Advice for Neurologists Treating Patients With Sialorrhea


Stuart Isaacson, MD: Because we’ve had these new approvals for indications for treating sialorrhea with botulinum toxic injections, and we’ve been able to talk about some of these studies, especially the Myobloc studies that were done in the United States, and talking to investigators and clinicians about it, I’m struck that a lot of clinicians taking care of people with Parkinson disease are interested in sialorrhea. They’re interested in hearing about the mechanisms, and the glands, and the autonomic involvement, and how toxic substances bind to muscarinic receptors. They’re interested in all that. They’re interested in knowing what question or 2 they can ask. I like your suggestion of the UPDRS [Unified Parkinson Disease Rating Scale] questionnaire. It’s a good screening question. And they’re not so sure about whom to treat—but I think we’ve covered some of that—and deciding when we should be treating a patient and how to present that to patients. Yet they’re often not treating with toxic injections. They may prescribe an anticholinergic that might be limited by systemic adverse effects. But why don’t you think more clinicians who treat people with Parkinson disease are not injecting, say, Myobloc into the salivary glands?

Richard M. Trosch, MD: I think they’re just not comfortable doing the procedure. No one has shown them how to do it or when to do it. And it may just be a matter of education. I believe the number that I heard of unique physicians who have used the 64611 procedure code for sialorrhea in the United States is 82.

Stuart Isaacson, MD: Under 100.

Richard M. Trosch, MD: There are 1,000,000 Parkinson patients, so that’s 750,000 with sialorrhea. Unless those 82 are really busy, most patients with sialorrhea are not being treated. It’s an easy procedure. It’s something I think I could teach a physician to do in about 5 minutes if they’re just using anatomic guidance. It’s a pretty safe procedure. There’s not a lot of systemic effects of these drugs. It’s mostly a local effect, and particularly if you’re just doing parotids, it’s just dry mouth, and you can avoid that.

Stuart Isaacson, MD: Temporary.

Richard M. Trosch, MD: Temporary dry mouth that you could avoid by starting at very low doses and working up until you find the dose that’s correct for that person. It’s a relatively safe and easy procedure. It doesn’t require a lot of equipment; just anatomic guidance. You need some 30-gauge ½-inch needles and a 1 cc syringe, and you have another procedure that can help you.

Stuart Isaacson, MD: It’s probably 1 of the simpler botulinum toxic injection paradigms compared with some of the others.

Richard M. Trosch, MD: A lot easier than doing migraine that neurologists picked up on pretty quickly. A lot easier than cervical dystonia or some of the other treatments—blepharospasm, hemifacial certainly requires a lot more expertise. These are big targets. Somewhere in here will do for most people. I’m hoping more physicians learn to do this procedure, because it’s certainly needed.

Stuart Isaacson, MD: We’ve covered a lot of ground today when talking about sialorrhea in Parkinson disease patients. I think in this era of shared clinical decision making and informing our patients and getting their input, it’s important to present all the options of what we can treat because a lot of things we can’t treat yet.

Richard M. Trosch, MD: Right.

Stuart Isaacson, MD: But the things we can treat, patients ought to be aware of it, and we ought to be able to tell them these things. Is there any last take-home message or 2 that you would share with your long experience treating sialorrhea in Parkinson patients?

Richard M. Trosch, MD: Well, I’d say most patients are going to do well. It’s not 100% effective, but it’s probably in the high 90s. It’s very rare that I see a patient and I can’t substantially diminish their drooling or completely eliminate it for a period of time. I think once you inject someone and they do well, they’ll keep coming back. Because even if they weren’t certain the first time if they needed it, when they see the difference, they’ll see the benefit. The caregivers see the benefit, and it is a huge burden for caregivers as well as patients. It’s more than just a cosmetic issue to keep in mind. There is a significant risk of aspiration. When patients are having aspiration pneumonia in Parkinson disease, it’s not food they’re aspirating, it’s secretions, and it’s from this excessive saliva. So it’s a nice thing to do for patients. It lessens their caregiver burden. It has cosmetic benefits for patients but also makes their lives, and it’s an easy procedure that I think physicians can pick up pretty quickly.

Stuart Isaacson, MD: Yeah, and the embarrassment and social withdrawal, especially going out to restaurants and such, is much more important than we give it credit for. Because we want our patients to be active and not limit their lives. This would be a terrible reason to not do some of those things.

Well, this has been extremely informative. Thank you, Dr Trosch, for this insightful discussion. And thank you to our audience for watching this NeurologyLive® presentation on “Management of Sialorrhea in Parkinson Disease.” We hope you have found this Peers & Perspectives® discussion to be useful and informative.

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