Reduction of salivary flow with transdermal scopolamine: a four-year experience

Longitudinal CT evaluation of transdermal scopolamine for aspiration pneumonia with sialorrhea in severe chronic brain injury: A case series

Sialorrhea is a major cause of recurrent aspiration pneumonia in severe chronic brain injury. Previous reports have shown that transdermal scopolamine can decrease saliva production. We present four patients with severe chronic brain injury who experienced repeat aspiration pneumonia with sialorrhea. Longitudinal computed tomography examinations to assess the therapeutic effect were performed in all four cases before and after transdermal scopolamine. Transdermal scopolamine was applied as a patch (0.1 g/2.5 cm2) behind the earlobe every 24 h after confirming the absence of glaucoma. Patches were formulated as an in-hospital preparation (scopolamine butylbromide 0.25 g and hydrophilic cream 4.75 g) under the approval of our institutional review board. Longitudinal computed tomography after transdermal scopolamine use showed a decrease in pleural effusions associated with continuous aspiration pneumonia in all four cases. The data from repeat computed tomography suggest that long-term transdermal scopolamine for reducing saliva production may be a reasonable option for appropriate palliative care in severe chronic brain injury patients.

The burden of sialorrhoea in chronic neurological conditions: current treatment options and the role of incobotulinumtoxinA (Xeomin®)

Sialorrhoea is a frequent symptom of neurological diseases (e.g. Parkinson's disease, motor neuron disease, cerebral palsy, and stroke) and is defined as excessive saliva accumulation leading to unintentional loss of saliva from the mouth. Sialorrhoea increases the overall burden on the patient and their caregivers, the impact of which can be both physical and psychosocial. Treatments for sialorrhoea range from lifestyle and behavioural guidance, to medications, surgery or radiation. Nonpharmacological interventions include advice on posture, swallowing control, cough management, dietary changes, eating and drinking techniques, and behavioural modification; however, these conservative measures may be ineffective for people with progressive neurological conditions. The pharmacological treatment of sialorrhoea is challenging because medications licensed for this purpose are limited, but treatments can include anticholinergic drugs and botulinum toxins. Surgical treatment of sialorrhoea is typically reserved as a last resort for patients. IncobotulinumtoxinA (Xeomin®) is the first botulinum toxin type A to receive US and UK marketing authorization for the symptomatic treatment of chronic sialorrhoea due to neurological disorders in adults. In this review, we discuss and compare the frequency and method of administration, location of treatment delivery, approximate annual costs and main side effects of botulinum toxin and different anticholinergic drugs. Management of patients with chronic neurological conditions requires input from multiple specialist teams and thus a multidisciplinary team (MDT) approach is considered fundamental to ensure that care is consistent and tailored to patients' needs. To ensure that adult patients with neurological conditions receive the best care and sialorrhoea is well managed, we suggest a potential clinical care pathway for sialorrhoea with a MDT approach, which healthcare professionals could aspire to.

Transdermal scopolamine for the prevention of a salivary fistula after parotidectomy

Our aim was to investigate whether perioperative transdermal application of scopolamine could help to prevent fistulas after parotidectomy, and to this end we retrospectively studied the records of all patients (n=645) who had benign parotid tumours treated by partial parotidectomy between 2011 and 2016. We found that scopolamine led to a significant decrease in the incidence of salivary fistulas from 54/371(15%) in the group not given it to 10/274 (4%) in the group given it (p<0.0001). The "number needed to treat" was 9.17. There was a relatively low incidence of all adverse effects after scopolamine. Our results are encouraging. Thorough consideration of the contraindications and a knowledge of the potential adverse effects are crucial for its successful implementation.

Ultrasound-Guided Botulinum Toxin Type A Salivary Gland Injection in Children for Refractory Sialorrhea: 10-Year Experience at a Large Tertiary Children's Hospital

BACKGROUND

Sialorrhea is problematic for neurologically impaired children, and botulinum toxin A salivary gland injection has been reported as effective in reducing sialorrhea. This article assesses the success and safety of ultrasound-guided weight-based botulinum toxin A injection for the management of sialorrhea in children.

