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Fayoux P, Dinomais M, Shaw H, Villain F, Schwartz D, Rondeau S, Letellier G, Auvin S. Glycopyrronium 320 μg/mL in children and adolescents with severe sialorrhoea and neurodisabilities: A randomized, double-blind, placebo-controlled trial. Dev Med Child Neurol 2024; 66:910-918. [PMID: 38214675 DOI: 10.1111/dmcn.15841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024]
Abstract
AIM To investigate the efficacy, safety, and impact on quality of life (QoL) of an oral formulation of 320 μg/mL glycopyrronium designed for children. METHOD A double-blind, placebo-controlled SALIVA (Sialanar plus orAl rehabiLitation against placebo plus oral rehabilitation for chIldren and adolescents with seVere sialorrhoeA and neurodisabilities) trial was conducted. Children (3-17 years) with neurodisabilities and severe sialorrhoea (modified Teachers Drooling Scale ≥6) were randomized to 320 μg/mL glycopyrronium or placebo, in addition to non-pharmacological standard care. RESULTS Of 87 participants, 44 were aged 10 years or under and 43 had cerebral palsy. The primary endpoint, change in total Drooling Impact Scale (DIS) score from baseline to day 84, was significantly greater (improved) with 320 μg/mL glycopyrronium versus placebo (median [quartile 1, quartile 3] -29.5 [-44.5, 0] vs -1 [-16, 5]; p < 0.001), an effect also observed at day 28 (median - 25 vs -2; p < 0.01). Significant reduction in bibs/clothes used per day was seen with glycopyrronium versus placebo at day 84 (median - 2 vs 0; p < 0.01). Glycopyrronium significantly improved DIS items 9 and 10 related to the extent that drooling affects the child's and family's life (p ≤ 0.03). Adverse events were reported by 77.3% and 69.8% of children with glycopyrronium and placebo respectively; the most common treatment-related adverse event was constipation (20.5% and 16.3%). INTERPRETATION The formulation of 320 μg/mL glycopyrronium significantly improved drooling and reduced its impact on QoL, with good tolerability in children with neurodisabilities. WHAT THIS PAPER ADDS The formulation of 320 μg/mL glycopyrronium significantly improved Drooling Impact Scale score versus placebo at day 84. The formulation reduced the impact of drooling on the child's and family's quality of life. There were no safety or tolerability concerns with this specific formulation.
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Affiliation(s)
- Pierre Fayoux
- Department of Paediatric Otolaryngology Head Neck Surgery, Jeanne de Flandre Hospital, Lille, France
- ULR 2694 - METRICS: Évaluation des technologies de santé et des pratiques médicales, Université de Lille, Lille, France
| | - Mickael Dinomais
- Department of Physical Medicine and Rehabilitation, CHU Angers-Les Capucins, Angers, France
| | | | | | | | - Stéphane Rondeau
- Department of Early Medico-Social Action (CAMSP), CHU de Rouen, Rouen, France
| | - Guy Letellier
- Department of Physical Medicine and Rehabilitation, ESEAN-APF, Nantes, France
| | - Stéphane Auvin
- APHP, Service de Neurologie Pédiatrique, EpiCARE ERN membre, Hôpital Robert Debré, Paris, France
- INSERM NeuroDiderot, Université Paris-Cité, Paris, France
- Institut Universitaire de France (IUF), Paris, France
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Fayoux P, Dinomais M, Shaw H, Probert N, Villain F, Pouchain D, Texier N, Auvin S. Randomised, double-blind, placebo-controlled trial of glycopyrronium in children and adolescents with severe sialorrhoea and neurodisabilities: protocol of the SALIVA trial. BMJ Paediatr Open 2023; 7:10.1136/bmjpo-2023-001913. [PMID: 37156563 PMCID: PMC10173983 DOI: 10.1136/bmjpo-2023-001913] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 04/20/2023] [Indexed: 05/10/2023] Open
Abstract
INTRODUCTION Severe sialorrhoea is a common, distressing problem in children/adolescents with neurodisabilities, which has adverse health and social consequences. The SALIVA trial is designed to evaluate the efficacy and safety of a paediatric-specific oral solution of glycopyrronium along with its impact on quality-of-life (QoL), which has been lacking from previous trials of sialorrhoea treatments. METHODS AND ANALYSIS A double-blind, placebo-controlled, randomised phase IV trial is ongoing in several centres across France. Eighty children aged 3-17 years with severe sialorrhoea (≥6 on the modified Teachers Drooling Scale) related to chronic neurological disorders in whom non-pharmacological standard of care has already been implemented or has failed, will be recruited. Patients will be randomised 1:1 to receive a 2 mg/5 mL solution of glycopyrronium bromide (Sialanar 320 µg/mL glycopyrronium) or placebo three times daily during a 3-month blinded period. After Day 84, participants will be invited into a 6-month, open-label study extension period, where they will all receive