Pharmaceutical Considerations and Dysphagia Risks



9. MEDICATION, DYSPHAGIA AND TUBE FEEDING

A person is considered to have dysphagia if their swallowing mechanism is compromised so that they have problems with coughing on food and/or aspirating drinks which can lead to frequent chest infections and failure to thrive. This can be overcome by presenting medication in alternative ways to ensure the patient receives an accurate dose in the most comfortable form. Many medicines come in different forms or an alternative one from the same class can be tried. When giving via a PEG or NG there are additional considerations. Medication can also compromise the swallowing mechanism in different ways.

1. Medication that may Compromise the Swallowing Mechanism:

The swallowing mechanism can be compromised by medication, which could be crucial for someone who already has a poor swallowing reflex for example:

a) Muscle relaxants like Baclofen, and the Benzodiazepines e.g. Clobazam, Diazepam or Lorazepam

b) The sedative effect of antipsychotics e.g. Chlorpromazine, Haloperidol, Olanzapine and hypnotics e.g. Temazepam, particularly with elderly people.

c) ACE inhibitors used for hypertension (high BP) e.g. Captopril, Enalapril, Lisinopril, Perindopril and others, may be a problem because they give some people a persistent dry cough

2. Effect of a Dry mouth on Swallowing:

This can make swallowing difficult, and may be due to the side effects of drugs e.g. antipsychotics, or too much mouth breathing. It can also give rise to increased mouth infections. If people have problems with this it can be helped with regular cleaning with Pink Swabs and a mouthwash solution.

3. Problems with Hypersalivation or Drooling:

Drooling can be a problem with some people, as it may be difficult to ensure the full dose is taken. It is a good idea to trying physical ways of coping with the problem e.g. encouraging/reminding people to swallow, improve mouth closure and encouraging better posture etc. The medicines we have for reducing saliva are called Anticholinergics or Antimuscarinics. They have an Atropine like effect and cause dry mouth (increased risk of mouth problems, infection etc), constipation, blurred vision, drowsiness and urine retention etc. However if patients are aspirating on their own saliva we have to offer something. Hyoscine is probably the medicine of choice. It is available as tablets of 300 micrograms ‘Kwells®’ Some people can be helped with a quarter of a tablet 3 or 4 times a day (they are cross scored), or as patches of ‘Scopoderm TTS®’. Hyoscine is also an antinausea drug. The other medicines we use are the Anticholinergic medicines like Procyclidine (which is also used for drug induced Parkinsonism), at a dose of 5mg 2 or 3 times a day.

Types of Oral Preparations

If altering the form of a medicine before administering it (i.e. crushing, opening capsules, thickening liquids or giving via a feeding tube) you are probably using it in an unlicensed way. You must check with the pharmacist (is it safe?) Always record sign and date decisions and have a documented care plan, and inform the prescriber. It is better to consider alternative preparations.

When liquids are being offered either as a medicine, or as a drink to aid swallowing, they must be of the correct consistency for the person who has a dysphagia problem, i.e. they may need thickening. The dysphagia team will devise a protocol for each person

There are various ways that medication can be given orally. When we swallow medication or food it goes via the oesophagus into the stomach, which is an acid medium and medicines are formulated with this in mind i.e. allowance has been made for them to be stable in an acid medium.

1. Liquids

These come in various thicknesses. If the mixture is too thin and it needs to be thickened it is usually all right to use one of the inert thickeners. However formulations change, so, the advisability of thickening a particular mixture should be checked. It is usually all right to dilute a liquid with water if it is too thick, but only do it immediately before administration. Dilution will be a problem if the medication precipitates out (snow effect in the liquid). This will depend on how the medicine is suspended in the mixture. Check and document your information

2. Sachets

These contain one dose of medicine in an envelope, the contents of which are added to water and then drunk. With some medicines this forms an easy to take liquid e.g. Movicol. With others it can form a sludge e.g. Fybogel so timing may be difficult. With some it forms a mixture with gritty granules in, (e.g. Sachets for Lansoprazole Suspension which contain enteric coated granules), which is difficult for the patient with Dysphagia to cope with. The company advises against using this formulation in Nasogastric tubes as the granules in the suspension may clog the tube.

3. Dispersible tablets

These can have the same difficulties as sachets. The tablets sometimes disperse to form a gritty solution e.g. Aspirin or Paracetamol. You may end up with the patient unable to cope with the swallowing the gritty bits and medicine left at the bottom of the glass.

