands, the size of salivary glands were measured before injection and 3 weeks after injection using computed tomography of the neck. The measurement values were analyzed by Wilcoxon signed rank test.

Results

Statistically significant improvements were shown in all three parameters for assessing the severity of drooling after BTXA injections (p<0.05). Size of the salivary glands were significantly decreased at 3 weeks after BTXA injection (p<0.05).

Conclusion

Salivary gland injection with BTXA could be a useful treatment method to reduce drooling in patients with cerebral palsy and decreased size of salivary glands may partially explain the mechanism.

Therapeutic use of botulinum toxin in neurorehabilitation

The botulinum toxins (BTX), type A and type B by blocking vesicle acetylcholine release at neuro-muscular and neuro-secretory junctions can result efficacious therapeutic agents for the treatment of numerous disorders in patients requiring neuro-rehabilitative intervention. Its use for the reduction of focal spasticity following stroke, brain injury, and cerebral palsy is provided. Although the reduction of spasticity is widely demonstrated with BTX type A injection, its impact on the improvement of dexterity and functional outcome remains controversial. The use of BTX for the rehabilitation of children with obstetrical brachial plexus palsy and in treating sialorrhea which can complicate the course of some severe neurological diseases such as amyotrophic lateral sclerosis and Parkinson's disease is also addressed. Adverse events and neutralizing antibodies formation after repeated BTX injections can occur. Since impaired neurological persons can have complex disabling feature, BTX treatment should be viewed as adjunct measure to other rehabilitative strategies that are based on the individual's residual ability and competence and targeted to achieve the best functional recovery. BTX therapy has high cost and transient effect, but its benefits outweigh these disadvantages. Future studies must clarify if this agent alone or adjunctive to other rehabilitative procedures works best on functional outcome.

Botulinum toxin type B for sialorrhoea in children with cerebral palsy: a randomized trial comparing three doses

AIM

The aim of the present study was to evaluate the efficacy and safety of three doses of botulinum toxin type B (BoNT-B) in reducing persistent sialorrhoea in children with cerebral palsy (CP).

METHOD

Children with CP and refractory sialorrhoea were randomized to one of four groups: a control group and three experimental groups receiving a low (1500 mouse units [MU]), medium (3000 MU), or high (5000 MU) dose of BoNT-B respectively, into bilateral salivary glands. Drooling was measured using the Thomas-Stonell rating scale, and the weight and the number of bibs used per day were counted in all children at baseline, 4, and 12 weeks after BoNT-B injection.

RESULTS

Twenty-seven children (15 males, 12 females; mean age 7 y 10 mo, SD 1 y 6 mo; range 5-15 y) were randomized into a control (seven children: four males, three females) and experimental groups receiving low (six children: four males, two females), medium (seven children: four males, three females), and high (seven children: three males, four females) doses of BoNT-B respectively. All children had mixed neurological disorders consisting of spastic paraparesis, tetraparesis, dystonic movements, and ataxia. Gross Motor Function Classification System levels ranged from III to V, and all children had moderate or severe intellectual disability. Estimated means with their standard errors (SEM) of drooling were at baseline, 4, and 12 weeks respectively, as follows: control group, 12.1 (2.1), 11.9 (2.1), 11.8 (2.2), p for trend 0.992; low dose group, 13.8 (2.3), 11.4 (2.3), 13.9 (2.3), p for trend 0.952; medium dose group, 13.9 (2.1), 6.7 (2.1), 7.1 (2.1) p for trend 0.008; and for the high dose group 14.4 (2.1), 5.0 (2.1), 5.6 (2.1), p for trend 0.002. Side effects included dense saliva, xerostomia, and difficulty in swallowing, and were more frequent in the high-dose group.

INTERPRETATION

A 3000 MU injection of BoNT-B into the salivary glands significantly improved the frequency and severity of sialorrhoea in children with CP. The lower dose was ineffective, and the higher dose produced no greater benefit and more side effects.

Novel use of glycopyrrolate (Robinul) in the treatment of anastomotic leak after repair of esophageal atresia and tracheoesophageal fistula

Anastomotic leak after tracheoesophageal fistula repair is a well-known complication and can represent a challenging clinical scenario. We present the case of an infant girl with VACTERL syndrome who underwent repair of a type C esophageal atresia and tracheoesophageal fistula repair, which was complicated by an anastomotic leak. Glycopyrrolate (Robinul), an anticholinergic agent, was successfully used to decrease copious salivary secretion and promote spontaneous closure of the leak. This report represents the first description in the medical literature of the use of glycopyrrolate in the treatment of an esophageal anastomotic leak. Glycopyrrolate may be a useful adjunct in the management of anastomotic leak after tracheoesophageal repair.

Glycopyrrolate Oral Solution

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Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service or The F.I.X., call The Formulary at 800-322-4349. The December 2010 monograph topics are on fingolimod, ezogabine, telaprevir, clonidine extended release, and risedronate delayed release. The DUE/MUE is on fingolimod.

Sublingual atropine drops for the treatment of pediatric sialorrhea

Excess oral secretions or sialorrhea is a common problem affecting children and adults with neurological disorders, as well as those approaching the end of life because of a variety of underlying illnesses. Systemic anticholinergic medications are often prescribed in an attempt to improve quality of life and reduce complications; yet, response rates are variable, and a sizable proportion of patients discontinue these drugs as a result of intolerable side effects. This report describes the successful use of a local treatment, sublingually delivered ophthalmic atropine drops, to reduce sialorrhea in a child receiving palliative care. In addition, medical evidence for the safety and efficacy of traditionally prescribed systemic medications for the treatment of pediatric sialorrhea is reviewed.

