Solid Oral Dose Forms and Swallowing Difficulties

A study has shown that pharmacists and physicians seldom discuss a patient’s ability to swallow medications. Only a few of the affected patients with swallowing difficulties seek advice from their physicians or pharmacists. Older individuals may not be aware of their inability to swallow, as they could perceive it to be a normal aging process. As a result, they do not seek appropriate advice from a healthcare professional. Some signs and symptoms of medication swallowing difficulties include coughing, choking and gagging during or immediately after swallowing the solid oral dose form. Some individuals with medication swallowing difficulties may be asymptomatic and not display signs or symptoms. This does not necessarily rule out any risk of medication swallowing difficulties.

More than 70% of medications are administered orally. More than 60% of active pharmaceutical ingredients are formulated as solid oral forms e.g. tablets and capsules. Hence, there is a need to create awareness in providing the appropriate recommendations.

Swallowing solid dosage forms whole goes against the innate chewing reflex. This may trigger a gag reflex in some people when the tablet or capsule touches the tongue. Successful swallowing of a solid dose depends on an individual’s ability to overcome their chewing and gag reflex. Swallowing tablets and capsules without chewing is a skill and it can be taught.

Contributing factors:

• Females are more likely to experience medication-swallowing difficulties than males as they have a shorter interval between swallows, and a smaller volume in each swallow.
• Aging, as swallowing flow and volume capacity decreases with age.
• Tablets and capsules that are too small may be difficult to swallow, as some individuals may be unable to feel them once they are in the mouth.
• Rough textures, irregular shapes and unpleasant tastes or smells of solid oral medications.
• Past traumatic events, e.g. choking episodes associated with swallowing solid dose forms.
• Medical conditions e.g. stroke, Parkinson’s disease, xerostomia.

Issues that arise due to swallowing difficulties:

• Individuals may not receive the full therapeutic dose due to medication non-adherence.
• An increase in medication retention time in the throat may result in oesophagitis especially when taking doxycycline, NSAIDs or bisphosphonates.
• The uncoordinated swallowing process may force the medication to penetrate the lungs, causing aspiration pneumonia.
• Prolonging the swallowing process may lead to solid medications to disintegrate in the mouth releasing a bitter taste, which may further aggravate the swallowing issues.

Management strategies for medication swallowing difficulties:

• Provide appropriate advice on dose form modification e.g. oral liquids, disintegrating tablets, wafers, patches, and injections. The pharmacist should initiate discussion with the prescriber before amendment to the dose form is made. When a formulation is not commercially available, pharmacists can contact a compounding pharmacy to check availability of an extemporaneous product.
• Modifying solid forms to ease swallowing e.g. splitting, crushing or chewing tablets and opening capsules. Spoons, syringes, knives, pill crushing devises, pill cutters, a mortar and pestle can be recommended. Consider potential drug loss when modifying dose forms. Certain modified release preparations can be halved but not crushed or chewed, while some cannot be halved, crushed or chewed.
• Postural adjustment – changing the head and neck position to alter the speed and flow of solid dose forms making it easier to swallow and reducing the risk of aspiration and laryngeal penetration. Consultation with the physician or speech pathologist to determine suitability is necessary.
• Mixing medication with foods like fruit puree, applesauce, yoghurt, honey, custard, pudding. A speech pathologist or dietician could advise on the most appropriate food textures and liquid consistencies to ensure a safe swallow. Complete consumption of medication containing food is necessary to avoid under dosing. Food –drug interactions when mixing medications with food and beverage should be taken into account.
• Recommending appropriate swallowing aids as this eliminates the need to modify dosage form e.g. use of medication lubricating gels (Gloup®).
• Recommend to swallow solid medications with at least 50 – 60 ml of water.

Pharmacists need to proactively approach patients and incorporate a discussion about medication swallowing difficulties when providing medication counselling to all patients. However, inappropriate dose form modifications may be harmful and result in serious health and legal consequences.