METHODS

A total of 111 patients (63 males; 48 females; average age 7 years) with refractory sialorrhea were treated with ultrasound-guided botulinum toxin type A salivary gland injections (144 procedures) from July 1, 2004, to July 1, 2014, using a single weight-based protocol. Patient history, procedural records, and clinical follow-up documents were retrospectively reviewed. Clinical data were compared with reported effectiveness and complications using odds ratios.

RESULTS

A total of 144 procedures were performed in 111 patients with refractory sialorrhea. Cerebral palsy was the most common underlying etiology for sialorrhea (29%), whereas others included encephalopathy (5%), anoxic brain injury (4%), and a variety of chromosomal anomalies (5%). There was a 100% technical success rate. Overall treatment effectiveness was 68%. Repeat injections were not associated with increased clinical success. No procedure-related deaths or major complications were identified; the minor complication rate was less than 2%.

CONCLUSIONS

The protocol used for ultrasound-guided injection of botulinum toxin A proved to be safe and effective in children suffering from sialorrhea. Image guidance technique may lead to a reduction in rates of adverse events reported in other series. Subsequent procedures do not improve upon initial efficacy.

Botulinum Toxin for the Treatment of Sialorrhea

Objectives

Botulinum toxin has emerged as an effective approach for the management of sialorrhea. This study presents a critical literature review and meta-analysis to determine the impact of botulinum toxin on drooling severity in patients with sialorrhea.

Data Sources

Ovid MEDLINE and the Cochrane databases.

Review Methods

The above sources were searched to identify studies examining botulinum toxin for the treatment of sialorrhea. Included studies were randomized, placebo-controlled trials. Excluded studies failed to report quantifiable outcome measures of drooling severity at 4 weeks postintervention.

Results

Eight studies involving 181 patients (83 placebo; 98 active) were included in the analysis. Botulinum toxin was found to significantly decrease the severity of drooling in patients with sialorrhea (standardized mean difference [SMD], −1.54; 95% confidence interval [CI], −2.05 to −1.04; P = .06; I2 = 48%) when compared with placebo control using random effects models. The effect was significant in both adult (SMD, −1.29; 95% CI, −1.88 to −0.71) and pediatric (SMD, −1.84; 95% CI, −2.67 to −1.00) populations. Both botulinum toxin A (SMD, −1.53; 95% CI, −2.27 to −0.79) and B (SMD, −1.56; 95% CI, −2.32 to −0.79) produced similar effects. Botulinum toxin doses greater than 50 U (SMD, −3.81; 95% CI, –6.19 to −1.43) produced much stronger effects compared with doses less than or equal to 50 U (SMD, −1.32; 95% CI, −2.28 to −0.36).

Conclusion

Botulinum toxin is a clinically effective therapy that improves drooling severity in patients with sialorrhea. Future studies will need to further evaluate the technique and examine dosages required to achieve optimal outcomes.

EFNS guidelines on the clinical management of amyotrophic lateral sclerosis (MALS)--revised report of an EFNS task force

BACKGROUND

The evidence base for the diagnosis and management of amyotrophic lateral sclerosis (ALS) is weak.

OBJECTIVES

To provide evidence-based or expert recommendations for the diagnosis and management of ALS based on a literature search and the consensus of an expert panel.

METHODS

All available medical reference systems were searched, and original papers, meta-analyses, review papers, book chapters and guidelines recommendations were reviewed. The final literature search was performed in February 2011. Recommendations were reached by consensus.

RECOMMENDATIONS

Patients with symptoms suggestive of ALS should be assessed as soon as possible by an experienced neurologist. Early diagnosis should be pursued, and investigations, including neurophysiology, performed with a high priority. The patient should be informed of the diagnosis by a consultant with a good knowledge of the patient and the disease. Following diagnosis, the patient and relatives/carers should receive regular support from a multidisciplinary care team. Medication with riluzole should be initiated as early as possible. Control of symptoms such as sialorrhoea, thick mucus, emotional lability, cramps, spasticity and pain should be attempted. Percutaneous endoscopic gastrostomy feeding improves nutrition and quality of life, and gastrostomy tubes should be placed before respiratory insufficiency develops. Non-invasive positive-pressure ventilation also improves survival and quality of life. Maintaining the patient's ability to communicate is essential. During the entire course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end-of-life care should be discussed early with the patient and carers, respecting the patient's social and cultural background.

