Patricia Dool, BSP

1
Practical Pearls to Manage Medications when
Patients Have Dysphagia

• Patricia Dool, BSP
• Clinical Pharmacist- Neurology
• London Health Sciences Center- University
  Hospital
• London, Ontario

2
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

3
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?

4
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 patients current state?

5
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 patients symptoms have not
  resolved?
• What has precipitated the patients current state?

6
Medications which can induce dysphagia

• Review medications which can cause dysphagia
• Expected side effect
• Esophageal mucosal injury
• Gastroesophageal reflux
• Affect esophageal motility and sensitivity

7
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

8
Medications which can cause gastroesophageal
reflux

• Affect lower esophageal sphincter resting
  pressure
• Barrett esophagus and/or adenocarcinoma
• Medications
• Nitroglycerins
• Anticholinergics
• Beta- blockers
• Benzodiazepines

9
Medications 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

10
Medications which affect GI tract lubrication

• Xerostomia
• Sjogrens syndrome
• Chemoradiation
• Medications
• National Institute of Dental and Craniofacial
  Research suggests over 400 medications can cause
  xerostomia

11
Medication induced Xerostomia

• Antidepressants
• Antipsychotics
• Antihistamines
• Analgesics
• Tranquilizers
• Antihypertensives

12
Medications which cause sedation

• Sedation affects patients ability to chew and
  swallow.
• Medications
• Opioids
• Antidepressants
• Anti epileptic agents

13
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.

14
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

15
Medication Delivery Systems(1)

• Began as simple extract of plants made into
  powders
• Present day complex delivery systems

16
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

17
Medication Delivery Systems(3)

• Stability and compatibility
• Physical and chemical properties of drug
• Excipents

18
Medication Delivery Systems(4)

• Site for dissolution
• Stomach
• Tap water

19
Medication Delivery Systems(5)

• Site for absorption in the GI tract

20
Types of Drug Formulations

• Solid immediate release tablets capsules
• Enteric coated tablets
• Sustained release tablets capsules
• Hard gelatin capsules
• Liquid solutions
• Suspensions
• Emulsions

21
Types of Drug Formulations

• Solid immediate release tablets capsules
• Enteric coated tablets
• Sustained release tablets capsules
• Hard gelatin capsules
• Liquid solutions
• Suspensions
• Emulsions

22
Types of Drug Formulations

• Solid immediate release tablets capsules
• Enteric coated tablets
• Sustained release tablets capsules
• Hard gelatin capsules
• Liquid solutions
• Suspensions
• Emulsions

23
Types of Drug Formulations

• Solid immediate release tablets capsules
• Enteric coated tablets
• Sustained release tablets capsules
• Hard gelatin capsules
• Liquid solutions
• Suspensions
• Emulsions

24
Types of Drug Formulations

• Solid immediate release tablets capsules
• Enteric coated tablets
• Sustained release tablets capsules
• Hard gelatin capsules
• Liquid solutions
• Suspensions
• Emulsions

25
Types of Drug Formulations

• Solid immediate release tablets capsules
• Enteric coated tablets
• Sustained release tablets capsules
• Hard gelatin capsules
• Liquid solutions
• Suspensions
• Emulsions

26
Types of Drug Formulations

• Solid immediate release tablets capsules
• Enteric coated tablets
• Sustained release tablets capsules
• Hard gelatin capsules
• Liquid solutions
• Suspensions
• Emulsions

27
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

28
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

29
To Crush or Not to Crush?Extended-Release
formulations

• Capsules- opened, sprinkled,
• Lansoprazole
• Diltiazem
• Duloxetine
• Tablets-
• K-Dur
• Tegretol CR

30
To Crush or Not to Crush?Enteric Coated tablets

• No
• Enteric coating will not dissolve
• Switch to regular tablet

31
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

32
To 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

33
Enteral Feeding Tubes

• What is the intent of the tube?
• Where is the drug delivered?
• How does the enteral feed affect medication
  delivery?

34
Best 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.

35
Best 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.

36
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

37
Methods of crushing

• The Sodium Bicarb vial
• Mortar and pestle
• Silent knight
• Crushing syringe

38
Specific Medications

• Phenytoin
• Fluoroquinolones
• Warfarin
• Proton Pump Inhibitors

39
Interdisciplinary Team

• Communication
• Physician
• Speech Language Pathologist
• Nurse
• Pharmacist
• Dietician
• Power chart alert for swallowing status
• Medication Administration Record
• Links to resources

40
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

41
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?

42
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 patients current
  state?
• How can this situation be avoided?

43
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
  patients symptoms have not resolved?
• What has precipitated the patients current
  state?
• How can this situation be avoided?

44
References

• 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.