This guideline was developed by a multidisciplinary expert panel: Wright D et al with the support of a grant from Rosemont Pharmaceuticals Ltd. See bottom of page for full disclaimer.
Identifying Patients with Swallowing Difficulties
Improved Communication
- Healthcare providers should always ask the patient or carer whether they have difficulty swallowing medication, and assess the reasons for this
- Speech and language therapists should state, if it is relevant, in their assessment recommendations that the patient could have potential problems with swallowing their medication
- Doctors should ensure that known swallowing difficulties are taken into consideration when prescribing medication
- Community pharmacists should assess the suitability of medication formulations for individual patients, and report swallowing difficulties to the prescriber
- Carers should inform the patient's doctor if they know or suspect that swallowing medication is an issue
Clinical Evaluation
- The causes of swallowing difficulties are numerous, manifesting as mechanical obstruction, or affecting the muscles or nerves involved in swallowing
- Consider individual investigation and management in the following conditions:
- neurological conditions (e.g. stroke, progressive neurological disease, dementia)
- mental health disorders
- cancer (e.g. head, neck, oesophageal cancer)
- cardiac and respiratory disease
- physical/learning disabilities
- Symptoms and signs indicating that an individual may experience difficulty swallowing medication include:
- difficult or painful chewing or swallowing
- dry mouth (xerostomia)
- difficulty controlling food or liquid in the mouth
- coughing/choking before, during or after swallowing
- hoarse/wet voice quality
- feeling of obstruction (e.g. globus sensation)
- unexplained weight loss
- regurgitation of undigested food
- recurrent chest infections
- Specialist assessment (e.g. speech and language therapy [SLT], gastroenterology, dietitian) may be required for patients with these clinical conditions that may require them to take liquid nutritional supplements or receive medicines by enteral feed tubes
- Oral medication usage may also be complicated in patients with neurological and/or psychological conditions, such as:
- learning disability
- severe mental illness
- dementia
- If the patient finds it easier to take their medication with food, advise them, or their carers to check that the food does not interact with the medication
- Providing postural stability during mealtimes might improve oral preparatory and oral phase stability
- In certain individuals, there may be a personal preference against taking certain medicines
Management
Click on the thumbnail to expand the algorithm
Management of Patients with Evidence of Swallowing Difficulty
- Figure 1 assumes that the patient has been assessed thoroughly, and non-adherence to medication due to a problem with the administration routine has been ruled out
- Check and scroll down the full list of the prescribing system screen display to identify all formulations that are available. If unsure, check with pharmacist and/or Medicines Information Centre to ascertain whether alternative formulations of the medication in question are available, for example:
- transdermal
- parenteral/injectable
- buccal
- rectal
- intranasal
- sublingual
- If a suitable formulation is not available:
- for patients who are not able to take medicines orally:
- consider prescribing an alternative medicine or discontinuing the treatment
- for patients able to take medicines orally:
- consider prescribing an alternative medication
- if no alternative exists, altering a solid-dose oral formulation may need to be contemplated (see below)
- for patients who are not able to take medicines orally:
Switching to Liquid or Dispersible Oral Formulations
- Changing the formulation of a product may alter its bioavailability, efficacy and/or side-effect profile
- do not assume that the dose of a liquid/dispersible formulation will be the same as the solid oral form of a particular product; check dose equivalence
- when switching from a sustained-release to a standard-release form of a medicine, dose frequency will need to be adjusted accordingly
- evaluate efficacy and side effects frequently
- Dispersible tablets may not give an even solution so part dosing is potentially inaccurate
- Some medicines are available as non-licensed liquid 'specials' or extemporaneous preparations, which are formulated to meet the requirements of a doctor for specific use by an individual patient:
- dose uniformity or reproducibility may not have been tested for extemporaneous preparations, or some 'specials'
- to minimize the variability of supply, the product specification should be documented: the formulation, method of preparation, and strength should be noted
- For a comprehensive list of products available in liquid or dispersible form, see www.swallowingdifficulties.com
Continuity of Care
- To ensure continuity of care, e.g. for patients moving from secondary to primary care:
- any changes to a dosage formulation should be noted, and this information clearly communicated on to subsequent prescribers and other healthcare professionals
- swapping between liquid formulations, particularly liquid 'specials' (which do not have bioavailability data), should be avoided
Altering a Solid-dose Oral Medication
- Altering a solid-dose formulation should be reserved as last-resort and practised only after appropriate advice has been sought from a pharmacist and/or Medicines Information Centre
- Certain types of drug should never be altered without advice from a pharmacist and/or the manufacturers due to the changes these actions impose on the pharmacokinetics and pharmacodynamics of the drug; these include the following types:
- modified release
- enteric coated
- hormonal, cytotoxic or steroidal
- film and sugar coated
- The outcome of such pharmacological changes can be accentuated in older people due to age-related differences in pharmacokinetics
- Prescribers should also consider:
- how stable the product is once opened to the environment
- whether the safety of the person preparing or administering the product would be put at risk
- alteration of a solid-dose oral formulation should be considered under Control of Substances Hazardous to Health (COSHH) regulations since there may be an increased exposure to chemical components
- the person may have a hypersensitivity to the product or its constituents
- whether the dose preparation could be accurately repeated
- the amount and type of diluent and/or thickening agents that would be used
- whether the results would be unpalatable
- Variation in the amount of drug reaching the system due to formulation change may impact efficacy and the potential for side effects, particularly in drugs with a small therapeutic window including:
- phenytoin
- digoxin
- carbamazepine
- theophylline
- sodium valproate