4. Simple Tablets

Many of these can be easily crushed between two spoons, a crushing syringe (available from Distinctive Medical Products), or other device, and added to a small quantity of water. This may mean that some of the active medicine is lost at the bottom of the container, and gritty bits will be difficult for the person with Dysphagia to manage. Then it is better to add to something sticky like jam yoghurt or fromage frais. However my SLT colleagues tell me that for people with Dysphagia we should avoid Yoghurt as it is inclined to lurk around and coat the back of the pharynx

We must not give some medicines with milk based products as they prevent the absorption of the medicine from the gut, e.g. Tetracyclines and Iron and the combined contraceptive pill

5. Capsules

These consist of a gelatine case containing powder or granules. They can often be opened and the contents treated like a crushed tablet e.g. Omeprazole Capsules, but do not crush the granules as they are enteric coated, or Venlafaxine. The firm who make capsules of Lansoprazole (which contain enteric coated granules) reported that the granules can be administered via a NG tube or a PEG by adding to apple or orange juice, the juice being acidic prevents the granules clogging. Any acidic liquid will do. Now they advise using the FasTabs

Medication that MUST NOT be crushed or opened:

1. Enteric coated Tablets

The Enteric Coat can have one of two functions:- to protect the medicine from being broken down by the acid in the stomach or to protect the stomach from an irritant medicine e.g. Sodium Valproate, Prednisolone or Aspirin. Do not give at the same time as indigestion mixtures or milk, as they will spoil the enteric coat.

2. Controlled Release Modified release, Sustained release, Long-acting, Retard, Chrono

These terms all indicate a special formulation. They have been devised so that medication need not be taken so frequently, and to give more consistent blood levels. This is specifically useful for medicines that are absorbed and metabolised quickly to prevent toxic peaks such as Carbamazepine Retard

3. Hormones and Cytotoxic medication

Because of possible harm to person administering the medication.

4. Nitrates

Theoretical risk of causing explosions.

Alternatives

Don’t forget there are other methods of giving medication e.g. Rectally (suppositories) and Patches (hyoscine and HRT) or Injections (we can open ampoules and add to PEGs or NGs if necessary but this is expensive). The other thing to remember is that there are alternative medicines, which may come in more suitable forms. So ASK

Medicines via Feeding Tubes

Liquid medication and food can be given via:

❖ A nasogastric tube to the stomach via the nasal passages

❖ A PEG tube inserted surgically directly into the stomach.

❖ A PEJ tube inserted surgically into the jejunum further down the digestive tract.

The problems that can arise with tube feeding are partly due to bypassing the normal body defence mechanisms (need to be careful of infections especially with PEJ tubes) and medication reacting with the tube or clogging it. Then there are problems with the medication itself:

a) Osmotic diarrhoea from the sorbitol in some oral liquids, they need to be well diluted.

b) Poor absorption especially with PEJ feeds as drug may enter the gut too low down.

c) Altered bioavailability when converting from tablets to liquid e.g. Phenytoin Sodium tablets 100mg = 90mg Phenytoin in the liquid form

d) Changing from a m/r tablet to a liquid means more frequent doses

e) Tube blocking by viscous liquids e.g. co-amoxiclav

f) Clumping because the feed is acidic

g) The medicine causes indigestible concretions e.g. sucralfate

h) Binding to the plastic tube e.g. carbamazepine, clonazepam, diazepam, phenytoin, so dilute with 30-60ml of water first.

i) If adding crushed tablets to a tube make sure they are completely dispersed in the water/liquid as sediment will increase the risk of clogging

j) If adding an injection to a tube, we need to check its osmolality, as it may be hypertonic or contain additives which may be unsuitable for oral administration e.g. polyethylene glycol. They should be diluted with 30-60ml of water.

When crushing tablets prior to adding to a feeding tube a crushing syringe can be useful

Do not forget if the method of administration is not a straightforward ‘take and eat’, then you need to have clear documentation on how medication is to be given. (such as ‘Good Practice in Medication Administration Form 2’ appendix 4 in the Medicines Guidelines or something similar). If the person is unable to give consent we need to have that recorded according to Trust policies. The protocol for giving medication via a tube should be agreed with the Dysphagia team dietitian, documented and followed.

