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Options for patients who can’t swallow

Dysphagia (difficulty or discomfort in swallowing) is a problem for 30% to 65% of stroke victims. Feeding-swallowing issues affect 15% of the elderly and are also common with advanced dementia. Increased difficulty with swallowing oral medications increases the risk of aspiration (breathing in a foreign object or sucking food into the airway) which can lead to pneumonia. Seizure disorders occur in about 13% of patients who are receiving palliative care (which relieves suffering but does not prolong life), and treatment options become limited when feeding and swallowing disorders develop. Hospice and palliative care patients often develop complications such as impaired gastrointestinal absorption, nausea, vomiting, delirium, or cognitive impairment, all of which would complicate the ability to take required oral medications. These are some of the reasons why alternative routes of administration, including transdermal or rectal, are utilized in the elderly and those receiving end-of-life care.

Suppositories are a reasonable option when limited routes of administration are available or to prevent seizures in the elderly or those receiving palliative care. Advantages of rectal administration include: limited patient or caregiver education is required, the medication does not pass through the liver before it is absorbed (this is important for people with fluctuating or declining liver function), and the medication has a rapid onset of action. Disadvantages include potentially significant variation in dose required for desired effects or to maintain therapeutic levels (dependent on the specific drug as well as the preparation of the suppository), variable absorption, lack of caregiver acceptance, and poor patient acceptance/compliance. Also, rectal medications should be avoided when a patient has low platelet or low white blood cell counts, diarrhea, and rectal disease or resection of the colon.

Transdermal administration is often preferred for patients who can’t swallow, including those who are not candidates for rectal therapy. Transdermal preparations are applied topically and absorbed through the skin. The extent of systemic absorption is influenced by the base that is used to deliver the medication through the skin and the compounding technique. If a patient has fluctuating or declining liver function, transdermal administration may be advantageous because transdermal meds do not need to pass through the liver before being absorbed, like oral medications do. Topical and transdermal therapies can be compounded to treat pain and inflammation, spasms, fungal infections of the skin and nails, wounds and scars, nausea/vomiting, hormone imbalance, and thyroid or heart disease in pets.

Ask our compounding pharmacist for more information. We are happy to answer your questions and work together with physicians, patients and their families to compound the most appropriate medication, strength and dosage form for each patient. Bring us your medication problems!

Consultant Pharmacist. 2016 June;31(6):313-9.

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