Choosing medicines formulations in swallowing difficulties

Consider using:

• medicines which are taken once daily, but avoid modified-release preparations as most should not be crushed or opened
• non-oral formulations such as transdermal patches or suppositories

Provide written and verbal medicine administration instructions, especially when patients move between care settings.

Monitor (SPS page) efficacy and adverse effects when changing a patient’s medicine, dose frequency or formulation.

Review a patient’s medicines regularly to ensure they remain suitable. Swallowing ability may change, and new treatment or formulation options may become available.

Patients who cannot swallow food and drink safely must be assessed by a speech and language therapist.

People who eat and drink normally

Special-order medicines for these patients are usually not justified.

Good pill-swallowing technique can help. The NHS website has examples.

For those who dislike large tablets or capsules, consider:

• small tablets and capsules
• snapping scored tablets in half

For those who can tolerate thin liquids, consider:

• dispersible or effervescent tablets in water
• orodispersible or chewable tablets
• oral liquid medicines
• crushed tablets or capsule contents with food or drink

Rarely, giving an injection orally may be an option. Consider carefully whether the patient or carer can do this safely, and the equipment they will need. This would not be initiated in primary care. Assessing injectables for enteral administration (SPS page) gives advice.

People who cannot eat and drink normally

These patients should have a swallow assessment by a speech and language therapist (SALT). The SALT will recommend an appropriate fluid consistency and food texture (described by IDDSI level). Food or drink that is thinner or thicker may not be swallowed safely.

Patients who need texture-modified food and drink may be able to swallow medicines with appropriate food or thickened fluid. Crushed tablets or capsule contents are usually the best option for them.

Why and how medicines are given with soft food or thickened fluid (SPS page) explains in more detail.

Only administer medicines in food or drink with the patient’s consent.

Hiding medication in food or drink so the patient takes the medicine without knowing is ‘covert administration’. This is only allowed under certain circumstances, after the appropriate procedure has been followed.

Covert administration of medicines: legal issues (SPS page) provides more information.

Who will prepare and give the medicine

Consider who will prepare and give medication (the patient or a carer) and other practicalities.

Skills and training

Before recommending a formulation, consider the patient or carer’s:

• manual dexterity; crushing tablets, opening capsules, or opening medicine bottles may be difficult for some people
• training or ability to follow instructions to give or take the medicine correctly; some patients are unable to follow instructions not to chew
• ability to give the medicine consistently

Health and Safety

Crushing tablets or opening capsules may create dust, increasing the risk of drug inhalation or skin exposure. This is particularly important for cytotoxic or teratogenic medicines, antibiotics, immunosuppressants and hormones. Carers should take precautions to reduce exposure, such as wearing gloves and dispersing tablets in oral syringes.

If patients or carers cannot crush tablets or open capsules safely, liquid medicines may be more appropriate.

Advising how to crush or disperse tablets and open capsules (SPS page) provides practical information on crushing and/or dispersing tablets and opening capsules.

Why and how medicines are given with soft food or thickened fluid (SPS page) includes advice on the types of food to use.

Medicine storage and supply

Liquid medicines may need more storage space, especially if several bottles are supplied at once. Some must be kept in a refrigerator.

Some liquid medicines have a short shelf-life, requiring more frequent supplies.

Some unlicensed liquids need to be ordered far in advance, which can be difficult for some people to manage.

Choose a product taking account of clinical suitability, quality, licensed status and cost.

When choosing between available medicines:

• use a licensed medicine within the terms of its product licence if suitable for the patient
• if not, use a licensed medicine outside its product licence, ‘off-label’
• if licensed medicines are unsuitable, consider using an unlicensed ‘Special’

Using a licensed medicine ‘off-label’ is preferred to using an unlicensed medicine . This is because licensed medicines have been evaluated by the MHRA for safety, quality, and efficacy but unlicensed medicines have not.

If you need to use a licensed medicine ‘off-label’ or an unlicensed medicine, the prescriber has extra responsibilities. Consult GMC guidance for further information.

Medicines suitable for adults with swallowing difficulties (SPS page) lists licensed and ‘off-label’ options in some therapeutic classes. The BNF lists licensed options.

Licensed medicines

Medicines used as licensed

The Summary of Product Characteristics (SmPC) for a medicine provides information on licensed uses.

Sometimes the SmPC will say how to give a medicine to people with swallowing difficulties. For example, edoxaban tablets are licensed to be crushed and given with water or apple puree.

Try to use the SmPC for the patient’s brand of medicine, as sometimes information differs between brands.

Medicines used ‘off-label’

Using a medicine differently than described in the SmPC is considered outside the licence or ‘off-label‘.

Crushing tablets and opening capsules can be the best option for a patient even if it is not included in the SmPC. However, not all tablets can be crushed or capsules opened safely. See step 5.

For carers or care home staff to administer medicines in an ‘off-label’ way, the prescriber must make a written direction. Instructions must be included in the patient’s Medication Administration Record (MAR) chart and care plan.

Unlicensed medicines

Unlicensed medicines include special-order medicines (‘Specials’) and medicines imported from abroad which do not have a UK licence. This means their quality and safety have not been assessed by the MHRA.

You can use an unlicensed medicine when licensed medicines, including ‘off-label’ use, cannot meet a patient’s clinical needs. The MHRA acknowledges use of licensed medicines ‘off-label’ is preferable to the use of unassessed, unlicensed medicines.

Unlicensed medicines may be difficult to obtain. Some must be ordered far in advance of when they are needed.

‘Special order’ medicines

‘Specials’ can be very expensive. The cost to the NHS of ‘Specials’ 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.

Crushing tablets or opening capsules that are unsuitable can expose the patient to toxic effects or lack of effect.

Medicines suitable for adults with swallowing difficulties (SPS page) lists licensed and ‘off-label’ options in some therapeutic classes.

See our guide Checking if tablets can be crushed or capsules opened (SPS page).

Giving a crushed tablet or capsule contents with food is common in swallowing difficulties. It is usually the best option for patients who need texture-modified food or fluid. It is also common in covert administration (SPS page).

Most medicines can be given safely with a spoonful of soft food, but there are exceptions.

Medicines suitable for adults with swallowing difficulties (SPS page) advises if medicines can be given with soft food for some therapeutic classes.

See our guide Checking if medicines can be given with food (SPS page).