How to prescribe for patients with dysphagia
Patients with dysphagia may have complex healthcare needs, requiring the administration of medicines. However, the convenience of prescribing a tablet or capsule that can be swallowed will not be appropriate for these patients. Alternatives must be considered. Patients with established dysphagia may require an assessment by Speech and Language Therapy (SALT) to establish the extent of their problem and the most appropriate formulations for them.
When prescribing for patients with dysphagia, the following points should be considered:
- The patient’s medication should be reviewed and unnecessary medicines stopped. It is important to consider whether continuation of all medicines is imperative. If the dysphagic state is likely to be temporary, then short-term discontinuation of some medicines may be more appropriate.
- For all medicines that need to be continued, an alternative delivery route should be considered, such as patches or suppositories.
- Where an alternative route is not available, a liquid preparation should preferably be sourced, for administration by the oral route
- A licensed liquid formulation should be used preferentially
- If a licensed liquid product cannot be sourced, it may be possible to obtain the medicine as a special. A pharmacist will be able to advise you as to whether this is possible.
- If the medicine is not available as a liquid, consider prescribing an alternative medicine in the same therapeutic group which is available as a liquid
- When switching from a solid to liquid dose form, be mindful that dose equivalence calculations may be required due to differing bioavailability.
- Soluble and dispersible tablets can be a convenient means of producing a liquid formulation
- The consistency of liquid formulation is an important consideration too. If too runny, the liquid may still go onto the patients lungs causing aspiration. However, overly viscous preparations may not be suitable for some patients, especially those with Parkinson’s disease. A SALT referral may therefore be required to determine the most appropriate medicine consistency for the patient.
- If a liquid medicine is not obviously available, it is worth asking a pharmacist if they are aware of any unlicensed liquid medicines available.
- Dispersion of non-dispersible tablets immediately prior to administration is frequently possible and is advocated by some professionals as a safe alternative to liquid medicines. This process will render the administration unlicensedand therefore should only be undertaken with the permission of the prescriber and after checking whether it is appropriate and possible. Most medicine information centres can refer to a list of non-dispersible tablets which can be dispersed. You should also remember that many tablets taste unpleasant and that although tablet dispersion may be appropriate for enteral feed administration, it may be unacceptable to patients with dysphagia.
- Recommending that a tablet be crushed or capsule opened should only be considered as an absolute last resort and practitioners should be aware that advising this will shift liability for any adverse effects that may ensue onto themselves as the protection offered by the Consumer Protection Act is lost when medicines are crushed or opened as they then fall outside their product license.
- If recommending that a tablet is crushed or capsule opened is the only practical option, ensure informed patient consent is obtained and that adequate documentation is made.
- Before recommending a tablet is crushed or capsule opened, it is also advisable to check that it is safe with a pharmacist. Certain medicines should never be crushed or opened including:
- Modified release preparations
- Enteric coated preparations
- Buccal or sublingual tablets
- Cytotoxics or hormonal products