Pediatric rehabilitation: 1. Common medical conditions in children with disabilities

OBJECTIVE

This self-directed learning module focuses on the physiatric management of the common morbidities associated with pediatric traumatic brain injury and cerebral palsy. It is part of the study guide on pediatric rehabilitation in the Self-Directed Physiatric Education Program for practitioners and trainees in physical medicine and rehabilitation and pediatric medicine. The goal of this article is to enhance the learner's knowledge regarding current physiatric management of complications related with pediatric traumatic brain injury and cerebral palsy.

Anticholinergic medications for managing noisy respirations in adult hospice patients

PURPOSE

Anticholinergic medications for reducing noisy respirations in adult hospice patients are evaluated.

SUMMARY

Anticholinergic medications used to reduce noisy respirations from retained secretions in terminal patients include atropine, glycopyrrolate, scopolamine, and scopolamine derivatives. Pharmaceutical anticholinergic treatment of retained secretions in hospice patients was evaluated in six studies, three of which compared the efficacy of glycopyrrolate to scopolamine in actively dying patients. Subcutaneous glycopyrrolate, scopolamine hydrobromide, and scopolamine butylbromide were similar in their ability to reduce noisy respirations overall and lower and the level of distress exhibited by family members and visitors. Two of the six studies compared the efficacy of medication therapy after institutional formulary changes from scopolamine to glycopyrrolate. The same dosages of subcutaneous glycopyrrolate and scopolamine, which delivered an initial bolus followed by continuous infusion, were reported in each study. Both studies concluded that there was equivalent efficacy between the two products. One study reported a more rapid response in patients treated with glycopyrrolate. In comparison, the last study reported more rapid responses in patients who received scopolamine compared with patients who received glycopyrrolate. Retrospective reports described symptom improvement with parenteral scopolamine in most patients.

CONCLUSION

Parenteral and transdermal anticholinergic medications are useful for the reduction of noisy respirations in hospitalized hospice patients. Difficult administration makes oral and sublingual products less desirable for use in this population.

Assessing and managing lung disease and sleep disordered breathing in children with cerebral palsy

The major morbidity and mortality associated with cerebral palsy (CP) relates to respiratory compromise. This manifests through repeated pulmonary aspiration, airway colonization with pathogenic bacteria, the evolution of bronchiectasis and sleep disordered breathing. An accurate assessment involving a multidisciplinary approach and relatively simple interventions for these conditions can lead to significant improvements in the quality of life of children with CP as well as their parents and carers. This review highlights the more common problems and potential therapies with regard to suppurative lung disease and sleep disordered breathing in children with CP.

Botulinum toxin A injection of salivary glands in children with drooling and chronic aspiration

PURPOSE

To review outcomes of ultrasound (US)-guided percutaneous submandibular gland injection of botulinum toxin A (BTX-A) in the treatment of drooling and chronic aspiration.

MATERIALS AND METHODS

A 3-year retrospective review was performed of 220 US-guided salivary gland injections in 36 patients. There were 21 male patients and 15 female patients with an age range of 1.4 to 19.8 years (mean, 8.6 y) and a weight range of 7.8 to 73 kg (mean, 24.4 kg). The mean pretreatment analysis period was 48 months and the mean follow-up period was 21 months. The study group was divided into groups with anterior (n = 9) and posterior (n = 27) drooling, with those with both (n = 10) included in the posterior group.

RESULTS

All procedures were technically successful. Bilateral submandibular injections were performed in 34 procedures and bilateral submandibular and parotid injections were performed in 38 procedures. Of the 27 patients with posterior drooling, improvement occurred in 24 patients (88%), no improvement was seen in two (8%), and one (4%) was lost to follow-up. Of the nine patients with anterior drooling, six (66%) showed improvement, there was no response in two (22%), and one (12%) was lost to follow-up. The total number of hospitalizations for respiratory issues and presumed aspiration pneumonia decreased by 56.4% per year in the patients with posterior drooling. There was one procedure-related complication: an episode of self-limited oral bleeding.

CONCLUSION

Salivary gland BTX-A injection for salivary control shows promising results in decreasing saliva production and frequency of respiratory symptoms in children with drooling and chronic aspiration.

Pulmonary care of children and adolescents with developmental disabilities

Caring for children and adolescents with developmental disabilities is challenging because of their susceptibility to varying degrees of respiratory morbidity and mortality. This article discusses the common pulmonary problems affecting children with developmental disabilities. Topics to be discussed include gastroesophageal reflux, drooling, and dysphagia and their relation to aspiration and aspiration pneumonia, upper airway obstruction and obstructive sleep apnea, and the role of airway clearance. Case studies are used to introduce a discussion of the underlying etiology, currently accepted methods to evaluate the conditions, and evidence-based treatment options. The goal of managing these problems is to use anticipatory guidance when possible and choose therapies that improve the child's quality of life with minimal side effects.

Cerebral palsy: medical aspects

Cerebral palsy describes a wide spectrum of motor problems caused by a nonprogressive lesion of the developing brain. It is variably associated with a variety of other developmental and medical problems that present challenges to parents and care providers alike. This article provides an overview of etiology and diagnosis, with a system-based discussion of management.