Stop unnecessary medicines

Any medicines that are not needed should be stopped by a prescriber.

Reduce the number of oral doses

Consider using:

• Medicines with a long therapeutic effect to reduce the number of doses needed. But remember most modified or slow-release preparations are not suitable to be crushed or opened.
• Non-oral formulations such as transdermal patches or suppositories.

Decisions must be made on an individual patient basis.

Ensure the patient is involved and is provided with written and verbal administration instructions for each medicine they are prescribed. This is particularly important when patients move between care settings.

Monitoring

When changes are made to the patient’s medication, it is important to monitor for efficacy and adverse effects and review the prescription regularly to ensure the patient’s needs are being met. The patient’s needs or severity of dysphagia may have changed or a new treatment option may be available.

People who eat and drink normally

• Adults who dislike swallowing large tablets or capsules may be able to manage small tablets and capsules, or large, scored tablets snapped in half.
• Good pill-swallowing techniques can help. Examples are available on the NHS website.

Patients who can safely swallow thin liquids may have:

• Dispersible or effervescent tablets in water,
• Orodispersible tablets,
• Oral liquid medicines,
• Crushed tablets, or the contents of capsules, with a drink or with food.

The use of costly special-order medicines for these patients is generally not justified.

People who cannot eat and drink normally

• These patients must have their swallow assessed by a speech and language therapist, who will recommend the appropriate fluid consistency and food texture for them.
• The appropriate fluid consistency and food texture (described by IDDSI Level) for the patient will be documented in their swallow assessment report. Food or drink that is thinner or thicker than that may not be swallowed safely.
• Patients who need texture-modified food and drink may be able to swallow medicines (usually crushed tablets or the contents of capsules), given with the appropriate food or thickened fluid for them. This is generally the best option for them.

Identify:

• who will be giving the medicine (the patient themselves or a carer)
• their manual dexterity, and
• their ability to follow instructions to administer the medicine correctly.

If patients or carers are unable to safely manipulate tablets or capsules, liquid medicines may be a more practical option, if appropriate for the patient.

People manipulating tablets or capsules may be at risk of inhalation or topical exposure of the drug – this is particularly important for cytotoxic medicines, antibiotics, immunosuppressants and hormones. Carers should take precautions such as wearing gloves and using ‘closed system’ crushing syringes.

Consider the needs of patients and carers. It may not be practical for a patient to store or carry several bottles of liquid medicines. Some liquid medicines require fridge storage.

Care homes and carers

• Homecare and care home staff may only administer prescription medicines on the instruction of the prescriber and must be trained and competent to do so.
• It is important that medicines are given consistently. Inconsistent approaches to dosage modification can make it difficult to stabilise patients on medication regimens.

Choose a product taking into account quality, licensed status and cost.

NHS healthcare professionals have a duty to make the best use of public resources; cost as well as clinical suitability and product quality must be considered when choosing appropriate preparations.

Option 1: Licensed medicine used as licensed

If possible, use a licensed medicine in a suitable formulation to meet the patient’s needs. Licensed medicines are associated with less risk and are usually less expensive than special-order products.

• Dispersible tablets or licensed liquid medicines can be used for patients who can safely swallow thin liquids.(e.g. switch from gabapentin tablets to gabapentin oral suspension)
• Orodispersible tablets can be an option, but may not be suitable for people who cannot control their swallow.
• Consider switching to a different agent in the same therapeutic class, to allow a licensed medicine to be used. (e.g. switch from perindopril tablets to ramipril oral solution)
• Consider switching to a different route of administration to allow a licensed medicine to be used.(e.g. switch from oral to transdermal HRT)
• Ensure switches are undertaken appropriately, with patient monitoring if necessary.

Option 2: Licensed medicine used ‘off-label’ (e.g. crushing a tablet or opening a capsule)

Consider using a licensed medicine in an unlicensed manner, for example by crushing a tablet and/or dispersing it in water, or by opening a capsule. Giving a crushed tablet or contents of a capsule with soft food that the patient can swallow safely is likely to be the best option for patients who need texture-modified food and fluid.

Licensed medicines, even used ‘off-label’, may be associated with less risk and are usually less expensive than special-order products.

Not all tablets can be crushed or capsules opened and it is important to check beforehand (see the guide below). Take into account the patient/carer’s ability to administer medicines in this way and consider any risks to the carer from exposure to medicines such as cytotoxics or hormones.

Prescribing medicines ‘off-label’

• Prescribers should be aware of the route and method of administration of medicines they prescribe.
• They need to be aware if a medicine is to be used outside its licence and take responsibility for its use in this manner.

