Title: Patricia Dool, BSP
1Practical Pearls to Manage Medications when
Patients Have Dysphagia
- Patricia Dool, BSP
- Clinical Pharmacist- Neurology
- London Health Sciences Center- University
Hospital - London, Ontario
2Objectives
- 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
3Cases
- 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?
4Cases
- 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 patients current state?
5Cases
- 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 patients symptoms have not
resolved? - What has precipitated the patients current state?
6Medications which can induce dysphagia
- Review medications which can cause dysphagia
- Expected side effect
- Esophageal mucosal injury
- Gastroesophageal reflux
- Affect esophageal motility and sensitivity
7Medications 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
8Medications which can cause gastroesophageal
reflux
- Affect lower esophageal sphincter resting
pressure - Barrett esophagus and/or adenocarcinoma
- Medications
- Nitroglycerins
- Anticholinergics
- Beta- blockers
- Benzodiazepines
9Medications which affect esophageal motility and
sensitivity
- Use to treat hypercontractile esophageal motility
abnormalities calcium channel blockers,
nitrates - Use to affect esophageal sensitivity- tricyclic
antidepressants and serotonin reuptake inhibitors
10Medications which affect GI tract lubrication
- Xerostomia
- Sjogrens syndrome
- Chemoradiation
- Medications
- National Institute of Dental and Craniofacial
Research suggests over 400 medications can cause
xerostomia
11Medication induced Xerostomia
- Antidepressants
- Antipsychotics
- Antihistamines
- Analgesics
- Tranquilizers
- Antihypertensives
12Medications which cause sedation
- Sedation affects patients ability to chew and
swallow. - Medications
- Opioids
- Antidepressants
- Anti epileptic agents
13Medications 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.
14Recommendations 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
15Medication Delivery Systems(1)
- Began as simple extract of plants made into
powders - Present day complex delivery systems
16Medication 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
17Medication Delivery Systems(3)
- Stability and compatibility
- Physical and chemical properties of drug
- Excipents
18Medication Delivery Systems(4)
- Site for dissolution
- Stomach
- Tap water
19Medication Delivery Systems(5)
- Site for absorption in the GI tract
20Types of Drug Formulations
- Solid immediate release tablets capsules
- Enteric coated tablets
- Sustained release tablets capsules
- Hard gelatin capsules
- Liquid solutions
- Suspensions
- Emulsions
21Types of Drug Formulations
- Solid immediate release tablets capsules
- Enteric coated tablets
- Sustained release tablets capsules
- Hard gelatin capsules
- Liquid solutions
- Suspensions
- Emulsions
22Types of Drug Formulations
- Solid immediate release tablets capsules
- Enteric coated tablets
- Sustained release tablets capsules
- Hard gelatin capsules
- Liquid solutions
- Suspensions
- Emulsions
23Types of Drug Formulations
- Solid immediate release tablets capsules
- Enteric coated tablets
- Sustained release tablets capsules
- Hard gelatin capsules
- Liquid solutions
- Suspensions
- Emulsions
24Types of Drug Formulations
- Solid immediate release tablets capsules
- Enteric coated tablets
- Sustained release tablets capsules
- Hard gelatin capsules
- Liquid solutions
- Suspensions
- Emulsions
25Types of Drug Formulations
- Solid immediate release tablets capsules
- Enteric coated tablets
- Sustained release tablets capsules
- Hard gelatin capsules
- Liquid solutions
- Suspensions
- Emulsions
26Types of Drug Formulations
- Solid immediate release tablets capsules
- Enteric coated tablets
- Sustained release tablets capsules
- Hard gelatin capsules
- Liquid solutions
- Suspensions
- Emulsions
27To 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
28To 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
29To Crush or Not to Crush?Extended-Release
formulations
- Capsules- opened, sprinkled,
- Lansoprazole
- Diltiazem
- Duloxetine
- Tablets-
- K-Dur
- Tegretol CR
30To Crush or Not to Crush?Enteric Coated tablets
- No
- Enteric coating will not dissolve
- Switch to regular tablet
31To 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
32To Crush or Not to Crush?Risk to Nurse
- Crushing some potential teratogenic/carcinogenic/a
llergenic medications can put nurse at risk. - Drugs
- Bosentan
- Methotrexate
- Arthrotec
- Dutasteride
- Mycophenolate
- Raloxifene
- Finasteride
33Enteral Feeding Tubes
- What is the intent of the tube?
- Where is the drug delivered?
- How does the enteral feed affect medication
delivery?
34Best Practice Guidelines from ASPENMethods 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.
35Best Practice Guidelines from ASPENMethods 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 thats 30ml or larger. - Flush the tube again with at least 15ml of
sterile water, taking into account the patients
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 patients 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.
36Methods 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
37Methods of crushing
- The Sodium Bicarb vial
- Mortar and pestle
- Silent knight
- Crushing syringe
38Specific Medications
- Phenytoin
- Fluoroquinolones
- Warfarin
- Proton Pump Inhibitors
39Interdisciplinary Team
- Communication
- Physician
- Speech Language Pathologist
- Nurse
- Pharmacist
- Dietician
- Power chart alert for swallowing status
- Medication Administration Record
- Links to resources
40Resources
- 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
41Cases
- 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?
42Cases
- 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 patients current
state? - How can this situation be avoided?
43Cases
- 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
patients symptoms have not resolved? - What has precipitated the patients current
state? - How can this situation be avoided?
44References
- Carl, LL, Johnson, PR Drugs and DysphagiaHow
Medications Can Affect Eating and Swallowing 1st
ed. Austin TXPro-Ed 2006. - ONeill, J, Remington, TL Drug Induced Esophageal
Injuries and Dysphagia The Annals of
Pharmacotherapy 2003 November, Vol 371675-1683. - 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 12188-193. - Mitchell, J Oral Dosage Forms That Should Not be
Crushed ISMP Institute for Safe Medication
Practices - Kelly, J, DCruz, 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 35156-9.