Season 2 Episode 2 – Julie Cichero, Oral Medications and Dysphagia

INTRO: Hello and welcome to Clinical Nutrition Notes – a podcast where we speak with guest experts and opinion leaders about the art and science of clinical nutrition – brought to you by Nestlé Health Science Canada. This podcast is intended for health care professionals, for education purposes.

I am your host, Bethany Hopkins, Medical Affairs Manager with Nestlé Health Science.

Today we will continue our dysphagia management conversation with Julie Cichero – focusing on considerations with oral medications for the individual with dysphagia.

Hopkins: Thank you for joining us Julie. In our last conversation we talked about use of thickened liquids in dysphagia management. Today we are tackling the issue of oral medication administration for individuals who require thickened liquids.

To begin, Julie can you set the stage as to why there is such an interest in medication administration in individuals who have dysphagia?

Cichero: Absolutely Bethany. I think for a long time we’ve focused on liquids and foods, and texture modified foods and thickened liquids without really thinking about medication administration. It started coming into the fore when you had people needing to swallow pills, tablets, and capsules when they were on a pureed diet and whether or not they could take those particular tablets and then how you would administer a thin liquid to someone who might need it for a pre-med for an operation, so needing to go in after a car accident for example, and how you would do that if they were on thickened liquids. So it’s become a growing area of interest.

Hopkins: And when we think about medications in general, the medications that are widely used to manage many different medical conditions and they’re often, the oral route is the most prevalent. Isn’t it?

Cichero: Exactly right.

Hopkins: So Julie, when you think about the considerations around use of medications and commercial thickeners if someone requires a thickened liquid, there are a number of factors that may come into play from bioavailability to viscosity, and I’m just wondering if you can describe some of these considerations for our listeners.

Cichero: That’s a great question. It feels a little bit like Pandora’s box I’ll be honest. There are in fact a number of different things to think about because quite often what people will do when individuals have trouble swallowing medications is that they start looking at crushing them. Now there are some medications that you can crush, and there are some that you can’t. So anything that’s a delayed release medication is not safe to be crushed. But the other thing that I want to say is please make sure that if you’re looking at altering your medication that you do speak to a pharmacist about that if you’re looking to do it, it’s done safely. We’ve done some work with the School of Pharmacy where we looked at just 4 different types of medications and what happens when they were crushed and mixed with extremely thick liquids. And so over a range of different types of thickening agents what we found was that the thicker it was with the crushed medication, the bioavailability certainly at bench testing was not fantastic. So we had some changes for example with Warfarin, which is commonly used as a blood thinner, to treat many patients, but if that tablet was crushed and administered in water as a bench test, it would simulate a gastric fluid, over 30 minutes, about 89% of it was available for use. When it was provided in an extremely thick liquid, it went down to only 14%. So that’s problematic. That is bench testing though, we obviously need testing to be done in vivo or with individuals, and each of the different drugs that we looked at had a different reaction. So this is why I said it’s like Pandora’s box because there wasn’t an ok, well, if we administer it with this level of thickness, thick liquid, or this type of thickener we get this result. They were all quite different. The medications had differences in ionic charge, in a whole range of different things that just interact with the different thickening agents.

Hopkins: And certain classes of medications, Julie, are more susceptible, are they not? The soluble medications, are they the ones that people need to watch out for more?

Cichero: So the medications are differentiated along their solubility and permeability lines, and to be honest, we haven’t got to the bottom of that because they are literally all different. We’re really not 100% sure. What we do know though is that the thicker it is, the more challenging it is for a crushed medication to make its way out of the thickened liquid regardless of the thickening agent. So administering on the thinner end, so the mildly thick and the moderately thick is better if you need to. But I’m going to stress here that because it is a new area that it’s really important to work with your pharmacist. And at times, you may in fact, rather than mixing it with a thickened liquid, look to an alternative route, whether it’s a patch, whether it’s a suppository, whether it’s an injection, looking at what’s going to be the safest for the person to get the medication that they need in the safest way possible, and that may not be through the oral route.

Hopkins: Which sort of leading into the next area I wanted to talk about, which was advice for clinicians who are interested in this topic and want to learn more practical kind of tips and things to think about. So one you mentioned, about looking at other alternative administration methods. What other comments or suggestions would you have for people, Julie?

Cichero: I think also, again working with a pharmacist. It’s an opportunity to look at medication reviews. Sohow many of the medications are actually essential for where they’re at at that point in time. We found a lot of success at looking at it from that perspective. Also looking and talking to the doctors. Anecdotally, I must stress it’s anecdotally, we found that with patients with epilepsy for example, that if the epilon drug is added to the thickened liquids that sometimes there’s an adjustment where they need to increase the dose of their medication. So again, working really closely as part of a multi-disciplinary team, talking to neurologists, talking to your epileptologists about any changes that are neeed, and are they needing to increase medication doses. And if they are a patient who’s on thickened liquids, we actually need some really good quality research around this. It’s still very much in its early phases as I say. The more we can talk to other disciplines, so the pharmacist, neurologist, geriatricians, you know, we haven’t even delved into what impact there is on medications for alzheimers dementia for example. This is where I think we’re going to see some really exciting things in the future.

