Clinical tips: swallowing difficulties


From crushing to patients who have had bariatric surgery, pharmacists need to keep up to date when dealing with swallowing issues, writes Karalyn Huxhagen

 Difficulty in swallowing causes may include the following:

  • Infection
  • Neuromuscular
  • Stroke
  • Impaired consciousness of the patient
  • Mechanical e.g. strictures, tumours/ulcers in the swallowing pathway
  • Patient inability to perform swallowing task e.g. supine patients who cannot sit up
  • Poor dental hygiene and ill-fitting dentures
  • Painful mouth
  • Bariatric surgery

Complications of swallowing difficulties can include:

  • Aspiration
  • Malnutrition
  • Choking
  • Vomiting
  • Damage to the oesophageal tract

Consideration needs to be given whether the patient can follow the directions of remaining upright after swallowing the medication. E.g. Bisphosphonates, Doxycycline. Some patients are unable to comply with this recommendation and are in danger oesophageal damage if they ingest these medications.

Treatment of inflammation of the oesophagus (oesophagitis) involves symptomatic management of inflammation as well as reducing irritation by processes such as gastric reflux.

Symptomatic treatment of oesophagitis or oesophageal ulcers includes Lidocaine 2% viscous solution 10ml orally, four-hourly; OR Sucralfate 1g dispersed in 5ml water orally, four times a day.

The Sucralfate coats the lining of the oesophagus. Agents to control acid reflux should also be given e.g. Alginate based antacids, PPIs and/or H2 receptor antagonists.

The Lidocaine Viscous retails between $85-$120 a bottle and is expensive for patients to continually purchase as a bottle only lasts for 20 doses. It is available on the Repatriation Benefits Scheme for $6.60.

A short course of Dexamethasone may be given if there is a form of tumour causing obstruction. The dose is Dexamethasone 8mg orally or subcut, in the morning for 3-5 days then cease.1

If the swallowing difficulty is going to be long term consideration may be given to using a nasogastric or percutaneous endoscopic (PEG) feeding tube. This is particularly relevant where the progression of the disease e.g. Multiple sclerosis, Motor neurone disease, will lead to further loss of swallowing function.

Some patients may experience swallowing difficulties due to the size of the medication that they are required to take. Some antibiotics, e.g. Amoxycillin and Clavulanic Acid, are very large and cannot be cut or manipulated easily. An alternative is to use a liquid medication equivalent or to crush the medication and place it into a base compound, e.g. puree, to enable easy swallowing.

There are two factors to consider when considering this task.

The first is whether the patient can swallow a bolus of liquid or puree. For many patients holding the bolus dose in the mouth and swallowing is just as difficult as swallowing a whole tablet.

A speech pathologist assessment may be needed to ensure that giving a liquid/puree is the correct way to go. Aspiration of the liquid/puree can lead to other complications such as pneumonia therefore careful consideration is needed.

The second consideration is whether the medication can safely be crushed and placed in a base for ingestion. The SHPA text ‘Don’t Rush to Crush Handbook’ is now a compulsory text and gives clear guidelines as to whether medications can be crushed and what other formats could be considered.

Compounding pharmacies are able to provide liquid forms of some medications in a concentrated formula, so less volume is needed per dose. Some medications can be compounded to a buccal absorption formula or even a transdermal formula.

Wherever you practice you should know how to assess a quality compounding pharmacy if needed.

The other patient subgroup who may experience issues with swallowing are those that have undertaken some form of bariatric surgery for weight loss. This is a whole new field of complication for dispensing pharmacists.

I have encountered patients who have had life-threatening issues with large tablets such as Metformin or Vitamins becoming caught in lap band openings closing off the ability to breathe. The size of hard medications and liquid doses is an important consideration for all bariatric surgery patients.

Swallowing is an essential part of ingestion of food, water and medicines. There are many causes of difficulty in swallowing.

When presented with a request to provide a solution to the problem of swallowing medication a thorough investigation of the overall issue needs to occur. Referral to a GP, speech pathologist and/or compounding pharmacy may need to be considered.

References:

  1. eTg Swallowing difficulties -accessed 11/2/2020

Karalyn Huxhagen is a community, consultant and locum  pharmacist and was 2010 Pharmaceutical Society of Australia Pharmacist of the Year. She has been named winner of the 2015 PSA Award for Quality Use of Medicines in Pain Management. Karalyn currently has many roles within the Health and Hospital Services and Primary Health Network sector in Queensland.

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