to the editor: In their article, “Sialorrhea: A Management Challenge,”¹ the authors advocate the use of glycopyrrolate tablets and scopolamine (Transderm Scop) topical patches for the treatment of sialorrhea. I propose that physicians also should consider two alternatives: low-dose atropine sulfate tablets and scopolamine hydrobromide tablets.

One study² documented that oral administration of atropine reduced the amount of resting secretion, intraoral accumulation, and pharyngeal-laryngeal pooling of saliva by more than 50 percent of baseline levels, with negligible side effects. Another study³ demonstrated depression of salivation up to 80 percent in healthy adult patients taking oral atropine.

Atropine tablets reduce salivation in infants, children, and adults. The medication may be administered every four to six hours as needed. The average wholesale price of atropine tablets is approximately one third of the price of glycopyrrolate tablets.⁴

Scopolamine tablets may be administered every eight hours as needed. This medication warrants consideration as a substitute for the scopolamine patch because of its dosing flexibility, faster onset of action, shorter duration of action, and significantly lower cost.^4,5

in reply: We appreciate Dr. Sherman’s insights into additional medical treatment options for sialorrhea and agree that a variety of preparations of anticholinergic medications may offer promising results. Unfortunately, study of the use of low-dose atropine sulfate tablets or scopolamine hydrobromide tablets for the treatment of sialorrhea is limited, especially in children.

Although oral anticholinergic medications are consistently reliable in their reduction of sialorrhea, side effect profiles frequently result in discontinuation of their use.^1,2 A retrospective review and a prospective randomized trial of the use of transdermal scopolamine for the treatment of drooling demonstrate high efficacy and low toxicity.^3,4

Dr. Sherman references a case report⁵ of the use of atropine to control sialorrhea in a patient with a closed head injury. The toxicities frequently associated with systemic anticholinergics may not have been apparent in this patient because of his underlying mental status. Dr. Sherman further indicates that oral atropine was demonstrated to reduce salivation by up to 80 percent in healthy adults; the applicability of this data to patients with pathologic sialorrhea has not been elucidated.⁶

Although there is potentially a variety of cost-effective, efficacious medications in the treatment of sialorrhea, further study is indicated.