References:

1. Swallowing Difficulties Protocol David Wright University of Bradford

2. Administering Drugs Via Enteral Feeding Tubes a Practical Guide, British Association for Parenteral and Enteral Nutrition .uk or British Pharmaceutical Nutrition Group bpng.co.uk

There is a very useful website and their July 2002 newsletter has guidelines and advice on adding medication to feeding tubes

CRUSHING MEDICATION TO AID SWALLOWING

AND/OR ADDING TO FEEDING TUBES

This information is in addition to information from the palliative drugs newsletter July 2002 to help inform carers who may need to adapt medication for people who have trouble swallowing or who need medication added to feeding tubes. I hope to add to it as time goes on.

|Medication |Manufacturer |Info Date |Comments |Warnings |

|Baclofen |Cephalon | |OK added to milk to reduce side |PEGs: Liq rather viscous. Dilute with |

|Liquid |Med Info Dept |18/11/03 |effects |water |

|Clomipramine Cap |Cephalon |12/2/04 |Only recommend swallow whole. |One case of numb throat and heart burn |

| |Med Info Dept | |But if patient is doing well when| |

| | | |having opened caps it is OK added| |

| | | |to water | |

|Lamotrigine Tab |GSK | |PEGs: GSK Do not know which would|GSK say PEG is unlicensed use |

| | Dept |15/5/03 |be best. MI at QEH: Dispersible | |

| | | |probably better | |

|Lamotrigine Dispersible |GSK | | |Dispersible Tabs contain more |

| | Dept |15/9/03 | |constituents |

|Lansoprazole |Wyeth | |For PEGs suspend Cap contents in |Sachets give a gritty suspension in water|

|Cap & Sachets |Med Info Dept |Fax |juice or dissolve in 8.4% Sod. | |

|Both contain E/C Granules | |29/10/01 |Bic |Can also sprinkle cap contents on food |

|Lansoprazole |Wyeth |Fax 11/11/03 |For PEGs/NGs |9-11% less plasma level from dispersed |

|FasTab |Med Info Dept |Contains some |Suspend in tap water |tab than from tab on tongue |

| | |stability research |Do not crush | |

| | |info | | |

|Levetiractam |UCB |Rep. |Crush & dissolve in tepid water |Sediment due to film coat and excipients |

| | |Nov 02 | | |

|Methylpheni-date |Cephalon |18/11/03 |Can be crushed. Its very soluble |Firm say no info |

| |.Dept | |in water |But should be OK in Jam or Yog |

| | | | |No info on possible shorter effect |

|Olanzapine Tabs |Lilly | |May crush and add to coke or | |

| |Med Info Dept |3/6/03 |squash | |

|Olanzapine Velotabs |Lilly |BNF Dispersible Tab |Can be dispersed in orange juice,|N.B. Will precipitate out in coke as has |

| | | |apple juice, milk, or coffee |different formula |

|Omeprazole Caps |Astra Zeneca |BNF |May add to fruit juice or Yoghurt|Contain E/C granules |

|Omeprazole |Astra Zeneca |BNF |They disperse in water with |May be able add to PEG |

|Dispersible tabs | | |pellets |But need to consult Astra Zeneca |

|(Losec MUPS) | | | | |

|Quetiapine |Astra Zeneca |Rep. 14/5/03 |Can crush tabs and add to yoghurt|May be able to add to other vehicles |

| | | | | |

| | |18/11/03 | | |

| |Med Info Dept | | | |

|Risperidone Liquid |Janssen- | |Add liquid to: |These are the ones we have evidence for |

| |Med Info Dept Cilag |May 03 |Orange Juice |There may be others |

| | | |Mineral Water | |

| | | |Black coffee or | |

| | | |Black tea | |

|Topiramate |Janssen-Cilag Med Info | |Sprinkle Cap contents on food |DO NOT put down feeding tubes as it will |

|Sprinkle Caps |Dept |2/9/02 |Rinse mouth afterwards |clog |

|Topiramate |Janssen-Cilag Med Info | |Crush tablets and add to water |This is the recommended option for tube |

|Tablets |Dept |2/9/02 | |feeds |

|Valproate |Sanofi-Synthelabo Med. | |Crushing Tabs will destroy |Give with or after food |

|Semi-Sodium |Info Dept |19/1/04 |protective formulation | |

|Depakote® | | | | |

|Venlafaxine Tabs |Wyeth |30/4/03 |Water soluble crush, add to water|Mix with acid rather than alkaline |

| |Med. Info Dept | |or fruit juice |liquids |

|Venlafaxine XL Caps |Wyeth | |Open caps and add to soft food |Mix with acid rather than alkaline |

| |Med Info Dept |30/4/03 |e.g. apple sauce |liquids |

| | | | |Do not crush the ‘spheroids’ |

|Zuclopenthixol |Lunbeck |22/4/03 |May Crush but only immediately | |

| |Med Info Dept | |before admin. | |

If crushing or mixing a medication, do so only immediately before administering

KEY

Tab = Tablet Cap = Capsule E/C = enteric coated

Med. Info Dept = Manufacturer’s medical Information Department

BNF = British National Formulary

PIL = Patient Information Leaflet (package insert)

Additional Information from July 2002 newsletter

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