Drug administration in dysphagia

 In Feature article, Improving Compliance, Medicines Management Processes

If a person develops swallowing difficulties (dysphagia), administration of medicines can become problematic, with issues ranging from trouble swallowing liquids, to a complete inability to take anything orally.

Tablets and capsules may pose a choking risk

Possible treatments include the use of food thickeners (BNF section A7.5.2) or feeding tubes in more severe cases.

Most medicines are available as tablets or capsules, which are easy to administer with normal swallowing, but may pose a serious choking risk to those with impaired swallowing and so an alternative approach is needed.

Liquid preparations are usually preferable as they’re easier to swallow or administer via a feeding tube.

However, in some cases switching to a liquid will require changing the dose, as they may have a higher bioavailability (e.g. citalopram 20mg tablet is equivalent to 16mg in drops), or the drug form may be different (e.g. phenytoin 50mg (sodium salt) capsule is equivalent to 45mg of phenytoin (base) suspension).

Alternatives to liquid preparation

Some liquids may not be suitable for administration via feeding tubes (e.g. ciprofloxacin liquid) and not all medicines are manufactured in liquid form (e.g. the best replacement for hyoscine tablets (Kwells®) would be hyoscine patch (Scopoderm TTS®)).

Some medicines are also available in dispersible or effervescent versions (e.g. tramadol is available as soluble or orodispersible tablets and oral liquid).

Other routes of administration may be possible, such as rectal or parenteral, but sometimes crushing tablets or opening capsules prior to administration may be the only option.

However, it is important to consult a pharmacist prior to crushing medication, as this practice may increase the risk of changing the drug’s pharmacokinetics, therapeutic efficacy and side effect profile (e.g. crushing controlled-release formulations such as diltiazem tablets, which are designed to release the drug slowly over 24 hours, will result in rapid release and absorption of the drug, leading to potentially toxic levels). As a general rule, no enteric coated or modified release preparations should be crushed.

Different methods of administration may be unlicensed

Crushing tablets or opening capsules prior to administration is unlicensed, unless the manufacturer specifies otherwise.

For this reason, the prescriber must document the rationale in the patient care notes and specify all instructions on the prescription chart (e.g. ‘tablets crushed’ or ‘open capsules and mix contents with water’).

Nurses should not administer in this way without these additional instructions from the prescriber.

The administration of most liquid medicines via feeding tubes will also be unlicensed, so the prescriber must document this route in the notes and on the prescription chart.

Be aware of medicines that can be inhaled or absorbed

Nursing staff should also be aware that some medicines can be absorbed by inhalation or by contact with the skin.

Personnel exposure needs to be taken into consideration, especially if crushing tablets or breaking capsules (e.g regular handling of crushed hormonal tablets like thyroxine or estradiol may result in accumulation and toxic effects), so wearing gloves and a face mask should be considered.

However, not all tablets have to be physically crushed prior to administration and some will disperse slowly if put in a small amount of water.

A step-by-step plan to follow:
  1. Is a liquid preparation available and suitable?
  2. Are there other forms available (dispersible, effervescent, drops)?
  3. Are there alternative medicines or routes of administration?
  4. Is an unlicensed liquid available?
  5. Consult literature before crushing tablets or opening capsules
  6. Document the decision and provide clear instructions with prescription
References

‘Handbook of Drug Administration via Enteral Feeding Tubes’, R. White and V. Bradnam, Pharmaceutical Press 2015.

‘The NEWT Guidelines for Administration of Medication to Patients with Enteral Feeding Tubes or Swallowing Difficulties’, Wrexham Maelor Hospital Pharmacy Department, 2015.

NOTE – The NEWT guidelines are available online via the Ashtons LiveView system.

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