Management of drooling in disabled patients with scopolamine patches

AIM

To evaluate the efficacy of scopolamine administered transdermally for the treatment of drooling in severely disabled patients.

METHODS

A prospective, randomized, double-blind, crossover, placebo-controlled clinical trial was designed. The study group consisted of 30 handicapped patients with persistent drooling. The exclusion criteria were the specific contra-indications of scopolamine. Severity of drooling was quantified using a modified Thomas-Stonell and Greenberg visual scale simplified into three grades: 1 = dry; 2 = mild/moderate; 3 = severe/fulsome. The frequency of drooling was estimated using the number of bibs used each day. The baseline observational phase was followed by the application of a 1.5 mg scopolamine (Scopoderm TTS; Novartis Consumer Healthcare, UK) or placebo patch every 72 h for a fortnight. This was followed by a 1 week washout period and then crossover of assignments for 2 weeks.

RESULTS

At baseline, 77% of patients showed grade 3 of drooling. The placebo administration showed no significant reduction in drooling. We found a significant drooling reduction (P < 0.005) in the scopolamine group in the 1 and 2 week controls (69% and 80% respectively <or= grade 3). The mean number of bibs/day decreased during the scopolamine phase from 6/day at baseline to 3/day at the 2 week control. Four patients (13.3%) dropped out because of scopolamine side effects and minor adverse reactions were observed in three other patients. No blood alterations were found during the study period.

CONCLUSION

Scopolamine can be useful to control drooling in severely disabled patients although it requires appropriate patient selection and is not free from adverse effects.

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.

Surgical treatment of dysphagia

The role of surgery in the management of dysphagia is clear in some areas and controversial in others. Evaluation for the causes of dysphagia can elucidate conditions in which surgery can improve safety, quality of life, or both. Surgical therapy, when indicated, is safe and effective for many causes of dysphagia. This article includes a general overview of the causes of dysphagia that can be addressed successfully with surgery as well as a discussion of why surgery may be less appropriate for other conditions associated with dysphagia.

Good practice in the management of amyotrophic lateral sclerosis: clinical guidelines. An evidence-based review with good practice points. EALSC Working Group

The evidence base for diagnosis and management of ALS is still weak, and curative therapy is lacking. Nonetheless, early diagnosis and symptomatic therapy can profoundly influence care and quality of life of the patient and relatives, and may increase survival time. This review addresses the current optimal clinical approach to ALS. The literature search is complete to December 2006. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. We conclude that a diagnosis of ALS can be achieved by early examination by an experienced neurologist. The patient should be informed of the diagnosis by the consultant. Following diagnosis, a multi-diciplinary care team should support the patient and relatives. Medication with riluzole should be initiated as early as possible. PEG is associated with improved nutrition and should be inserted early. The operation is hazardous in patients with VC <50%: RIG may be a better alternative. Non-invasive positive pressure ventilation improves survival and quality of life but is underused in Europe. Maintaining the patient's ability to communicate is essential. During the course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end of life care are important and should be discussed early with the patient and relatives if they so wish.

Hyoscine skin patches for drooling dilate pupils and impair accommodation: spectacle correction for photophobia and blurred vision may be warranted

Hyoscine skin patches diminish salivation by their anticholinergic action. The aim of reporting this case series is to present the ophthalmic side effects in children, and to highlight the precautions to take. Five children (two males, three females; age range 8-18y) with quadraplegic cerebral palsy (Gross Motor Function Classification System Level V) and profound intellectual impairment, wearing hyoscine skin patches to control excessive salivation, were examined. Binocular visual acuity, pupil reaction, pupil diameter, and dynamic retinoscopy were recorded before and after instilling guttae cyclopentolate 1%. The accommodative responses were compared with the expected norms. Spectacle correction was provided for refractive error and to compensate for lack of accommodation. Tinted lenses were provided for photophobia. Visual assessment was repeated 6 months later. All children had dilated pupils with a mean diameter of 7.8mm (range 7-9mm) before instilling guttae cyclopentolate. Mean pupil constriction to bright light was only 1.8mm (range 1-2mm). Mean resting accommodation was 0.45 dioptres (D; range 0-1D) and no accommodative responses were detected on dynamic retinoscopy. Three children were photophobic. Visual behaviour was seen to improve after the use of appropriate spectacles. Photophobia was relieved by tinted lenses. The anticholinergic effects of hyoscine skin patches can cause photophobia and impair vision due to pupil dilatation and paralysis of accommodation. Appropriate spectacles are recommended.

