Clozaril and Sialorrhea

[gabaergic1]

I'm not super experienced with managing Clozaril side effects but I've done the atropine thing a couple of times on inpatient services (sublingual). I was always under the impression that cogentin isn't frequently necessary with Clozaril due its own anticholinergic effects...I had an attending ask me to do both atropine ("swish and spit" dilution) and cogentin at one time for massive drooling. Is the drooling mechanism poorly understood?...Or was my attending a bit rusty on the topic?

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[michaelrack]

You can try atrovent nasal spray.

 

[FrasierMD]

Both atropine and cogentin are anticholinergic so not necessarily countering one another if giving both. I remember reading somewhere that excess drooling can be secondary to the alpha1 blockade and vasodilation as well.

 

[billypilgrim37]

Try glycopyrrolate.

 

[masterofmonkeys]

Try glycopyrrolate.

I've had my best success with glycopyrrolate.

 

[notdeadyet]

Try glycopyrrolate.

Ditto this.

 

[gabaergic1]

I've had my best success with glycopyrrolate.

how much and how often

 

[Psychobabbling]

Usually start at 2 to 4 mg qHS. Doesn't cross BBB (so no added memory issues) but adds to anticholinergic effects in the periphery. Probably would want to add some Colace, especially if they're older

 

[whopper]

Atropine eye drops. No I'm not joking. I never heard of it until working at a long-term psych facility and it's state approved so this isn't something not reviewed. The eye drops are put in a cup of water and the patient is asked to swish and spit out. I forgot, however, the exact recipe. It was one of those options on the computer as an automatic click. If you want me to ask for the recipe post here or PM me.

 

[Ron Mexico]

As I understand it, Clozapine antagonizes m1,m2,m3,m5 but is a agonist at m4 which is partly responsible for secretory action. There is some alpha blocking activity that is involved as well.

 

[F0nzie]

Atropine eye drops. No I'm not joking. I never heard of it until working at a long-term psych facility and it's state approved so this isn't something not reviewed. The eye drops are put in a cup of water and the patient is asked to swish and spit out. I forgot, however, the exact recipe. It was one of those options on the computer as an automatic click. If you want me to ask for the recipe post here or PM me.

Interesting!

Found this off the web from a site about motor neuron diseases:

Atropine - anecdotal experience in community settings suggests that 1% strength atropine eye drops can be used orally to reduce saliva production. Drops can be diluted 1ml in 100ml of water and used as a mouth rinse up to three times a day. For patients who are physically unable to rinse their mouth 2 or 3 drops can be given sublingually up to 3 times a day.

Same recipe? I'm thinking of trying this for one of my patients since they are already on a ton of PO meds.

 

[285963]

I just got off an inpatient palliative care rotation last month. We often used atropine drops sublingually for patients who were being transitioned to comfort care. The EMR would not give a sublingual route as an option for delivery so we would put an addendum to the order for the nurse to give it sublingually rather than to the eyes. 2 drops q1-2 hours. It would decrease saliva production so there would be no "rattling" upper-respiratory noises from the saliva dripping to the back of the patient's throat with a decreased swallowing function. It seemed to work pretty well for most of our patients.

 

[whopper]

That's pretty much the recipe Fonzie. I haven't double checked the exact one but it sounds about the same. The one I'm talking about is state approved in Ohio and to get that approval several psychiatrists appointed by the state along with pharmacists had to put it for review. In short, if you ever prescribed such a treatment, it's not completely out there. If you want me to get the exact recipe let me know just in case you want to CYA.

When doing long-term psychiatric care and working in a facility for such, the treatment focus is very different from usual psychiatric units. It's not out of the ordinary to have maximum dosages way above FDA approved levels and have several pharmacists and doctors working at the institution that are familiar with evidenced-based data showing this has some merit to it (and you're dealing with very treatment resistant patients).

Likewise you get a lot of patients on Clozapine and doctors with excellent experience in dealing with it. Before I worked for the state in a long-term facility I probably only had a handful of patients on Clozapine. After leaving the state hospital I probably treated a few dozen on Clozapine.

 

[F0nzie]

That's pretty much the recipe Fonzie. I haven't double checked the exact one but it sounds about the same. The one I'm talking about is state approved in Ohio and to get that approval several psychiatrists appointed by the state along with pharmacists had to put it for review. In short, if you ever prescribed such a treatment, it's not completely out there. If you want me to get the exact recipe let me know just in case you want to CYA.

When doing long-term psychiatric care and working in a facility for such, the treatment focus is very different from usual psychiatric units. It's not out of the ordinary to have maximum dosages way above FDA approved levels and have several pharmacists and doctors working at the institution that are familiar with evidenced-based data showing this has some merit to it (and you're dealing with very treatment resistant patients).

Likewise you get a lot of patients on Clozapine and doctors with excellent experience in dealing with it. Before I worked for the state in a long-term facility I probably only had a handful of patients on Clozapine. After leaving the state hospital I probably treated a few dozen on Clozapine.

Thanks for the reply. I have a handful of Clozapine patients but none of them have sialorrhea. The one I am working with now developed sialorrhea after I started Fluphenazine. I don't want to stop it because nothing else has helped with psychosis.