Managing Secretions in MND Dr. Liz Williams Associate Specialist Palliative Care Team Chair MND DSAG BCUHB 29th November 2016

Managing Secretions in MND Management of problems Non Pharmacological Phamacological Nice guidance ** End of life care secretion management Clinical Case Normal saliva management Abnormal saliva management in MND Definition of Sialorrhoea Problems with secretions in MND Assessment

Normal Secretion Management and Swallow Role of Saliva Digestion Enables speech & swallow Cleaning & lubricating Enables taste Maintains healthy mucosa and teeth PHLEGM thick mucus from respiratory mucus membranes SALIVA 0.5 - 1 L per day Average adult: 600 Swallows /day A normal swallow is produced by up to 50 pairs of muscles 3 pairs major Salivary Glands and many minor glands Sympathetic innovation ( flight/flight ): increases protein rich thick mucus Parasympathetic innovation (rest and digest) : increases serous thin watery saliva

Problems caused by Abnormal Secretion Management in MND Social Social isolation Poor communication Poor social understanding Poor body image Increased dependence & level of care Psychological Fear Poor self esteem Depression Anxiety

Clinical Saliva Score Sheffield validation but still some concerns and not validated For research use

Pinapple contains proteolytic enzyme

Pharmacological Management of Secretion Problems in MND Thin Watery Saliva II TRICYCLIC ANTIDEPRESSANTS Amitryptilline Low dose (start 5-10mg) Oral / PEG Night sedation Avoid with cardiac conditions & Glaucoma May help emotional lability ANTIHYPERTENSIVES Clonidine Low dose Oral / PEG or CSCI Avoid in renal failure

Pharmacological Management of Secretion Problems in MND Thin Watery Saliva III BOTULINUM TOXIN (BOTOX) Medically refractory Sialorrhoea should be considered for Botox therapy** Grade B recommendation Supported by NICE 2016 Class I & II studies Review by Miller 2009, Orrell 2010, Young et al 2011 Can cause further weakness and swallowing problems RADIOTHERAPY Lower level recommendation Grade C May be permanent or temporary

Pharmacological Management of Secretion Problems in MND Thick, Tenacious Saliva , Mucus & Phlegm I Review current medication which may dry secretions** HUMIDIFICATION** Saline Saline nebulizers Humidification of O2 if required MUCOLYTICS** Carbocystine Oral / PEG only 125 - 500mg QDS Rare risk of peptic ulceration

Pharmacological Management of Secretion Problems in MND Thick, Tenacious Saliva , Mucus & Phlegm I Anxiety and unease from frequent and self limiting choking episodes BENZODIAZEPINES Lorazepam S/L or oral/PEG PRN only Midazolam Buccal or nasal or S/C PRN Only Sedating - consider in refractory problems in EOL care BETA BLOCKERS Propranolol Limited evidence Monotor BP and HR

Secretion Management in MND at End of Life Anticipatory Antisecretory medication as one of 4As Hyoscine Hydrobromide & Glycopronium Just in case PRN medication

Just In Case Boxes ( JICB)

Further Information www.mndassociation.org www.nice.org.uk Palliative Care Teams: East : 01978 727448720 177 Central : 01745 ext 7960 West: 01286 662775 Dr. Liz Williams Tel: 01248 363535 ElizabethL.Williams@wales.nhs.uk