Botulinum Toxin Injections Provide Relief for Excessive Saliva Production in ALS Patients: A Promising Treatment Option

Excessive saliva production, known as sialorrhea, is a distressing symptom experienced by patients with amyotrophic lateral sclerosis (ALS). This condition can lead to complications such as aspiration and frequent hospital visits. While anticholinergic medications have been commonly used to manage sialorrhea, they are associated with systemic side effects. However, a small retrospective study suggests that botulinum toxin (BoNT) injections may offer a well-tolerated and safe alternative for ALS patients. This article explores the findings of the study and highlights the potential of BoNT injections as a frontline therapy for ALS-associated sialorrhea.

The study, conducted at a single ALS center from 2013 to 2023, included 19 veterans with ALS. The researchers evaluated the patients’ health records to analyze the frequency and timing of BoNT injections, as well as immediate adverse events (AEs). The results showed that 47.7% of the patients received multiple BoNT injections, and 26.3% discontinued the injections due to changes in salivary secretion. Additionally, in 26% of the cases, one or more antisialagogues were stopped after BoNT injections. Before the study intervention, a third of the patients were taking three or more oral medications simultaneously. Importantly, no immediate postprocedural complications were reported.

Dr. Joshua Wilson, from the University of Washington/Seattle VA Medical Center, emphasized that BoNT injections provide a temporary fix for sialorrhea in most patients. He acknowledged that the effect is nondurable, but noted that it offers a favorable alternative to the systemic side effects associated with anticholinergic medications. While the study did not directly compare the effectiveness of BoNT injections to oral medications, some patients were able to discontinue systemic therapies with the introduction of BoNT injections. This finding highlights the potential benefits of BoNT as a frontline therapy for ALS-associated sialorrhea.

Following tracheostomy, nearly 88% of the patients continued to receive BoNT injections. This suggests that physicians recognize the efficacy and safety of the treatment option in managing sialorrhea even in more advanced stages of the disease. Dr. Wilson expressed his intention to explore the possibility of initiating BoNT injections as a front-line therapy for ALS sialorrhea. The advantage of working in Veterans Affairs facilities is the reduced need for insurance authorization, allowing for potentially earlier initiation of botulinum toxin therapy.

Patients with ALS often face difficulties with swallowing, and the excess saliva in the mouth can lead to aspiration, bulbar crises, and increased hospital visits. Sialorrhea significantly impacts the quality of life of ALS patients, leading to increased social isolation due to the need for frequent mouth and throat suctioning. Recognizing the burdensome nature of sialorrhea, the need for effective and well-tolerated treatment options becomes paramount.

While the FDA has approved the use of incobotulinumtoxinA (Xeomin) for chronic sialorrhea in adults and children, there has been limited research investigating its use specifically in ALS patients. However, the findings from this study suggest that BoNT injections are a viable treatment option for sialorrhea in ALS patients. Further research and clinical trials are warranted to establish the long-term efficacy, optimal dosing, and timing of BoNT injections to maximize the benefits for ALS patients.

Sialorrhea is a distressing symptom experienced by ALS patients, significantly impacting their quality of life. This small retrospective study demonstrates that BoNT injections provide relief from sialorrhea and offer a well-tolerated and safe therapy option compared to traditional anticholinergic medications. The temporary relief provided by BoNT injections and the potential to discontinue systemic therapies highlight the promising nature of this treatment approach. Further exploration and research into the early initiation of BoNT injections as a front-line therapy for ALS-associated sialorrhea are necessary to optimize patient outcomes. By addressing this debilitating symptom, healthcare providers can improve the well-being and overall quality of life for ALS patients.


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