Welcome

Prescribing medicines for patients with dysphagia

DAVID WRIGHT

PROFESSOR OF PHARMACY PRACTICE

COPYRIGHT UEA 2016

Presentation

Dysphagia aetiology & prevalence (Survey)

Patient & professional opinions (Interviews and focus groups)

Dysphagia & medicines practice (Observation)

Medicines administration in dysphagia (Science bit)

Recommendations (Protocol)

Definitions‘Dysphagia’◦ Physical problem with swallowing

◦ Stroke

◦ Dementia

◦ Parkinson’s disease

◦ Huntingdon’s chorea

◦ Gastro Oesophageal Reflux Disease

◦ Ageing

‘Swallowing difficulty’◦ ‘Dysphagia’

◦ ‘Psychological aversion to swallowing tablets’

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DysphagiaCauses difficulties with◦ Social life

◦ Nutrition & hydration

◦ Medicines administration

Associated with Aspiration Pneumonia

Pneumonia most common cause of death in

◦ Parkinson’s disease

◦ Dementia

National UK survey 2002Regional care home nurse training days

540 nurses response to:

‘Frequency of crushing medicines’

Wright D. Medication administration in nursing homes. Nursing standard 2002; 16(42): 33-8.

Healthcare professional viewsSpectrum of dysphagia

‘Parkinson’s patients and epileptic patients, we know if they don’t get their medication their swallowing is going to get worse’

Medicine formulation

‘I suspect its really the compliance problem with those having great difficulty swallowing their medication probably once they are out of our sight.. don’t!’

Information transfer

‘we don’t know our medication, we don’t have the medical knowledge and the pharmaceutical knowledge to know drug forms and how they can be modified..’

Kelly J, Wright D. A qualitative study of the problems surrounding medicine administration to patients with dysphagia. Dysphagia 2009;24(1):49-56

Patient viewsSpectrum of dysphagia

‘I don’t have difficulty swallowing every day. Sometimes it’s OK..’‘..knowing that this is the last chore before going to sleep..’

Medicine formulation

‘Horrible, they really are!’

‘It’s the chalky texture. If they were all like Gabapentin, and other torpedo-shaped tablets that I take, that would be brilliant’

Information exchange

‘My GP has not asked if I have problems taking my medications… hospital X manages my medicines… they (the GP) just provide repeat prescriptions’

Kelly J, Wright D. A qualitative study of dysphagic patients' experiences of taking medication. Journal of Advanced Nursing. 2009; 66(1), 82–91

Observation of ward rounds4 hospitals, 8 wards

2129 drug administrations observed◦ 817 had an error◦ 313 involved patients with dysphagia

Administration errors◦ Patients with dysphagia 21.1%

◦ Patients without dysphagia 5.9% (p<0.001)

◦ Increases with enteral tubes (p<0.001)

Administrator was last line of defence

Kelly J, Wood J, Wright D. Medication administration errors in secondary care older person’s wards: A multi-centre observationalstudy. Journal of Advanced Nursing: 67(12), 2615–2627.

Wrong preparation 65 preparation errors including:

◦ 2.5mL of Oramorph™ measured using cup

◦ Inappropriate syringes used via enteral tube

◦ Frequent non-flushing of enteral tubes

◦ 26 cases of mixing different medicines together before dispersing

Kelly J, Wright D. An analysis of two incidents of medicine administration to a patient with dysphagia. Journal of Clinical Nursing. September 2010.

Wrong formulation8 patients inappropriately chewing their medicines such as Dipyridamole Modified Release◦ Dysphagia not previously identified

Tablets crushed in 24 cases◦ All without the prescriber’s written authorisation

◦ Seven cases alternative licensed liquid formulation available

◦ 19 cases the tablets could have been more appropriately dispersed in water

Dose omissions due to dispersing medicines and leaving them

Critical Incident analysis 9.30am Nurse W dispersed the sachet of Calfovit D3 in water and added Thick and

EasyTM to produce pudding consistency as prescribed by the dietician.

Added 30 mL of Calogen and administered the mixture to patient.

Nearly finished administering the Calfovit D3 / Calogen mixture, Nurse W added the 20mL of Docusol™ and continued to give it to Patient, who started to refuse to take the medicine as the last mouthful was given.

Whilst still at Patient’s bedside, Nurse W also dispensed the other four due medicines.

Critical Incident analysis Dispensed two ordinary paracetamol tablets into a medicine cup with two Sinemet-110™

tablets and a dispersible aspirin.

A second medicine cup used to measure out 3mL of rivastigmine, before locking the two

medicine cups in the patient’s bedside medicine cupboard.

At 10.10, having completed the rest of the drug round, Nurse W returned to Patient. She

removed the two medicine cups from his locker, added water to the cup containing the

paracetamol, Sinemet-110™ and dispersible aspirin.

When the tablets had dispersed she added Thick and Easy™ to produce a pudding

consistency, poured in the rivastigmine from the other pot, and gave the mixture.

Potential errorsEffect of mixing medicines is unknown,

Effect of adding thickening agents to medicines unknown

Mixing of two licensed medicines, where one is not a vehicle for the administration of the other, is “manufacture”

Dispersing non-dispersible paracetamol tablets

Dispersed Sinemet-110 tablets given over two hours late.

