Drooling in Parkinson’s disease - Management of
|Next review: 21/04/2024|
|Approved By: Trust Clinical Guidelines Group|
|Copyright© Leeds Teaching Hospitals NHS Trust 2021|
This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
Management of Drooling in Parkinson’s disease
Saliva plays a vital role in facilitating swallowing, speaking and maintaining oral health. Inability to control oral secretions is known formally as ‘sialorrhea’ and informally as ‘drooling’. It leads to excessive saliva accumulation - it is not an issue with overproduction of saliva.
In Parkinson’s disease, this may be due oro-facial rigidity, lingual bradykinesia and aspects of oro-pharyngeal dysphagia. Drooling can have a distressing impact and lead to reduced social interactions through embarrassment, oral odour as well as clinical issues such as skin breakdown, aspiration and infection.
Early intervention, even when symptoms are not unduly bothersome should be considered to prevent potential complications. Severity should be assessed, and the need for treatment to be established.
On the recommendation of Speech and Language Therapist (SLT)
- Attention to posture (e.g. raising eye level of reading material/computer screens, activities that require leaning forward)
- Support collars
- Boiled sweets/chewing gum (if eating IDDSI Level 7 Regular foods - use with caution as can also exacerbate the accumulation and production)
- Frequently sipping drinks
- Swallow prompts (e.g. apps (https://speechtools.co/swallow-prompt), timers, verbal reminder from a companion)
- Sage (tea, tincture, capsules)
- Dark grape juice
- Surgical intervention (including radiotherapy and salivary gland removal)
- Avoiding acidic foods/fruits
- Avoiding alcohol
Factors to consider prior to initiating pharmacological therapy include:
- past medical history - some therapies are contraindicated or advised to use with caution in certain conditions (e.g. glaucoma, urinary retention, cardiovascular disorders, dementia)
- current medication and allergy status - patients already taking medicines with anti-muscarinic effects. Where clinically appropriate consider titrating the dose of existing therapy before initiating any of the following options
- consider how long pharmacological therapy is needed. E.g. if short-term consider oral or sublingual treatment options
- as always involve patient in the decision-making
For all therapies, use the minimum effective dose to manage symptoms and monitor closely for reduce potential for anti-cholinergic (e.g. dry mouth, blurred vision, confusion, constipation, urinary retention). Patients started on an individual therapy should have a review of efficacy/adverse effects at 5 to 7 days after a dose change, or at a frequency decided on an individual basis.
Xeomin (Clostridium Botulinum neurotoxin type A)
Licensed for symptomatic treatment of chronic sialorrhea due to neurological disorders
Not interchangeable with other Botulinum toxin type A preparations
For further information refer to the Summary of Product Characteristics:
- reconstitute with sodium chloride 0.9 % solution for injection in accordance with good clinical practice guidelines
- repeat doses a minimum of every 16 weeks
- may be considered first line in long term patients or where multiple daily dosing could be a problem/patient unable to administer the dose of liquid/drops.
Glands - site of administration
30 per side
0.6 ml per injection
20 per side
0.4 ml per injection
Atropine 1% drops sublingually
- The only available preparation is in the form of eye drops - please take care when prescribing and educating patient/carer., as this is an un-licensed use of a licensed medicine.
- Administer: sublingually (under the tongue – note this is an unlicensed use)
- Starting dose: 1 drop twice a day (increasing to 1 drop four times a day - liaise with pharmacy)
- Patients may experience a bitter taste and patients with limited dexterity may struggle with self-administration
- Caution if patient has any cardiac co-morbidities, as systemic absorption may occur.
- For further information refer to the Summary of Product Characteristics: https://www.medicines.org.uk/emc/product/3297/smpc
- Has a long duration of action and less likely to cause central or cardiac –related adverse effects
- Glycopyrronium bromide 400micorgrams/mL (Sialanar®) oral solution, for use in patients with dysphagia and/or an enteral tube in situ.
- For further information refer to the Summary of Product Characteristics:
- Still monitor closely for anticholinergic effects but does not cross the blood brain barrier, so less likely to cause central nervous system anti-muscarinic effects.
400 micrograms – 1 milligram
600micrograms – 1.2 milligrams
Three times a day (TDS)
Continuous infusion over 24 hours and 200 micrograms subcutaneous bolus as needed
Palliative / EOL
See LTHT guidance - A Guide to Symptom Management in Palliative Care:
|Clinical condition:||Parkinson's disease|
|Target patient group:|
|Target professional group(s):||Pharmacists
Secondary Care Doctors
Secondary Care Nurses
International Dysphagia Diet Standardisation Initiative (IDDSI). 2016. The IDDSI Framework. Available online: https://iddsi.org/framework/
National Institute for Health and Care Excellence (NICE): Evidence Summary - Severe sialorrhoea (drooling) in children and young people with chronic neurological disorders: oral glycopyrronium bromide. Available online: https://www.nice.org.uk/advice/es5/chapter/Introduction-and-current-guidance
Owen S, 2017. Hypersalivation – can glycopyrronium be used to treat it? Available online: https://www.sps.nhs.uk/wp-content/uploads/2015/11/UKMi_QA_Hypersalivationglycopyrronium_update-May-2017.doc
Owen S, 2017. Hypersalivation – what drug treatment options are available? Available online: https://www.sps.nhs.uk/articles/hypersalivation-d-what-drug-treatment-options-are-available/
Summary of Product Characteristics - see individual drug monographs
Trust Clinical Guidelines Group
LHP version 1.0
Equity and Diversity
The Leeds Teaching Hospitals NHS Trust is committed to ensuring that the way that we provide services and the way we recruit and treat staff reflects individual needs, promotes equality and does not discriminate unfairly against any particular individual or group.