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Summary for primary care

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


Click on the thumbnail to expand the algorithm
Figure 1: Algorithm for the Medication Management of Adults with Swallowing Difficulties

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

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