glycopyrronium. The primary endpoint of the double-blind period will be the change from baseline to Day 84 in the Drooling Impact Scale (DIS), a validated measure to assess sialorrhoea. A series of secondary efficacy endpoints involving change in total DIS, specific DIS items and response (DIS improvement ≥13.6 points) will be analysed in a prespecified hierarchy. QoL data will be collected from parents, caregivers and patients where possible using specific DIS questions and DISABKIDS questionnaires. Safety endpoints, including adverse events, will be assessed throughout the trial periods. ETHICS AND DISSEMINATION In total, 87 children have been recruited and recruitment is now complete. Final results are expected by the end of 2023. Findings will be presented at conferences and published in peer-reviewed journals. TRIAL REGISTRATION NUMBER EudraCT 2020-005534-15.
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Affiliation(s)
- Pierre Fayoux
- Department of Paediatric Otolaryngology Head Neck Surgery, Jeanne de Flandre Hospital, Lille, France
| | - Mickael Dinomais
- Department of Physical Medicine and Rehabilitation, CHU Angers, Angers, France
| | - Helen Shaw
- Proveca Limited, Manchester, England, UK
| | | | | | - Denis Pouchain
- Department of General Practice, University of Tours, Tours, France
| | | | - Stéphane Auvin
- Service de Neurologie Pédiatrique, Robert-Debré Mother-Child University Hospital, Paris, France
- INSERM NeuroDiderot, Université Paris Cité, Paris, France
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Abstract
Pediatric leukodystrophies are rare neurodegenerative diseases involving multiple systems. Each form has unique neurologic features but are characterized by encephalopathy with accompanying impairments evidenced in reflexes, muscle tone and movement control. Weakness of expiratory, inspiratory, and upper airway muscles may lead to impaired airway secretion clearance resulting in recurrent respiratory infections, dysphagia, sleep-disordered breathing, restrictive lung disease, and ultimately chronic respiratory insufficiency.
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Riva A, Amadori E, Vari MS, Spalice A, Belcastro V, Viri M, Capodiferro D, Romeo A, Verrotti A, Striano P. Impact and management of drooling in children with neurological disorders: an Italian Delphi consensus. Ital J Pediatr 2022; 48:118. [PMID: 35854335 PMCID: PMC9297577 DOI: 10.1186/s13052-022-01312-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 06/24/2022] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND The rate of chronic drooling in children older than 4 years is 0.5%, but it rises to 60% in those with neurological disorders. Physical and psychosocial consequences lead to a reduction in the quality of Life (QoL) of affected patients; however, the problem remains under-recognized and under-treated. We conducted an Italian consensus through a modified Delphi survey to discuss the current treatment paradigm of drooling in pediatric patients with neurological disorders. METHODS After reviewing the literature, a board of 10 experts defined some statements to be administered to a multidisciplinary panel through an online encrypted platform. The answers to the questions were based on a 1-5 Likert scale (1 = strongly disagree; 5 = strongly agree). The scores were grouped into 1-2 (disagreement) and 4-5 (agreement), while 3 was discarded. The consensus was reached when the sum of the disagreement or agreement was ≥75%. RESULTS Fifteen statements covered three main topics, namely clinical manifestations and QoL, quantification of drooling, and treatment strategies. All statements reached consensus (≥75% agreement). The 55 Italian experts agreed that drooling should be assessed in all children with complex needs, having a major impact on the QoL. Attention should be paid to investigating posterior hypersalivation, which is often neglected but may lead to important clinical consequences. Given that the severity of drooling fluctuates over time, its management should be guided by the patients' current needs. Furthermore, the relative lack of validated and universal scales for drooling quantification limits the evaluation of the response to treatment. Finally, the shared therapeutic paradigm is progressive, with conservative treatments preceding the pharmacological ones and reserving surgery only for selected cases. CONCLUSION This study demonstrates the pivotal importance of a multidisciplinary approach to the management of drooling. National experts agree that progressive treatment can reduce the incidence of complications, improve the QoL of patients and caregivers, and save healthcare resources. Finally, this study highlights how the therapeutic strategy should be reconsidered over time according to the available drugs on the market, the progression of symptoms, and the patients' needs.
