Aripiprazole and Unexpected Salivation: A Case of Drug-Induced Sialorrhea Refractory to Anticholinergics

Sialorrhea, or excessive drooling, is a distressing side effect of certain antipsychotic medications, including aripiprazole, clozapine, and olanzapine. We present the case of a 53-year-old female with bipolar I disorder who presented with altered mental status, dysphagia, a 2-day history of excessive drooling, and acute hypoxic respiratory failure. Despite being alert and responsive, she required intubation due to the inability to manage oral secretions. At the time, she had been taking aripiprazole 20 mg once daily and lithium 450 mg twice daily for about three months for bipolar 1 disorder, which were continued inpatient. Aripiprazole was discontinued on the third day of hospitalization. Standard treatments for sialorrhea, including anticholinergics such as scopolamine, glycopyrrolate, and sublingual atropine, were ineffective. Substantial improvement only occurred after the initiation of dexmedetomidine, an alpha-2 adrenergic agonist, on day nine, leading to decreased oral secretions and successful extubation. The patient was transitioned to oral clonidine, another alpha-2 adrenergic agonist, and remained extubated for the rest of her hospital stay. Upon further improvement, she was discharged on glycopyrrolate, a 3-day taper of clonidine, and trazodone, with bipolar I disorder management switched to valproic acid monotherapy. This case highlights the potential role of alpha-2 adrenergic agonists in managing refractory aripiprazole-induced sialorrhea, offering a viable alternative when traditional anticholinergic therapies are ineffective.