Administering medicines ‘off-label’

• Homecare and care home staff may only administer prescription medicines on the instruction of the prescriber and must be trained and competent to do so.
• If staff are to crush tablets or open capsules, a written direction should be included in the patient’s MAR (Medication Administration Record) chart and care plan.
• If equipment is shared, it must be thoroughly cleaned to avoid contamination between medicines for different patients.

Option 3: Special-order product (‘Special’)

Where the patient’s needs cannot be met by licensed medicines, including  ‘off-label’ use, consider using a special-order product (‘Special’).

Special-order medicines can be obtained when medicines are not commercially available in suitable licensed formulations.  Special-order medicines, and extemporaneous preparations, are unlicensed and should only be considered for use when a patient’s needs cannot be met by licensed medicines.

The use of special-order or extemporaneous products may increase the risk to both patient and prescriber. The products are not assessed for safety or efficacy by the regulatory authorities and prescribers assume greater liability for their use.

In many cases, special-order medicines or extemporaneous preparations are not required. The MHRA acknowledges that, while it does not recommend ‘off-label’ use, the use of licensed medicines ‘off-label’ is preferred to the use of unassessed, unlicensed medicines.

Special-order medicines can be expensive, sometimes many times the cost of alternative licensed medicines. The cost to the NHS of some special-order products (those listed in Part VIIIB of the Drug Tariff or Part 7S of the Scottish Drug Tariff) is fixed but the cost of others is unregulated.

Sources of information

• In some cases, information on administration to patients with swallowing difficulties is included in a product’s Summary of Product Characteristics or Patient Information Leaflet. If so, such use is licensed rather than ‘off-label’.
• Medicines suitable for adults with swallowing difficulties provides examples of medicines options (licensed and ‘off-label’) in some therapeutic classes.
• The NEWT guidelines (subscription required) provides information on medicines administration for people with swallowing difficulties or feeding tubes. Drug monographs provide information on crushing or dispersing tablets and opening capsules and  may also note if medicines taste bitter or have a local anaesthetic effect in the mouth.
• The Handbook of drug administration via enteral feeding tubes (subscription required) provides information on medicines administration via feeding tubes. Drug monographs provide information on crushing or dispersing tablets, and on opening capsules, for specific brands and generic preparations.
• The SPS Medicines Advice service and local medicines management pharmacy teams may provide advice to healthcare professionals.

Pharmaceutical considerations

Modified-release preparations

• Modified-release tablets or capsules (they might have names that include MR, SR, XL or LA) are usually not suitable for crushing or opening.
• Some (but not all) tablets and capsules that contain modified-release granules can be dispersed or opened. However, the granules must not be crushed or chewed, making them unsuitable for patients with limited understanding or who are unable to follow instructions.
• Consider switching to an immediate-release formulation that can be crushed, if possible.

Tablet coating

• Enteric-coated tablets (they might have names that include EC) are not suitable for crushing.
• Film-coated tablets can be difficult to crush and, once crushed, may have an unpleasant taste or anaesthetic effect on the tongue.
• A bitter taste might be disguised by giving the medicine with a small amount of strongly flavoured food or drink such as chocolate custard or blackcurrant squash.
• If medicines cause an anaesthetic effect on the tongue, patients must be advised to be careful when eating and drinking, particularly with hot food and drink.

General principles

• Most medicines can safely be given with a mouthful of food or thickened fluid.
• Thickening liquid medicines is discouraged owing to difficulty in checking the final consistency; Giving a medicine with food or thickened fluid is likely to be safer and is preferred.

Drug-food interactions

Medicines ‘to be given on an empty stomach’

• The bioavailability of some medicines can be reduced by food (they may require dispensing label 21 or 23), but if the interaction can usually be managed pragmatically:
• If the patient switches from taking such a medicine on an empty stomach to taking it with food, its effects may be reduced. This is important if the medicine has a narrow therapeutic range. Monitor clinical effects (or serum levels if appropriate) and adjust the dose according to effect until stabilised. If the medicine continues to be given at the same time and with similar food, any variation in absorption should be minimal.
• Levothyroxine is an example: bioavailability might be reduced by food, but so long as the tablets are taken consistently with regards to food, the effects can be monitored and the dose adjusted accordingly.

Medicines that should not be given with milk

• Medicines that should not be given with milk (those that require dispensing label 7) must not be given with dairy products (or calcium-fortified non-dairy products) such as yoghurt or custard. Apple puree is a suitable alternative if safe for the patient to swallow.

Drug-thickener interactions

• If thickeners are used to thicken medicines, there is the potential for a drug-thickener interaction. Information on interactions between medicines and thickeners is limited.
• There is a known interaction between macrogol (PEG) laxatives and starch-based thickeners.