Artificial Saliva Agents in Xerostomia

By: Neal Shah, Co-Editor-in-Chief

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Xerostomia, commonly known as dry mouth, is an anti-muscarinic side effect of numerous medications.  Antidepressants, analgesics, diuretics, and antihistamines have a high propensity to cause xerostomia.¹  Xerostomia may also result from Sjogren’s syndrome, Parkinson’s disease, and various chemotherapy agents.²  Traditionally, muscarinic agonists like pilocarpine have been used to reverse xerostomia.  Interestingly, angiotensin-converting enzyme-inhibitors (ACEi) are also reported to increase salivary production.³   There are salivary replacements available via prescription commonly referred to as artificial saliva (i.e. Caphosol®, NeutraSal®, Aquoral®, and Numoisyn®).  Over the counter  artificial saliva products include Biotene®, which also has antimicrobial properties, and SalivaSure®, which is a xylitol salivary stimulant.

Caphosol® and NeutraSal® are supersaturated calcium phosphate rinses that are indicated for xerostomia caused by chemotherapy.  Patients are instructed to mix the different colored Caphosol® vials together and rinse with half the liquid for one minute, then repeat.  If swallowed, the manufacturer states there are no adverse effects, nor are there any interactions with other medications.⁴  NeutraSal® is a powder-packet dissolved in a glass of water with similar rinsing directions as Caphosol®.⁵  Aquoral® is an oral spray consisting of oxidized glyceral triesters that coats the mouth and provides extended lubrication; since it coats the lining of the mouth, this product may also help heal ulcerations.  Like Caphosol®, it does not have any side effects if swallowed nor any drug interactions reported by the manufacturer.  It is dosed as two sprays three or four times a day.⁶  Numoisyn® is a prescription salivary inducing agent, available in both tablet and liquid dosage forms.  Numoisyn® tablets primarily consist of mannitol and malic acid designed to stimulate the salivary glands to produce saliva, while the liquid resembles salivary consistency.  Both preparations are contraindicated in fructose-intolerant patients and can be used up to 16 times per day.  Like Aquoral® and Caphosol®, no drug interactions or adverse effects if swallowed are reported by the manufacturer.⁷

These salivary replacements provide a benefit compared to pilocarpine.  Pilocarpine (Salagen®) tablets taken orally produce systemic muscarinic agonist effects, including sweating, diarrhea, tearing, blurred vision, and excessive urination.⁸  These side effects are minimized with the introduction of pilocarpine spray, but this medication is unavailable in the United States.  For patients who wish to resolve their xerostomia without systemic effects, Caphosol®, Aquoral® or Numoisyn® are attractive, but expensive alternatives.  A one-month Caphosol® supply through a discount program and Medicare costs about $128, which may be too costly for some patients.⁹  Aquoral®, if not covered by insurance, can cost $110 for a 40mL bottle.  A 100-count of Numoisyn® lozenges can cost up to $40; and a 300 mL bottle of Numoisyn® can cost up to $65.  Artificial saliva agents thus have significant advantages and disadvantages to consider when choosing a treatment regimen for xerostomia.

SOURCES:

1. Xerostomia (Dry Mouth). Available at: http://www.uic.edu/classes/peri/peri343/xerost/xerost1.htm. Accessed June 24, 2012.
2. Dry Mouth (Xerostomia). Available at: http://www.nidcr.nih.gov/oralhealth/topics/drymouth/. Accessed June 24, 2012.
3. Bossola M, Tazza L. Xerostomia in patients on chronic hemodialysis. Nat Rev Nephrol. 2012 Jan 17;8(3):176-82. doi: 10.1038/nrneph.2011.218.
4. Caphosol [package insert].  EUSA Pharma.
5. Neutrasal [package insert]. Available at: http://www.neutrasal.com/. Accessed June 24, 2012.
6. Aquoral [package insert]. Auriga Labororatories.
7. Numoisyn [package insert]. ALIGN Pharmaceuticals, LLC.
8. Pilocarpine. Available at: http://www.ncbi.nlm.nih.gov/pubmedhealth/PMH0000465/. Accessed June 24, 2012.
9. Caphosol  Exclusive Medicaid Offer. Available at: http://live.caphosol.com/us/PAT/Medicare-Offer.aspx. Accessed June 24, 2012.