Botulinum toxin for the treatment of severe sialorrhea induced by clozapine: a case report

ABSTRACT

We present a clinical case of a long-standing institutionalized patient diagnosed with treatment-resistant paranoid schizophrenia. The patient was admitted to the hospital due to catatonic symptoms caused by high-dose antipsychotic treatment. These antipsychotics were progressively escalated in response to psychotic symptoms and aggression, which posed challenges in the residential setting. Exhausting all therapeutic options for psychotic symptoms, we noted that the patient had previously responded to clozapine but discontinued it due to socially debilitating sialorrhea. During the current admission for catatonia, antipsychotics were discontinued, and a tapering regimen of lorazepam was initiated, resulting in a gradual reduction of catatonic symptoms. However, psychotic symptoms and aggression resurfaced, leading us to reintroduce clozapine after carefully weighing the benefit-risk balance. The patient exhibited a marked reduction in aggression and both positive and negative psychotic symptoms, without significant rigidity or hypokinesia. Unfortunately, a notable recurrence of severe sialorrhea necessitated the use of adult bibs, requiring up to 8 changes per day. Consequently, we reviewed strategies for managing clozapine-induced sialorrhea, including the potential use of botulinum toxin. Although the results in this clinical case were partially positive, we believe that botulinum toxin represents a valuable tool in addressing clozapine-induced sialorrhea.