Inaccurate measuring 3mls of rivastigmine with a measuring cup

◦ significant proportion of the drug not being administered as it remained in the cup

Observation in care homes•738 administrations

•166 residents• 38 (22.9%) Dysphagia

•Medication administration error• 57.3% patients with dysphagia

• 30.8% patients with dysphagia

• P<0.001

Serrano Santos M, Wright D, Poland F, Longmore T. Medication administration for residents with dysphagia in care homes: A small scale observational study. International Journal of Pharmaceutics Feb 22, 2016.

Swiss cheese model

Dysphagia prevalent condition in older persons

Frequently not communicated to prescriber

Likelihood of errors significantly increased

oPoor administration practices

oUnstandardised approaches

oNew errors introduced

oIllegal practices

Culture which allows lots of minor errors will result in a major error

Administration of medicines

Dysphagia◦ Aspiration

◦ Asphyxiation

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The swallowing process

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Normal Swallow

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Parkinson’s swallow

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Swallow with aspiration

InterventionsAlternative non-oral formulations◦ Patches, suppositories

Liquid medicines◦ Less likely to block the pharynx

◦ If too runny can cause aspiration

◦ Need to be ‘Gloopy’ in consistency

Crushing or dispersing medicines

Percutaneous Endoscopic Gastrostomy or Jejunostomy tubes (PEG or PEJ)

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Alternative formulations

Alternative routesPatches◦ Pain control, hormones, smoking cessation

Suppositories◦ Pain control, laxatives

Buccal◦ Anti-nausea drugs, angina and migraine treatments

IV Administration◦ Impractical, costly and introduces infections

Liquid medicinesoPalatable

oKnown consistency

oDose standardisation

oStable

oDesigned for dysphagia

Liquid medicine considerationsTexture & taste

Licensed

◦ Long shelf life

◦ Agreed national price

Unlicensed

◦ Quality

◦ Certificate of compliance (Followed formula)

◦ Single supplies

◦ Certificate of analysis (Confirmed contents)

◦ Batch specials

Cost

◦ Tariff & non-tariff

Crushing or dispersing medication

The beautiful tablet

Plus• Enteric coats• Film/Sugar coats• Modified release mechanisms

TabletsIngredients selected to minimise interactions with active ingredient◦ Should not be crushed/dispersed and mixed together

Compressed to control release rate◦ Crushing/dispersing increases peak effects

Unaltered minimal contact of active with tongue◦ Crushed increase surface area of active

Drug Absorption

Modified release absorption

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Modified release crushed

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Enteric coatingsRelease at higher PH◦ To protect stomach

◦ To protect the medicine

◦ To deliver medicine to appropriate location

Remove coating◦ Cause adverse drug reaction

◦ Reduce medicine efficacy

Film or sugar coatings

To mask flavour

◦Quinine

To protect from skin sensitisation

◦Chlorpromazine

To protect from environment during storage

SafetyCrushing or dispersing can expose administrator to harm

◦ Skin sensitisation or rash

◦ Co-danthrusate

◦ Chlorpromazine

◦ Cytotoxics

◦ Methotrexate

◦ Hormonal products

◦ Misoprostol

◦ Finasteride

◦ Tamoxifen

LiabilityCrushing or dispersing medicines outside of license

Prescriber authorised unlicensed medicine use

Liability for harm for any unlicensed medicine lays with prescriber and administrator

Preferable to ◦ Record decisions to administer medicines in unlicensed manner with rationale

◦ Provide some form of written authorisation

Advice before tampering

Ask pharmacist◦ Aware of coatings and their rationale

◦ Aware of alternative options

◦ Able to comment on liquid consistency

Check reference sources◦ Information frequently not evidence based

Obtain authorisation

Record decision making process

Enteral Feed Tubes

Enteral feed tubesDesigned for administration of food and liquid

◦ Foods and liquids designed for feed tubes

Not designed for medicines

◦ Medicines not designed for feed tubes

◦ > 5 medicines 4.8 x risk of blockage

◦ > 13 doses/day 5.3 x

◦ > 10 days 2.6 x

Heineck, I., D. Bueno, and J. Heydrich, Study on the use of drugs in patients with enteral feeding tubes. Pharm World Sci, 2009. 31(2): p. 145-8.

Enteral feed tubesMost administrations unlicensed

◦ Liquid formulations currently being licensed

Primary concerns

◦ Blockage

◦ Feed interactions

◦ Drug stability

Recommendations

RecommendationsIdentify swallowing problem◦ Observe medication administration rounds

◦ Ask about dysphagia & chewing

Review medicines

Consider formulation / route

Tablet crushing/dispersing last resort◦ Introduces unexpected errors

◦ Custom and practice -> errors

Authorise anything process which is unlicensed

Wright D. Swallowing difficulties protocol: Medication administration. Nursing Standard 2002;17(no.s 4-15):43-5.

Further resourceswww.swallowingdifficulties.com

Future learn free access Massive On-line Open Course on ‘Medicines administration in dysphagia’

‘Pharmaquest’ APP for Apple and Android

◦First 25 medicines information cards free

Thanks for listeningANY QUESTIONS?