Practical Pearls to Manage
Medications when Patients
Have Dysphagia
Patricia Dool, BSP
Clinical Pharmacist- Neurology
London Health Sciences Center- University Hospital
London, Ontario
Objectives:
• Medications which can cause Dysphagia
• Review Medication Delivery Systems
• Review methods of medication delivery for
patients with dysphasia
• Review methods of medication delivery for
patients with feeding tubes
• Why be concerned: Cases?
• How can the Interdisciplinary team help?
• Resources
Cases:
• AT is a 80yr old female with a past medical
history of hypertension, diabetes, osteoporosis,
GERD and stroke. Recent diagnosis of
dementia. Her medications include: Aspirin
81mg, Metoprolol 12.5mg bid, Atorvastatin 10mg
od, Lansoprazole 30mg po od, Alendronate 5mg
po od, Calcium 500mg po bid and Vitamin D
1000u po od. Recently added: Donepezil 5mg
po od
• AT has recently had choking episodes. Could
her medications be contributing?
Cases:
SF an 84-year old woman diagnosed with acute dysphagic
stroke is admitted to the rehabilitation floor. The Speech
Language Pathologist suggests a pureed, liquid diet and
administration of medications crushed with
applesauce. The Physician responsible for the patient
approves this. This patient presents with severe pain in
her back which is slowing down her rehab progress
and consequently requires her to be on a number of pain
medications. She was initially started on Oxycodone
hydrochloride tablets which were then switched to the
slow release formulation (Oxycontin®) yesterday. Today
the patient is increasingly lethargic and unresponsive.
What has precipitated the patient’s current state?
Cases:
• DB is a 75year old man with a percutaneous
endoscopic gastrostomy tube complains of
severe heartburn and undergoes endoscopy. He
is found to have severe reflux esophagitis and is
given omeprazole (Losec) 20mg orally once daily
to be administered via the feeding tube. After 1
month of therapy the patient’s symptoms have
not resolved?
What has precipitated the patient’s
current state?
Medications which can induce
dysphagia
• Review medications which can cause
dysphagia :
•
•
•
•
Expected side effect
Esophageal mucosal injury
Gastroesophageal reflux
Affect esophageal motility and sensitivity
Medications which cause
esophageal injury
• Local acid or burn
• Pill retention
• Esophageal hemorrhage, strictures and
perforations
• Medications:
•
•
•
•
•
•
Antibiotics-doxycycline, tetracycline
Non steroidal anti-inflammatory drugs
Aspirin
Bisphosphonates
Chemotherapeutic agents
Potassium chloride
Medications which can cause
gastroesophageal reflux
• Affect lower esophageal sphincter resting
pressure
• Barrett esophagus and/or adenocarcinoma
• Medications:
•
•
•
•
Nitroglycerins
Anticholinergics
Beta- blockers
Benzodiazepines
Medications which affect
esophageal motility and sensitivity
• Use to treat hypercontractile esophageal
motility abnormalities – calcium channel
blockers, nitrates
• Use to affect esophageal sensitivitytricyclic antidepressants and serotonin
reuptake inhibitors
Medications which affect GI tract
lubrication
• Xerostomia
• Sjogren’s syndrome
• Chemoradiation
• Medications
– National Institute of Dental and Craniofacial Research
suggests over 400 medications can cause xerostomia
Medication induced Xerostomia
•
•
•
•
•
•
Antidepressants
Antipsychotics
Antihistamines
Analgesics
Tranquilizers
Antihypertensives
Medications which cause sedation
• Sedation affects patient’s ability to chew
and swallow.
• Medications:
• Opioids
• Antidepressants
• Anti epileptic agents
Medications which can cause
tardive dyskinesia
• Fine motor movements
• May affect mastication and swallow
• Antipsychotic agents
• Older agents- haloperidol, chlorpromazine
• Newer agents (atypical)- cause less tardive
dyskinesias.
