Current treatments for thin, watery hypersalivation in MND include conservative methods, anti-muscarinics, and Botulinum toxin injection or radiotherapy of the salivary glands (Young, Ellis, Johnson, Sathasivam, & Pih, 2011).Objective
To report a case of sialorrhea in an MND patient in whom conventional treatment options were not helpful or tolerated. Morphine was trialled and found to reduce symptoms.Results
W is a 42-year-old gentleman who was diagnosed with MND in 2013 needing BiPAP ventilation by January 2015. In February 2016, W presented with sialorrhea, and was started on 12.5 mg Amitriptyline once nightly. However, he developed daytime somnolence, without significant symptom improvements and was switched to Benzhexol (Artane), 2 mg/day in March. W was also trialled on Oramorph 2–4 mg PRN as an adjunct to Benzhexol, which he took about twice daily.Results
In August 2016, W presented with increased mucus plugging of his lower respiratory tract, intolerably dry oral mucosa, and thick oral secretions that became stuck at the back of his throat. Benzhexol was stopped and W underwent one session of radiotherapy. This only reduced his sialorrhea for 2 weeks, after which W developed salivary flooding every 1–2 hours. Morphine was then delivered via a continuous subcutaneous infusion (CSCI) 20 mg/24 hours, which improved W’s symptoms and alleviated salivary flooding.Results
As the MND progressed, W developed an ineffective cough and was unable to clear thick lower respiratory tract secretions. A cough assist machine was introduced.Results
W is currently on 25 mcg Fentanyl Patch (72 hourly) and a cough assist machine. W does not report any problems with daytime drowsiness, excessively dry oral mucosa, salivary flooding or thick secretions in the upper or lower respiratory tract.Conclusion
We propose that opioids have a measure of anticholinergic effects, which when used as an adjunct with existing therapies for MND, address the balance between excessive watery secretions and thick mucus plugging.