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The design and implementation of a crushability algorithm: first experiences of a pharmacist-lead medication review in patients with swallowing difficulties
European Statement
Clinical Pharmacy Services
Author(s)
Nicolas Sagaria, Daniele Mengato
Why was it done?
Dysphagia is a swallowing disorder more common in the elderly. The pharmaceutical market is not always able to meet the needs of dysphagic patients and manipulation of a medication is sometimes the only possible way to ensure its administration. This activity is often delegated to nurses or other professionals without the necessary education.
What was done?
The manipulation of solid oral pharmaceutical forms, such as tablets or capsules, is such a common act that it is sometimes regarded superficially. In order to guide the clinical pharmacist in assessing the crushability of a tablet, we designed, and validated through an on-field application, a decision-making algorithm.
How was it done?
The first two steps of the algorithm help, respectively, to understand whether there are clear indications in the summary of product characteristics on how to manipulate the drug and/or whether there are alternatives on the market, other than the solid oral, suitable for administration to the dysphagic patient. When neither of these steps is feasible, the pharmacist is guided towards direct manipulation of the drug, supported by evidence in literature and study of excipients. If a solution cannot be found, the physician should be advised to consider a switch or a discontinuation of therapy. Finally, we tested the algorithm by including it in a medication review form in a otolaryngology-ENT department, where the incidence of dysphagic patients was higher.
What has been achieved?
In the second half of 2020, we analyzed 45 medrev forms filled out in the ENT-department. Each form contained an average of 2.8 drugs to be re-analyzed for the dysphagic patient. We applied our algorithm to a total of 123 drugs. For 101 (82%) of these, we provided precise information on the correct way to administer and manipulate the drug. For only 22 drugs, a discussion with the prescriber was necessary to identify an alternative. In this way we have improved patients’ and operators’ safety.
What next?
In the near future we will expand our test to other departments, not only surgical, and try to minimise the rate of drugs for which we could not provide information on manipulation. In addition, we are planning to develop a software to simplify the process.