Recommendations for Prevention
of Esophageal Mucosal Damage
• Encourage at least 100ml of water after swallowing
medication
• Recommend a preliminary swallow of water prior to
medication
• Recommend remaining upright for at least 5-10 minutes
following drug adminstration
• Maintain administration schedule, especially with
bisphosphonates
• Choose tablets with film coating
• Select safest dosage forms when appropriate and
available(eg potassium liquid)
• Suggest chewable tabs, liquids or crushable dosage
forms in high risk patients
• Educate patients on signs and symptoms of esophageal
injury and dysphagia
Medication Delivery Systems(1)
• Began as simple extract of plants made into
powders
• Present day: complex delivery systems
Medication Delivery Systems(2)
• Consider stability and compatibility of the
drug entity
• Site for dissolution in the GI tract
• Site for absorption in the GI tract
• Altering the intended route of administration
and liability
Medication Delivery Systems(3)
• Stability and compatibility
• Physical and chemical properties of drug
• Excipents
Medication Delivery Systems(4)
• Site for dissolution
• Stomach
• Tap water
Medication Delivery Systems(5)
• Site for absorption in
the GI tract
Types of Drug Formulations:
•
•
•
•
•
•
•
Solid immediate release tablets & capsules
Enteric coated tablets
Sustained release tablets & capsules
Hard gelatin capsules
Liquid solutions
Suspensions
Emulsions
Types of Drug Formulations:
•
•
•
•
•
•
•
Solid immediate release tablets & capsules
Enteric coated tablets
Sustained release tablets & capsules
Hard gelatin capsules
Liquid solutions
Suspensions
Emulsions
Types of Drug Formulations:
•
•
•
•
•
•
•
Solid immediate release tablets & capsules
Enteric coated tablets
Sustained release tablets & capsules
Hard gelatin capsules
Liquid solutions
Suspensions
Emulsions
Types of Drug Formulations:
•
•
•
•
•
•
•
Solid immediate release tablets & capsules
Enteric coated tablets
Sustained release tablets & capsules
Hard gelatin capsules
Liquid solutions
Suspensions
Emulsions
Types of Drug Formulations:
•
•
•
•
•
•
•
Solid immediate release tablets & capsules
Enteric coated tablets
Sustained release tablets & capsules
Hard gelatin capsules
Liquid solutions
Suspensions
Emulsions
Types of Drug Formulations:
•
•
•
•
•
•
•
Solid immediate release tablets & capsules
Enteric coated tablets
Sustained release tablets & capsules
Hard gelatin capsules
Liquid solutions
Suspensions
Emulsions
Types of Drug Formulations:
•
•
•
•
•
•
•
Solid immediate release tablets & capsules
Enteric coated tablets
Sustained release tablets & capsules
Hard gelatin capsules
Liquid solutions
Suspensions
Emulsions
To Crush or Not to Crush?
For patients who are on altered swallowing
regimens:
• Extended release products- ER, SR,
• Enteric coated tablets
• Taste
• Opening capsules
• Potential harm to staff
To Crush or Not to Crush?
Regular tablets or capsules
• Usually acceptable to crush
• Crush one at a time and follow with water
• Ensure tablet is not a long acting product
To Crush or Not to Crush?
Extended-Release formulations
• Capsules- opened, sprinkled,…
• Lansoprazole
• Diltiazem
• Duloxetine
• Tablets• K-Dur
• Tegretol CR
To Crush or Not to Crush?
Enteric Coated tablets
• No
• Enteric coating will
not dissolve
• Switch to regular
tablet
To Crush or Not to Crush?
Taste
•
•
•
•
Altered texture of medication
Local anesthetic effect
Stain teeth
Irritate mouth, esophageal mucosa or stomach
lining
• Coating on tablets or capsules to mask bitter
or unpleasant taste
To Crush or Not to Crush?
Risk to Nurse
• Crushing some potential
teratogenic/carcinogenic/allergenic
medications can put nurse at risk.
• Drugs:
•
•
•
•
•
•
•
Bosentan
Methotrexate
Arthrotec
Dutasteride
Mycophenolate
Raloxifene
Finasteride
Enteral Feeding Tubes
• What is the intent of
the tube?
• Where is the drug
delivered?
• How does the enteral
feed affect medication
delivery?
Best Practice Guidelines from ASPEN:Methods of
Administering Medications via Enteral Feed Tubes (1)
• Do not add medication directly to an enteral feeding formula.
• Administer each medication separately through an appropriate
access site.
• Liquid dosage forms should be used when available and if
appropriate.
• Only immediate-release solid dosage forms may be substituted.
• Grind simple compressed tablets to a fine powder and mix with sterile water.
• Open hard gelatin capsules and mix the powder with sterile water.
• Avoid mixing together medication intended for administration
through an enteral feeding tube, given the risks of physical and
chemical incompatibilities, tube obstruction, and altered drug
responses.
Best Practice Guidelines from ASPEN:Methods of
Administering Medications via Enteral Feed Tubes (1
• Before administering medicatoin, stop feeding and flush the tube
with at least 15ml of sterile water.
• Dilute the solid or liquid medication as appropriate and administer
using a clean oral syringe that’s 30ml or larger.
• Flush the tube again with at least 15ml of sterile water, taking into
account the patient’s volume status.
• Repeat the previous three steps before administering the next
medication.
• After all the medications have been administerd , flush the tube one
final time with at least 15ml of sterile water.
• Restart feeding in a timely manner to avoid compromising the
patient’s nutritional status. Feeding may be delayed for 30minutes or
longer, when appropriate, to avoid altering the bioavailability of the
drug.