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Affiliation(s)
- Antonella Riva
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Via Gaslini 5, 16148, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
| | - Elisabetta Amadori
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Via Gaslini 5, 16148, Genoa, Italy.,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy
| | - Maria Stella Vari
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Via Gaslini 5, 16148, Genoa, Italy
| | - Alberto Spalice
- Department of Pediatrics, "Sapienza" University of Rome, Rome, Italy
| | | | - Maurizio Viri
- Department of Child Neuropsychiatry, Hospital Maggiore della Carità, Novara, Italy
| | - Donatella Capodiferro
- Department of Biomedical Sciences and Human Oncology, Neonatology and Intensive Care Neonatal Unit Section, University of Bari Aldo Moro, Bari, Italy
| | - Antonino Romeo
- Pediatric Neurology Unit and Epilepsy Center, Fatebenefratelli Hospital, ASST Fatebenefratelli Sacco, Milan, Italy
| | | | | | - Pasquale Striano
- Pediatric Neurology and Muscular Diseases Unit, IRCCS Istituto Giannina Gaslini, Via Gaslini 5, 16148, Genoa, Italy. .,Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health, University of Genova, Genoa, Italy.
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Jost WH, Steffen A, Berweck S. A critical review of incobotulinumtoxinA in the treatment of chronic sialorrhea in pediatric patients. Expert Rev Neurother 2021; 21:1059-1068. [PMID: 34516331 DOI: 10.1080/14737175.2021.1979959] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Sialorrhea, also known as hypersalivation, ptyalis, or drooling, results in physical and psychosocial complications that may have a significant negative impact on quality of life for both the patient and their caregiver. The goal of pharmacological treatment is to reduce excessive salivary flow, while maintaining a moist and healthy oral cavity; until recently, however, few of the agents used to treat chronic sialorrhea have been approved in pediatric patients. AREAS COVERED This article summarizes early evidence for the use of botulinum neurotoxin A formulations in the treatment of children/adolescents with chronic sialorrhea, and findings of the recently completed phase III trial of incobotulinumtoxinA in this indication. Alternative therapies are also briefly discussed. EXPERT OPINION IncobotulinumtoxinA is the first botulinum neurotoxin A to be approved for the treatment of chronic sialorrhea in children and adults, following the results of phase III trials that demonstrate the efficacy and safety of the drug in these patients. The authors expect that the positive findings will result in updates to clinical guidelines for the treatment of children with chronic sialorrhea. ABBREVIATIONS AE, adverse event; AESI, adverse event of special interest; BoNT/A, botulinum neurotoxin A; CI, confidence interval; CP, cerebral palsy; DIS, drooling impact scale; DQ, drooling quotient; DSFS, Drooling Severity and Frequency Scale; GICS, Global Impression of Change Scale; LS, least squares; mTDS, modified Teacher's drooling scale; NR, not reported; PD, Parkinson's disease; SAE, serious adverse event; SE, standard error; SIAXI, Sialorrhea in Adults Xeomin Investigation; SIPEXI, Sialorrhea Pediatric Xeomin Investigation; SNAP-25, synaptosomal associated protein-25; TBI, traumatic brain injury; TDS, Teacher Drooling Scale; USA, United States of America; uSFR, unstimulated Salivary Flow Rate; VAS, visual analog scale.
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Affiliation(s)
| | - Armin Steffen
- Department for Otorhinolaryngology, University of Lübeck, Lübeck, Germany
| | - Steffen Berweck
- Specialist Center for Paediatric Neurology, Neurorehabilitation and Epileptology, Schön Klinik, Vogtareuth, Germany.,Department of Pediatric Neurology and Developmental Medicine, LMU Center for Children with Medical Complexity - Integrated Social Pediatric Center, Dr. Von Hauner Children's Hospital, Ludwig Maximilians-University, Munich, Germany
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