Feasibility and structure of a state hospital botulinum neurotoxin clinic for clozapine-induced sialorrhea

Clozapine is uniquely effective for treatment-resistant schizophrenia, treatment-resistant mania, and for aggression, suicide, or psychogenic polydipsia related to schizophrenia. Among its adverse effects, sialorrhea is an important barrier to clozapine treatment. Topical anticholinergic medications show limited efficacy, while systemic anticholinergics carry elevated risks of constipation, bowel impaction, or ileus. A superior treatment option for clozapine-induced sialorrhea exists in the form of periodic injection of major salivary glands with botulinum neurotoxin. This paper describes the feasibility and logistical issues involved in establishing a botulinum treatment clinic within a forensic psychiatric hospital. Critical elements in establishing a successful botulinum clinic for treatment of sialorrhea include adequate hospital administrative support, sufficient nursing staff, clinician injection training, education of treating psychiatrists regarding the availability and effectiveness of botulinum treatment for sialorrhea, and development of a clinic protocol, including procedural elements and relevant rating scales. Finally, botulinum treatment was evaluated to be cost-effective.