[Dysphagia] Medication administration

[eripley at yahoo.com (Irene Campbell-Taylor)]

While revising and updating my CD on medications that cause dysphagia, and after reading the disturbing (although not unfamiliar) message about administration of drugs to persons with DD in long term care, I realized that I would have to include an expanded section on medication administration errors as there appears to be a great deal of misunderstanding about the issue. The following is adapted from:

American Society of Consultant pharmacists : Guidelines for administration.

In addition to regular updates in Hospital Pharmacy, ?Oral Dosage Forms That Should Not Be Crushed? is reproduced yearly in the American Drug Index.

Anyone who visits any acute- or long-term care facility can observe personnel meticulously grinding tablets or the contents of capsules in a mortar and pestle or plastic pill crusher. Their rationale is well intentioned: they have an order to administer medication to a patient with an enteral tube or who cannot swallow  and have to alter the drug to an ingestible form. However, they do so at the risk of changing the pharmacokinetics of the solid dosage formulation. Examples of special formulations include sublingual or buccal, enteric-coated, and extended-release tablets or capsules. Products containing extended-release dosage forms frequently have an abbreviation affixed to their brand name that serves as a clue that crushing may affect the formulation . In addition, some medications are inherently corrosive to the oral mucosa and/or upper gastrointestinal tract, remarkably bitter to the taste, or capable of staining the oral mucosa and teeth.

 

Then, there is the problem of  mixing of drugs in the crusher.  I have seen facilities in which, on each unit there is  only one plastic screw type crusher  I have also seen the mortar and pestle not being thoroughly cleaned between medications.. The plastic crusher type  is ineffective when medications need to be completely crushed, and the possibility of different drugs being mixed together is high in both scenarios.

Cutting pills that are not scored for splitting  is also potentially hazardous since it is possible to get all of the active ingredient in one half and only the excipient material in the other.

 

Alternatives to Crushing

For patients who cannot swallow whole tablets or capsules, the most logical approach is to use liquid suspension forms of the same medication.  Unfortunately, liquid medications are subject to the problem of precipitation i.e. there is more of the active agent at the bottom of the bottle than at the top. In some cases, there must be a dosage adjustment when the liquid is substituted. This is especially true if the tablet or capsule is an extended-release medication. If a liquid or suspension is not commercially available, the pharmacist should be consulted to determine if a liquid formulation could be prepared. Occasionally, it is possible to substitute the injectable form of the medication by placing the appropriate amount of injection in some suitable fluid, such as juice. This should be done, however, only after consultation with a pharmacist to insure that there are no problems regarding compatibility or changes in absorption of the drug.

There are several types of medication administration error:

Preparation Error. A medication incorrectly formulated or manipulated before administration, such as incorrect or inaccurate dilution or reconstitution, failure to shake suspensions, crushing medications that should not be crushed, mixing drugs that are physically or chemically incompatible, and inadequate product packaging

Administration Technique Error. Use of an inappropriate procedure or improper technique in the administration of a drug. Examples of wrong technique errors include incorrect manipulation of inhalers, failure to maintain sanitary technique with medications, not wiping an injection site with alcohol, failure to use proper technique when crushing medications, failure to check nasogastric tube placement or flushing NG tube before and after administration of medication, failure to wash hands or improper hand washing technique used.

 

Of course, the best answer for many medications would be to have them available in gel, cream, patch or suppository.  This is common in Europe but relatively rare in North America. I am given to understand by representatives of the pharmaceutical industry that there is a reluctance to produce such forms for medications on which there is no longer a patent, the perception being that the market is too small.



Dr I Campbell-Taylor
Clinical Neuroscientist
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