Medication Management of Adults with Swallowing Difficulties

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

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)

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