General guidelines for administration of medications to patients with swallowing difficulties

Liquids
Liquids are the preferred method of administering medications to patients with swallowing difficulties. Sorbitol-containing preparations can cause diarrhoea when large volumes (and therefore large sorbitol doses) are given.²⁴⁵ Hyperosmolar liquids can cause nausea, bloating, and diarrhoea.^22,26 Dilution of liquids with water can reduce their osmolality and thereby reduce the rate of adverse effects.²⁶

Unlicensed "special" liquids are sometimes very expensive, and it may be necessary to consider this when choosing how to administer therapy to patients, particularly when the therapy is likely to be long-term.

Standard tablets
Crushing tablets to aid administration to patients with swallowing difficulties is almost always outside the marketing authorisation (product licence). Crushed tablets are often unpalatable, and may sometimes have an anaesthetic effect on the oral mucosa, which can put the patient at risk of burns. Rinsing the mouth with water after administration of tablets may help to reduce this.

If tablets need to be halved in order to obtain the prescribed dose, it is best to cut them using a tablet splitting device. Such devices split tablets more accurately than splitting scored tablets by hand, or cutting tablets with a knife.⁵⁵⁸

Sugar-coated (s/c) and film-coated (f/c) tablets
These tablets are usually coated to improve appearance or to mask unpleasant taste, and they are usually suitable for crushing, although the presence of the coating may make crushing difficult.²²⁵

Dispersible / effervescent tablets
Dispersible and effervescent tablets can usually be administered to patients with swallowing difficulties in the normal manner. Dispersible and effervescent tablets should not be mixed with fluids other than water unless specifically indicated in the product information or the individual drug monograph, as this would cause administration to be outside the marketing authorisation (product licence).

Enteric-coated (e/c) tablets - do not crush
The enteric coating is designed to prevent drug dissolution in the stomach and to promote absorption in the small intestine. If the tablet is crushed undesirable side effects may occur. These could include stomach irritation and a decrease in drug effectiveness.^4,212,214

Buccal and sublingual tablets - do not crush
Drugs formulated in these dosage forms can be used as normal in most cases even if a patient becomes nil by mouth, provided that the patient is safe to have tablets held in their mouth, and is still producing normal quantities of saliva.^225,249

Modified-release (MR) and controlled-release (CR) preparations (also ER, SR, LA, XL, XR, Retard, Once Weekly) - do not crush
Using modified-release preparations in patients with swallowing difficulties poses the same problems as using them in patients with enteral feeding tubes. If the tablet is crushed, an increase in the expected peak plasma level may occur ("dose-dumping").²²⁵ The patient will be initially exposed to significantly higher-than-normal levels which will increase the chance of side effects. Later, the drug will not last the full dosage interval, resulting in a period with little or no drug present, possibly resulting in loss of control of the patient's condition.²¹⁴

A conversion to a non-modified-release preparation is necessary, usually requiring a dose decrease and a dosing frequency increase. Some modified-release capsules contain modified-release beads or granules which can be administered in water or on soft food to patients with swallowing difficulties. However there is a risk of giving excessive doses to patients if the beads / granules are crushed prior to swallowing. Therefore this method should only be used where it is the best possible option for a specific patient, and only if the patient has the ability and understanding to be able to swallow the water / soft food without chewing.

Cytotoxic tablets - do not crush
All staff should avoid contact with cytotoxic drugs. There is a risk of cytotoxic powder being aerosolized if cytotoxic tablets are crushed, exposing staff to hazardous materials.²²⁵ Cytotoxics should be handled in accordance with local procedures. Contact Pharmacy for advice.

Chewable tablets - do not crush
Chewable tablets can be used as normal in patients with swallowing difficulties.

Capsules
Opening capsules for administration to patients with swallowing difficulties is almost always outside the marketing authorisation (product licence). The contents of capsules are often unpalatable, and they may have an anaesthetic effect on the oral mucosa, which can put the patient at risk of burns. The capsule shell may provide stability to the medication or protect if from gastric acid.