Rushing to crush – ask before you prescribe

More than one million Australians have difficulty swallowing. For the very young it is usually due to lack of coordination needed to swallow, while for older people it may be due to a medical condition such as stroke or Parkinson disease, or age-related changes in salivary gland function. Sometimes it is simply an aversion to swallowing tablets and capsules.

An Australian study (Lau, 2014) looked at the prevalence of swallowing difficulties and medicine modification in community pharmacy customers and found that swallowing difficulties increase with the number of doses of medicine that a person takes, and that people will crush, chew or otherwise modify their medicines without asking a pharmacist or their GP for advice first.

Start the conversation

Asking your patients or customers if they can swallow their medicines is an important role that pharmacist and GPs can play in avoiding medicine-related harm.

It is reasonably easy to identify people with medical conditions that are associated with swallowing difficulties who might modify their medicines. A harder task is identifying people who may modify their medicines for no obvious reason, other than to make them easier to swallow.

Wednesday 16 March 2022 is Swallowing Awareness Day, the perfect opportunity for pharmacists and GPs to ask their customers and patients if they have trouble swallowing their medicines. For those who answer yes, there is a wealth of information available to help you offer solutions or alternatives that avoid the need to crush or modify a medicine, and minimise the risk of harm.

Give the right advice

A swallowing disorder left untreated can have devasting consequences. As a first step, anyone with difficulty swallowing should be assessed by a speech pathologist. A speech pathologist can assess and treat swallowing disorders, as well as make recommendations about the appropriate texture of food and thickness of drinks.

For many people with swallowing difficulties, swallowing a thin fluid such as water, tea or coffee presents a challenge. The speed and unpredictability of the direction of flow means a thin liquid may be inhaled into the lungs (aspirated), which can lead to pneumonia.  A thicker fluid will flow more slowly and is easier to control when swallowing. However, thicker is not always better – a substance that is too thick, or sticky, can cause choking.

The Fourth Edition of the Australian Don’t Rush to Crush Handbook provides recommendations (options) in order of preference, for people with swallowing difficulties for over 590 medicines. For the first time, this edition includes advice about the thickness of oral liquid medicines and whether they are a suitable option for people with swallowing difficulties.  Don’t Rush to Crush classifies over 100 oral liquid medicines according to the International Dysphagia Diet Standardisation Initiative (IDDSI) framework. The IDDSI framework provides a common terminology for describing the texture of food and the thickness of drinks – Don’t Rush to Crush is the first resource to test and publish the thickness of oral liquid medicines.

To crush or not to crush

In the absence of clear, up-to-date advice from a health professional, patients and customers may be unaware of the potential harm that can come from inappropriate modification of tablets and capsules, including:

• Crushing a modified-release formulation can cause toxicity, fatalities have occurred.
• Crushing or dispersing an enteric-coated formulation can mean the active ingredient does not reach the site of absorption or action, or it can cause toxicity.
• Some tablets cannot be halved.
• Mixing medicines with apple puree or yoghurt can reduce the absorption of some medicines.
• Grapefruit juice is a moderate inhibitor of CYP 3A4/5 and must be avoided with some medicines.

Even if a formulation is not modified-release or enteric-coated, there may be a better option than crushing. When a medicine is crushed, there will always be some of the dose lost to the equipment used. If proper technique is used, a minimum of 5% of the dose will be lost, while if crushing technique is poor, such as inadequate rinsing of the crushing device, an average of 24% of the dose is lost.

Don’t Rush to Crush provides advice about the best technique for crushing or dispersing a medicine. The latest edition includes a patient leaflet for people who have to crush or disperse their medicines, with step by step instructions in plain English.  The leaflet is designed to be used together with advice from a pharmacist about which method is the most appropriate for each medicine. Download the patient resource How to prepare your medicines if you have difficulty swallowing from the SHPA website or see the Patient Resources link in How to use Don’t Rush to Crush in AusDI.

Swallowing Awareness Day presents an ideal opportunity for pharmacists and GPs to ask their customers and patients if they are having trouble swallowing their medicines. Not only can this avoid the risk of medicine-related harm, it can also lead to the proper diagnosis and treatment of a swallowing disorder.

All the information you need to give the right advice about safe swallowing of medicines is in 4^th edition of Don’t Rush to Crush, available in AusDI.