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JCPSLP
Volume 17, Number 2 2015
Journal of Clinical Practice in Speech-Language Pathology
to the speech pathology assessment. Previous use of
alendronate combined with swallowing difficulties may
have resulted in or contributed to her initial oesophageal
irritation, thereby increasing difficulties swallowing, which
led to the paracetamol becoming “stuck”. The medication
was ceased following this episode. The pharmacist
recommended the investigation of a non-oral osteoporosis
medication.
Following the change in paracetamol tablet brand,
liquid paracetamol use dropped by two-thirds across the
medical and rehabilitation wards. Subjectively, there has
been a reduction in referrals to SLP for “difficulty swallowing
medications”. Twelve months following the implementation
of the alternative brand of paracetamol tablets, some staff
and patients still comment on how difficult the tablets of
the previous brand were to swallow. Changing the brand
may have reduced the number of people having difficulties
swallowing paracetamol, and the subsequent use and cost
of liquid alternatives.
Discussion
As difficulties swallowing medications appear to increase
with age, consideration of ability to swallow medication will
become increasingly important with an ageing population.
Although liquid forms may be available, in the case of
paracetamol, they can be 100 times more expensive than
tablets, and cannot be packed into dose administration
aids (e.g., Webster packs). Older people may not have the
dexterity to open a bottle with a child proof cap and
accurately pour a dose of liquid medication. It was also
highlighted in the article by Schiele et al. (2013) that in the
community patients missed doses deliberately because
medications were difficult to swallow.
Our case study highlights the fact that simple changes
in practice can have important service-wide impact
in addressing the needs of patients with swallowing
difficulties. Paracetamol is a very common medication,
particularly in the hospital environment, and is taken
numerous times per day by many patients. In this case
study, the simple action of changing brand and tablet shape
had a significant impact for this individual. The change
resulted in a less expensive, less modified, and more
reliable dose for this medication. As a consequence of this
trial the new brand of medication was rolled out across the
hospital.
This case also highlights the importance of utilising a
multidisciplinary approach to dysphagia management.
An advantage of employing a multidisciplinary approach
is that it encourages different approaches to solving a
problem, which may result in more individualised, practical,
and successful solutions for patients. In this instance, an
alternative approach to addressing the patient’s difficulty
swallowing the paracetamol tablet may have been to
substitute it with alternative oral, rectal, or intravenous dose
forms. These may not be practical, acceptable, or cost
effective for the patient involved. The changing of brand
and therefore tablet presentation, through consultation with
the pharmacy department, provided an acceptable, cost-
effective, long-term solution for this patient which benefited
many others.
Our experience suggests that prior to considering dose
form modifications, it may be appropriate to consider if
a different brand or coating improves a person’s ability
to swallow the medication. This approach may allow
the person to receive the least modified form, potentially
improving compliance with taking the medication, and
reducing the cost burden to the patient or facility.
that cutting tablets results in “twice as many tablets to
swallow”. Some medications can improve swallowing
by reducing excess saliva, or improving motor control,
for example, in patients with Parkinson’s disease. Other
medications can impair swallowing by causing xerostomia,
reflux, oesophagitis, or reducing muscle co-ordination
(Gallagher and Naidoo, 2009).
Despite the challenges associated with administration,
tablets are generally preferable to liquid formulations
due to manufacturing, storage, dispensing, and cost
advantages. Liquid medications tend to leave residue in
the bottom of medicine cups, are often unstable, may have
short expiration dates, are more difficult to measure, and
typically cost more per dose. As many liquid medications
are for the paediatric population, the volume required to
swallow for an adult dose is often large (Singh, Philip, &
Pathak, 2008). A usual adult dose of paracetamol (1000
mg four times per day) is almost 100mls of commercially
available preparations per day. A person with dysphagia
may have difficulty taking this volume of medication. Liquid
paracetamol is almost 100 times more expensive per
dose than tablets (approximately 8c per day for tablets,
$8 per day for liquid, and $10 per day for intravenous
administration).
In the community, many people with swallowing
difficulties make their own dose form modifications by
choosing brands that they find easier to swallow over
others. However, in the hospital setting, the choice of brand
may be limited by the hospital formulary. We present here
a case which initiated a review of the brand of paracetamol
stocked by the hospital and the benefits of this review for
patients.
Case example
A patient admitted to the hospital for rehabilitation following
a fracture was complaining of increasing difficulty
swallowing. She was managing thin fluids and a soft diet,
although she reported that her swallowing was “not as
good as usual”. Following this increased difficulty
swallowing, she had an episode where a regular medication
(paracetamol) “got stuck and burned her throat”. She then
had significant difficulty and pain on swallowing, and was
acutely unwell. Her diet was modified to a minced diet, and
she remained on thin fluids.
A pharmacy review was requested regarding crushing
medications and liquid alternatives. She was commenced
on liquid paracetamol to reduce pain, but declined doses
stating that it caused stinging in her throat. A different
brand of paracetamol tablet was trialled, which the patient
was able to swallow with water without difficulty. This tablet
was a different shape and texture. With other supportive
care, and an improvement in ability to swallow food, fluids
and medications, she improved over the following days and
returned to her normal soft diet within a week.
In addition to providing advice on modified dose forms,
the pharmacists identified that the patient was prescribed
alendronate. Alendronate is a once weekly medication,
and requires the patient to be able to swallow tablets
whole with a glass of water on an empty stomach first
thing in the morning and remain upright for 30 minutes
following consumption. Alendronate is known to cause
oesophageal irritation (de Groen et al., 1996). Difficulty
swallowing the required amount of water, or the presence
of reflux, would increase the risk of irritation from this
medication, which may cause further difficulties swallowing.
The patient had received her weekly dose two days prior