Swallowing medication is a significant issue for 15-30% of the healthy population, and this has become more problematic in recent years with the increased use of tablets and capsules as main form of medical treatment across a variety of medical conditions. It is even more of a problem for those individuals who experience dysphagia.

As humans, it is very unnatural to not chew something that we place into our mouths. In order to swallow a medication, we have to suppress this chewing reflex AND the gag reflex that forcefully ejects items that aren’t chewed effectively.

Predictors for difficulty swallowing medications

• Remembering an occasion when a medication was previously choked on
• People with an increased number of taste receptors in the oral cavity
• Higher Mallampati score (used by Anaesthetists to determine how much free space is able to be visualised within the oral cavity for intubation)

The issue that arises when a person has difficulty swallowing medication, is the tendency to alter the form of a medication to make it easier to swallow.

Why is altering the form of a tablet/capsule a problem?

Crushing changes how effective the medication is:

• A medication needs to deliver a certain dosage to be effective, and this can be reduced with crushing, leading to a dose that is insufficient or sub-therapeutic
• Increased risk of side effects
• Crushing destroys the enteric coating on some tablets, removing the controlled release mechanism and potentially providing a dose of the medication that is much higher than intended

Crushing reduces how safe the medication is:

• Toxicity if the initial dose is too high
• Can harm the person altering the medication (e.g. vapours, inhalation of powder)

Challenges of Crushing Tablets

• Most medications taste bitter and this is why they are initially provided in a tablet or capsule form
• Providing the correct dose of the medication – you can’t leave any powder behind!Approximately 5-8% of the full dose is left behind in the device once the medication is crushed, even rinsing the device twice with water and using this water to re-administer only reduces the lost dose to 4.2%
• Cross-contamination when using the same crushing device for multiple patients/medications
• Impact of the carrier substance on the bioavailability of the medication
• Changes in bioavailabilityFor a medication to achieve its prescribed therapeutic benefit, 100% of that dose should be dissolved in gastric fluid after a 30 minute period. However, if you mix your medication with different substances, it can affect how much of the dose is resolved, and the medication’s bioavailability. For some medications, getting the dose exactly right is essential (e.g. warfarin) and the substance the medication is provided in can greatly affect how much of the dose is actually received by the individual.

“Off-Label” or “Unlicensed” Use

As soon as you modify the original form of a medication, the manufacturer of that medication will no longer confirm its safety.

If someone takes the medication in the modified form, it is considered to be an ‘off-label use’ as the medication is not being taken the way that it was intended to be taken, and the manufacturer is no longer liable for adverse medication effects!

Key Tips for Swallowing Medications:

• 60mL of liquid required to ensure efficient transfer
• If 35mL of water or less, little improvement to a dry swallow where only 9% of tablets were efficiently transferred
• Position to be upright, and seated with an incline of not less than 45 degrees
• Improvement in transfer did not occurred with more upright positioning than this!
• Practice!
• Research suggest 14 days of daily practice is enough to learn!

More Information about crushing medications can be found in the 2018 book ‘Don’t Rush to Crush’ which provides detailed information provided by Pharmacists on the best way to administer medication for people with dysphagia or who require tube-feeding where they can’t have their medications orally.

Always be sure to consult with your Pharmacist before crushing medications or your Speech Pathologist if you are having difficulty swallowing your tablet.

References

Cichero, J. (2020). ‘Medications and dysphagia: Challenges across the lifespan’. Webinar – Speech Pathology Australia.

Karch, A. M., & Karch, F. E. (2000). Practice errors: A hard pill to swallow. The American Journal of Nursing.

Manrique, Y. J., Lee, D. J., Islam, F., Nissen, L. M., Cichero, J. A. Y., Stokes, J. R., & Steadman, K, J. (2014). Crushed Tablets: Does the Administration of Food Vehicles and Thickened Fluids to Aid Medication Swallowing Alter Drug Release? Journal of Pharmacy & Pharmaceutical Sciences.

Thong, M. Y., Manrique, Y. J., & Steadman, K. J. (2018). Drug loss while crushing tablets: Comparison of tablet crushing devices. PLoS ONE, 1;13(13). DOI: 10.1371/journal.pone.0193683