Drugs Affecting Salivary flow

Question 1

Recount appropriate patient questions regarding xerostomia

Answer 1

1. Does your mouth feel dry?
2. Does your mouth feel dry when eating a meal?
3. Do you have difficulty swallowing dry foods?
4. Do you use liquids to aid in swallowing dry foods?
5. Do you have too little saliva in your mouth most of the time?
6. Is the dryness constant or only present at night?

Question 2

Recall drugs most commonly associated with xerostomia as an ADE

Answer 2

ANTI-HISTAMINES (1st gen): Diphenhydramine, Chlorpheniramine

Decongestants: 
Antidepressants
Anti-psychotics: 
Anti-hypertensives:
Anti-cholinergics:

Question 3

Describe the common causes of temporary and chronic salivary gland
hypofunction

Answer 3

Short term drug use (antihistamines)
Viral infection (mumps)
Dehydration
Psychological (anxiety)

Question 4

Explain the etiology of Sjorgens syndrome and describe an appropriate
patient treatment plan.

Answer 4

Sjogrens syndrome is caused by the auto immune destruction of the tear and salivary glands.
Treatment involves relief of symptoms with DMARDs, water, saliva substitute and enhanced dental care.

Question 5

Describe the process of saliva secretion and the control exerted by the
sympathetic and parasympathetic nervous systems and by locally
derived modulators

Answer 5

Ach –> M3 (Gq) –> IP3/Ca –> opens apical membrane Cl and basolateral K channels –> Secretion

NE –> Adenylate cyclase –> cAMP –> Secretion

Question 6

Explain the clinical role of amifostine in reducing radiation-induced
salivary gland dysfunction

Answer 6

Amifostine can be given to patients radiation treatment because it has been shown to reduce acute and chronic Xerostomia without adversely affecting the efficacy of the cancer treatment.

Question 7

Recall the drugs used in the treatment of hypersalivation and their
mechanisms of action

Answer 7

Botulinum Toxin
Scopolamine
Hyoscyamine (off label)
Glycopyrrolate (off label)

Question 8

What are the drugs used to treat xerostomia?

Answer 8

Cevimiline
Pilocarpine
Amifostine

Question 9

What are the saliva substitutes that are used to treat xerostomia?

Answer 9

They all sound like they would be moist.

Oasis
Salivert
Caphosol
Numoisyn
Aquoral
NeutraSal
Mouth Kote

Question 10

What are the health consequence of salivary gland dysfunction?

Answer 10

1. Difficulty chewing, swallowing, and speaking
2. Increased risk of mucosal, gingival, and tongue lesions.
3. Halitosis
4. Taste alteration

Question 11

What is a key difference in the saliva secretion stimulated by the parasympathetic nervous system versus the sympathetic nervous system?

Answer 11

Parasympathetic stimulation causes the secretion of copious amounts of protein poor saliva.
Sympathetic innervation causes the secretion of more sparse but protein rich saliva.

Question 12

Compare and contrast the ADME of pilocarpine and cevimeline

Answer 12

Cevimeline: Oral dose (30mg) every 8 hrs, CYP 3A3/4, CYP 2D6

Pilocarpine: Oral dose (5mg) every 6 hours. NO CYPs

Question 13

Compare and contrast the Receptor specificity of Cevimeline and Pilocarpine?

Answer 13

Cevimeline: M3»M1

Pilocarpine: All muscarinic receptors

Question 14

Compare and contrast the AEs associated with Cevimeline and Pilocarpine?

Answer 14

Cevimeline: Contra-(asthma, glaucoma, iritis)
CV problems
pregnancy/breastfeeding
decreased visual acuity
COPD, cholelithiasis, children
Children/geriatric.

Pilocarpine: Contra-(same as Cevimeline)
Same AEs plus psychosis due to more CNS activity.

Question 15

What is the MOA of amifostine?

Answer 15

Scavenger of free radicals. Used as cytoprotective agent in cisplatin therapy

Question 16

What is the MOA of Cevimeline?

Answer 16

Muscarinic agonist (M3 selective)

Question 17

What is the MOA of pilocarpine?

Answer 17

non-selective muscarinic agonist

Question 18

What drugs are especially linked to pill esophagitis?

Answer 18

bisphosphonates