Transdermal scopolamine for prevention of motion sickness : clinical pharmacokinetics and therapeutic applications

A transdermal therapeutic system for scopolamine (TTS-S) was developed to counter the adverse effects and short duration of action that has restricted the usefulness of scopolamine when administered orally or parenterally. The plaster contains a reservoir of 1.5 mg of scopolamine programmed to deliver 0.5 mg over a 3-day period. A priming dose (140 microg) is incorporated into the adhesive layer to saturate certain binding sites within the skin and to accelerate the achievement of steady-state blood levels. The remainder is released at a constant rate of approximately 5 microg/hour. The protective plasma concentration of scopolamine is estimated to be 50 pg/mL. TTS-S attains that concentration after 6 hours; a steady state of about 100 pg/mL is achieved 8-12 hours after application. Yet 20-30% of subjects failed to attain the estimated protective concentration, and plasma concentrations measured in subjects who failed to respond to TTS-S were lower than in responders. These findings may explain some of the treatment failures. Overall, the product appears to be the approximate functional equivalent of a 72-hour slow intravenous infusion. A combination of transdermal and oral scopolamine (0.3 or 0.6 mg) was effective and well tolerated in producing desired plasma concentrations 1-hour post-treatment. TTS-S has proved to be significantly superior to placebo in reducing the incidence and severity of motion sickness by 60-80%. It was more effective than oral meclizine or cinnarizine, similar to oral scopolamine 0.6 mg or promethazine plus ephedrine, and the same as or superior to dimenhydrinate. The addition of ephedrine or the use of two patches did not improve its efficacy, but rather increased the rate of adverse effects. TTS-S was most effective against motion sickness 8-12 hours after application. Despite previous evidence to the contrary, a recent bioavailability study demonstrated similar intraindividual absorption and sustained clinical efficacy with long-term use of the drug. The adverse effects produced by TTS-S, although less frequent, are qualitatively typical of those reported for the oral and parenteral formulations of this agent. Dry mouth occurs in about 50-60% of subjects, drowsiness in up to 20%, and allergic contact dermatitis in 10%. Transient impairment of ocular accommodation has also been observed, in some cases possibly the result of finger-to-eye contamination. Low-dose pyridostigmine was found effective in preventing cycloplegia but not mydriasis. Adverse CNS effects, including toxic psychosis (mainly in elderly and paediatric patients), have been reported only occasionally, as have difficulty in urinating, headache, rashes and erythema. Adverse effects were not correlated with plasma scopolamine concentrations. TTS-S produced only about half the incidence of drowsiness caused by oral dimenhydrinate or cinnarizine, and a level of adverse effects similar to that found with oral meclizine. Performance is not affected by short-term use. Prolonged or repeated application may cause some impairment of memory storage for new information. However, sea studies revealed significantly less reports of a decrement in performance or drowsiness due to prevention of sea sickness. The recommended dosage is a single TTS-S patch applied to the postauricular area at least 6-8 hours before the anti-motion sickness effect is required. For faster protection, the patch may be applied 1 hour before the journey in combination with oral scopolamine (0.3 or 0.6 mg). After 72 hours, the patch should be removed and a new one applied behind the opposite ear. Its place in therapy is mainly on long journeys (6-12 hours or longer), to avoid repeated oral doses, or when oral therapy is ineffective or intolerable.

Personality analysis of patients complaining of sialorrhoea

BACKGROUND

Sialorrhoea, the symptom of apparent excessive secretion of saliva is a relatively uncommon complaint. Some authors consider that in the absence of clinical findings, then these patients have a psychiatric disorder masquerading as a physical illness. However, there is little evidence in the literature to support this conclusion and a detailed psychological assessment of this population has not previously been reported.

METHODS

In total, 18 patients and 18 age- and sex-matched controls were studied. All had a history of a complaint of excess salivation in the absence of any oral mucosal or systemic abnormality. All patients completed an Eysenck Personality Questionnaire.

