Oral drug therapy in elderly with dysphagia: between a rock and a hard place!

Abstract

Demographic indicators forecast that by 2050, the elderly will account for about one-third of the global population. Geriatric patients require a large number of medicines, and in most cases, these products are administered as solid oral solid dosage forms, as they are by far the most common formulations on the market. However, this population tends to suffer difficulties with swallowing. Caregivers in hospital geriatric units routinely compound in solid oral dosage forms for dysphagic patients by crushing the tablets or opening the capsules to facilitate administration. The manipulation of a tablet or a capsule, if not clearly indicated in the product labeling, is an off-label use of the medicine, and must be supported by documented scientific evidence and requires the patient's informed consent. Compounding of marketed products has been recognized as being responsible for an increased number of adverse events and medical errors. Since extemporaneous compounding is the rule and not the exception in geriatrics departments, the seriousness and scope of issues caused by this daily practice are probably underestimated. In this article, the potential problems associated with the manipulation of authorized solid oral dosage forms are discussed.

Keywords: compounding; dysphagia; gastrointestinal tract toxicity; geriatric medicine; modified-release formulations.

Figure 1

Median plasma concentrations of clopidogrel metabolite SR26334 following administration of whole or crushed 300 mg clopidogrel tablet. Notes: The crushed tablet has been administered through a nose-gastric tube. Reproduced from Zafar MU, Farkouh ME, Fuster V, Chesebro JH. Crushed clopidogrel administered via nasogastric tube has faster and greater absorption than oral whole tablets. J Interv Cardiol. 2009;22(4):385–389, with permission from John Wiley and Sons. Copyright 2009. Abbreviations: AUC, area under the curve; conc, concentration.

Figure 2

Left side: (A) intact microspheres (40 mg) obtained by empting one capsule of Deterx^®; (B) crushed microspheres (40 mg) from one capsule of Deterx; (C) OxyContin^® tablet intact (40 mg); (D) Oxycontin tablet crushed (40 mg); (E) two 20 mg intact immediate-release oxycodone tablets; (F) powder from two crushed immediate-release oxycodone tablets. Right side: mean plasma concentration–time curve profiles generated by the administration of intact and crushed Deterx compared with crushed immediate-release oxycodone (upper figure); mean plasma concentration–time curve profiles generated by the administration of intact and crushed Oxycontin compared with crushed immediate-release oxycodone (lower figure). Reproduced from Gudin J, Levy-Cooperman N, Kopecky EA, Fleming AB. Comparing the effect of tampering on the oral pharmacokinetic profiles of two extended-release oxycodone formulations with abuse-deterrent properties. Pain Med. 2015;16(11):2142–2151, by permission of Oxford University Press.

Figure 3

Sample endoscopic and microscopic views of gastrointestinal tract mucosae damaged by NSAIDs. Notes: (A) Endoscopic view of a stricture in the cecum of the colon in a patient after long-term NSAID use. The stricture has resulted in significant narrowing of colonic lumen. Such diaphragms have also been reported to occur in the small intestine. (B) Histologic section from a colonic biopsy showing a moderate inflammatory infiltrate in the lamina propria, mild lymphocytic infiltration of the glandular epithelium, and scattered eosinophils. Adapted by permission from Macmillan Publisher Ltd: Nat Clin Pract Gastroenterol Hepatol, Pusztaszeri MP, Genta RM, Cryer BL, Drug-induced injury in the gastrointestinal tract: clinical and pathologic considerations, 2007;4(8):442–453, copyright 2007. Abbreviation: NSAID, nonsteroidal anti-inflammatory drug.