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

1. Patricia Dool, BSP Clinical Pharmacist- Neurology London Health Sciences Center- University Hospital London, Ontario Practical Pearls to Manage Medications when Patients Have Dysphagia

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 patient’s 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 patient’s symptoms have not resolved? What has precipitated the patient’s 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 • Sjogren’s 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 patient’s 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/allergenic 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 ASPEN:Methods 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 ASPEN:Methods 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 that’s 30ml or larger. • Flush the tube again with at least 15ml of sterile water, taking into account the patient’s 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 patient’s 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 patient’s 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 patient’s symptoms have not resolved? What has precipitated the patient’s current state? How can this situation be avoided?

44. References Carl, LL, Johnson, PR Drugs and Dysphagia:How Medications Can Affect Eating and Swallowing: 1st ed. Austin TX:Pro-Ed 2006. O’Neill, J, Remington, TL Drug Induced Esophageal Injuries and Dysphagia The Annals of Pharmacotherapy 2003 November, Vol 37:1675-1683. 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 12:188-193. Mitchell, J Oral Dosage Forms That Should Not be Crushed ISMP Institute for Safe Medication Practices Kelly, J, D’Cruz, 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 35:156-9.