Hopkins: I think, as you mentioned earlier on when we first started looking at the role of texture modified diets and certainly thickeners were developed for use with foods and liquids, dietary foods and liquids, not for use with medications. There are so many layers of complexity, or the Pandora’s box as you described, when we start to look at their application for delivering medications. I know one of the things that’s received some attention in Canada recently is the Institute for Safe Medicine Practice published a bulletin around the interaction with polyethylene glycol and pre-thickened starch-based liquids, where the product caused thinning of the liquid, so the viscosity was reduced, and I know it’s created some concern for clinicians. One of the things people have looked at is evaluating, is there an alternative route of administrating that medication, or something else that can be used instead to make it safe for people with dysphagia.

Cichero: That’s right Bethany, so that’s a really interesting one. That particular product, we had it here under a different name, is quite often used as a treatment for constipation. And what you have got there is that particular drug is designed to pull water. That’s the way that medication works, because it’s wanted to soften the stool for example. So when you add a thickening agent to it, your thickening agent has held the water together if you like, so the medication then, is trying to pull the liquid out, which is why it’s thinning. You’re probably ending up with a thin watery layer on top with something thicker underneath. So you’ve got 2 things which are working directly against each other for 2 different purposes. One that’s trying to hold the bolus together so that it’s safe to swallow, and then the actual medication. What it’s designed to do is release the water to soften the stool. So that in those circumstances, I would say that trying to use a thickening agent in the oral route is probably not ideal, if that’s the case and looking for alternative routes, of how best to administer and treat that issue is the better way to manage it.

Hopkins: Yes, now Julie, one last question, or I guess the second last question is, you mentioned working with pharmacists, you mentioned research that has to happen with patients, in vivo research. Right now, where you are today, where do you see this field going/what should we be watching for?

Cichero: I think we’re starting to see, you mentioned a little bit earlier on as well, about individualized care, and we starting to see a real push for personalized medicine. And I think, for a while, one of the challenges we’ve had with dysphagia is that it’s a medical orphan, for want of a better term. When you have a stroke, you’ll go and see a stroke physician. If you have a heart problem, you’ll go to see a cardiologist. But for dysphagia, we don’t have a single medical discipline that looks after it. We’ve got lots of different medical disciplines. So we haven’t had the ability I guess to really go after grant funding on the back of that, because it is in so many different fields. So there’s a potential I guess, we’ve got our otolaryngologists, or ear, nose and throat surgeons here, looking after the oral cavity and the pharynx, and our gastroenterologists looking after the esophagus and the stomach and the rest of the digestive tract, but if we can have a focus on dysphagia, which is sort of what we need. I do wonder whether there will be that opportunity, through personalized medicine to see some sort of research coming out of that. Ideally, I guess our group, and there will be others around the world as well, will need to be looking at moving it from bench testing to other testing. Whether they’re observational studies of people who are already on thickened liquids with one particular type of medicine, I’m not sure. I think they are lots of opportunities out there. But I think it could, as you mentioned earlier, become the mainstay of treatment, and we are all living longer. The average person in a nursing home takes 7-8 medications every day. I think it’s something that we can’t afford to ignore.

Hopkins: It really is a growing issue, and one that more and more clinicians are beginning to take seriously and think about because of some of the publications that we’ve seen in the last few years. It will be interesting to see how this area evolves.

So Julie, thank you for reviewing this important topic, and the complexities that are involved around medication administration for people with dysphagia. So before we sign off, I would like to take a minute to ask you one last question so our listeners can get to know you a little more. Can you tell us how you first became interested in the field of nutrition and dysphagia?

Cichero: It’s a funny story actually because when I first practiced as a speech pathologist, this idea of working in dysphagia scared the daylights out of me. I remember our lecturer talking about this is the one area where if you mess up the patient can die, and I remember thinking, oh my goodness, there’s no way I want to work in that area. And it wasn’t until I came to my clinical placement and recognized that people, you know, food is such an important part of your life. My grandmother was Polish, and we gathered around the table every Sunday night, and it reminded me that families come together around food. It doesn’t matter whether it’s a christening, a wedding, mealtime, those places where people come together. It’s such an important part of life. So from the fear in my lectures, I was physically going and seeing patients and recognizing that all they wanted to do was have their cup of tea, or have something to eat, something that they really loved, and you know, to know that I had a role in that, I had some knowledge to do that. To put the fear aside, if you like, and I guess that’s what has motivated me to really look into the area, to make sure that I’m doing it as safely as possible, and for their safety as well, so that they can again be part of this richness that is such an integral part of our everyday life.

Hopkins: Well thank you for sharing that story, and it’s interesting to see how it started out with this fear. It is scary when you think about the implications of dysphagia and choking and so on. But we’re really glad that you made that leap or that decision to explore this area in your professional practice and food really is such an important part or our lives and the social fabric of the world that we live within. On that note Julie, we will conclude this podcast. I would like to thank you for joining us and thank all of our listeners.

To listen to more podcasts or to subscribe to Clinical Nutrition Notes, visit our website at nestlehealthscience.ca.