• Consult with a pharmacist as needed.
Methods to Unclog Feeding Tubes:
• Flushes before and after medication
administration
• Warm Water flushes
• Carbonated beverage 30-50mls
• Avoid cranberry juice
• Sodium Bicarbonate 325mg tab and
Pancreatic Enzyme capsule
• Use a syringe of greater than 30mls to
avoid rupture of tube
Methods of crushing:
• The “Sodium Bicarb” vial
• Mortar and pestle
• Silent knight
• Crushing syringe
Specific Medications:
•
•
•
•
Phenytoin
Fluoroquinolones
Warfarin
Proton Pump Inhibitors
Interdisciplinary Team
• Communication
•
•
•
•
•
Physician
Speech Language Pathologist
Nurse
Pharmacist
Dietician
• Power chart alert for swallowing status
• Medication Administration Record
• Links to resources
Resources:
• Institute for safe medication Practices:
http://www.ismp.org/Tools/DoNotCrush.pdf
• American Society for Parenteral and
Enteral Nutrition: (ASPEN)
http://www.nutritioncare.org/
Free to join both these organizations
Cases:
• AT is a 80yr old female with a past medical
history of hypertension, diabetes, osteoporosis,
GERD and stroke. Recent diagnosis of
dementia. Her medications include: Aspirin
81mg, Metoprolol 12.5mg bid, Atorvastatin 10mg
od, Lansoprazole 30mg po od, Alendronate 5mg
po od, Calcium 500mg po bid and Vitamin D
1000u po od. Recently added: Donepzil 5mg po
od
• AT has recently had chocking episodes. Could
her medications be contributing?
Cases:
SF an 84-year old woman diagnosed with acute dysphagic stroke is
admitted to the rehabilitation floor. The Speech Language
Pathologist suggests a pureed, liquid diet and administration of
medications crushed with applesauce. The Physician responsible for
the patient approves this. This patient presents with severe pain in
her back which is slowing down her rehab progress
and consequently requires her to be on a number of pain
medications. She was initially started on Oxycodone hydrochloride
tablets which were then switched to the slow release formulation
(Oxycontin®) yesterday. Today the patient is increasingly lethargic
and unresponsive.
What has precipitated the patient’s current state?
How can this situation be avoided?
Cases:
• DB 75year old man with a percutaneous
endoscopic gastrostomy tube complains of
severe heartburn and undergoes endoscopy. He
is found to have severe reflux esophagitis and is
given omeprazole (Losec) 20mg po od to be
administered via the feeding tube. After 1 month
of therapy the patient’s symptoms have not
resolved?
What has precipitated the patient’s current
state?
How can this situation be avoided?
References
Carl, LL, Johnson, PR Drugs and Dysphagia:How Medications Can Affect Eating and Swallowing: 1 st ed. Austin
TX:Pro-Ed 2006.
O’Neill, J, Remington, TL Drug Induced Esophageal Injuries and Dysphagia The Annals of Pharmacotherapy 2003
November, Vol 37:1675-1683.
Gallagher, L and Naidoo, P Prescription Drugs and Their Effects on Swallowing Dysphagia (2009) 24: 159-166.
Tutuian, R Adverse effects of drugs on the esophagus Best Practice & Research Glinical Gastroenterology 24 (2010)
91-97.
Boullata, JI Drug Administration through an enteral feeding tube AJN October 2009 Vol 109 No 10 34-42.
Cornish, P Avoid the crush: hazards of medication administration in patients with dysphagia or a feeding tube. CMAJ
March 29, 2005 172(7) 871-872.
White, R Handbook of drug Administration via enteral Feeding Tubes
Preventing Errors When Administering Drugs Via an Enteral Feeding Tube ISMP Medication Safety Alert May 6, 2010
Reising, DL, Neal, RS Enteral Tube Flushing-What you think are the best practices may not be. AJN March 2005 Vol
105 No.3 58-63.
Administering medication to adult patients with dysphagia Nursing Standard March 25-31 2009 23 (29) 62-67.
Administering medication to adult patients with dysphagia (Part 2)Nursing Standard March 3 24 (6) 61-68.
The Natural History of Dysphagia following a stroke Dysphagia 1997 12:188-193.
Mitchell, J Oral Dosage Forms That Should Not be Crushed ISMP Institute for Safe Medication Practices
Kelly, J, D’Cruz, G, Wright, D A Qualitative Study of the Problems Surrounding Medicine Administration to Patients with
Dysphagia Dysphagia 2009 24: 49-56.
Paparella, S Identifies Safety Risks with Splitting and Crushing Oral Medications. J Emerg Nurs 2010 35:156-9.