RESULTS

There were no differences in the extroversion of psychoticism scores between the study and control group. However, the result showed significant increases in the neuroticism and Lie Scale score in the patient group.

CONCLUSIONS

The overall results of this study indicate that the complaint of sialorrhoea in otherwise healthy individuals does not have an organic basis and suggest that sialorrhoea is associated with high levels of neuroticism and a tendency to dissimulate.

EFNS task force on management of amyotrophic lateral sclerosis: guidelines for diagnosing and clinical care of patients and relatives. An evidence-based review with good practice points

Despite being one of the most devastating diseases known, there is little evidence for diagnosing and managing patients with amyotrophic lateral sclerosis (ALS). Although specific therapy is lacking, correct early diagnosis and introduction of symptomatic and specific therapy can have a profound influence on the care and quality of life of the patient and may increase survival time. This document addresses the optimal clinical approach to ALS. The final literature search was performed in the spring of 2005. Consensus recommendations are given graded according to the EFNS guidance regulations. Where there was lack of evidence but consensus was clear we have stated our opinion as good practice points. People affected with possible ALS should be examined as soon as possible by an experienced neurologist. Early diagnosis should be pursued and a number of investigations should be performed with high priority. The patient should be informed of the diagnosis by a consultant with a good knowledge of the patient and the disease. Following diagnosis, the patient and relatives should receive regular support from a multidisciplinary care team. Medication with riluzole should be initiated as early as possible. PEG is associated with improved nutrition and should be inserted early. The operation is hazardous in patients with vital capacity < 50%. Non-invasive positive pressure ventilation improves survival and quality of life but is underused. Maintaining the patients ability to communicate is essential. During the entire course of the disease, every effort should be made to maintain patient autonomy. Advance directives for palliative end of life care are important and should be fully discussed early with the patient and relatives respecting the patients social and cultural background.

Dysphagia: evaluation and treatment

The evaluation of dysphagia begins with a careful history, which usually points to the underlying cause in up to 80% of cases. The goals of the history are to distinguish oropharyngeal causes from esophageal causes of dysphagia and to distinguish mechanical from motor disorders of the esophagus in those patients with esophageal dysphagia. Evaluation typically begins with a videofluoroscopic examination in patients with oropharyngeal dysphagia and begins with a routine barium swallow or upper GI endoscopy in patients with esophageal dysphagia. Esophageal manometry may be an adjunct to the evaluation of patients with esophageal dysphagia, particularly to confirm specific motor disorders, such as achalasia. The management of functional causes of dysphagia is supportive and empiric given the lack of well-controlled treatment studies in this heterogenous group of patients.

Glycopyrrolate treatment of drooling in an adult male patient with cerebral palsy

1. The aim of the study was to assess the effect of glycopyrrolate on drooling in an adult male patient with cerebral palsy. 2. After a thorough medical examination and consent in writing by the responsible guardian, a baseline sum score for frequency and seriousness of drooling was established over a 2 week period in addition to data on shifts of handkerchiefs, urination, defecation and observation of behaviour. Glycopyrrolate (1 mg) tablets were then administered, starting with one tablet daily the third week and increasing the daily dose by one tablet per week until a maximum of four tablets during week six and 4 days of week seven when the daily dose was reduced to two tablets for 3 days. For the four weeks 8-11 three tablets were given daily. In week 12 the dose was reduced to two tablets and for the weeks 13-15 no tablets of glycopyrrolate were given. 3. For as long as the patient received three to four tablets of glycopyrrolate daily, drooling was markedly reduced and handkerchiefs were not necessary on some days. After the tablets were withdrawn drooling increased to approximately the same level as it was before treatment. No adverse medical, psychological, or social effects were observed. 4. For shorter periods, glycopyrrolate can be given in controlled doses provided that an adequate medical assessment has been undertaken.

Transdermal scopolamine for reduction of drooling in developmentally delayed children

Ten developmentally delayed children with excessive drooling were randomized in a double-blind, placebo-controlled study to assess the efficacy and safety of transdermal scopolamine. Over half of the patients had a statistically significant reduction in drooling, and one-third had cessation of drooling, while wearing the scopolamine patch. This short-term study supports earlier reports of the safety and efficacy of transdermal scopolamine for reducing excessive drooling in developmentally disabled children.