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Are Medications Hard to Swallow? Ways to Help!

Summary: Some people have no problems swallowing their medications. Others have troubles swallowing their medications, which can be a problem. The good news, is that there are many things that can be tried. One can try the Head Posture Swallowing Technique, a way of swallowing while turning your head to find the best posture for swallowing. Or practicing swallowing with different sized candies, ranging from small to larger. Finally, a compounding pharmacy can create a liquid version of the medication.
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First try the Head Posture Swallowing Technique…

For those who have troubles swallowing medications, perhaps one of the easiest things to try first is the “Head Posture Practice” swallowing technique from Dr. Bonnie Kaplan at the University of Calgary.

Most people try to swallow with their head in the ‘centre’ position. But it turns out that many people swallow better if they try a different head position such as:

  • Turning one’s head to one side;
  • Turning one’s head down slightly;
  • Turning one’s head up slightly.

If there are problems with swallowing pills, try different head positions to see which one works best.

Watch this 8-minute video to learn how:

Try practicing with different sized candies…

Do’s

  • Be patient. Learning to swallow pills is like learning any skill and takes time.

  • Do practice swallowing with candy first, before trying out medications.
  • Do get an assortment of candies of different sizes, such as:
    • Cupcake sprinkles
    • Nerds
    • Tic Tacs
    • Smarties
    • Skittles
  • Get the candy ready, along with a glass of water, and practice swallowing.

    When there is success with a smaller candy, then move up to a larger candy. 
  • Do practice ideally for at least 14-days before trying medications.

Don’ts

  • Try not to get discouraged if the technique doesn’t quickly work. It takes time!

Troubles swallowing ADHD medications?

Are there issues with ADHD medications?

Try crushing or dissolving these medications:

  • Lisdexamfetamine (Vyvanse): Can be dissolved in liquid
  • Dextroamphetamine salts (Adderall): Can be cracked open and tiny beads sprinkled on pudding, yoghurt, ice cream, etc.
  • Methylphenidate controlled release (Biphentin): Can be cracked open and tiny beads sprinkled on pudding, yoghurt, ice cream, etc.

Note that these cannot be crushed:

  • Methylphenidate OROS (Concerta)
  • Atomoxetine (Strattera)

Reference: https://www.caddra.ca/pdfs/Medication_Chart_English_CANADA.pdf

Still Struggling? Consider a Compounding Pharmacy

A compounding pharmacy is a pharmacy that can create a liquid version of the hard to swallow medication. The patient’s specific needs can be taken into account (e.g. taste preferences, intolerance of certain ingredients or tastes), and compounds can even be flavoured to make them more preferable to the child.

How long does the medication last?

  • 14 days with water-based formulations
  • Up to a 6 months with oil-based formulations.

Note that only a few 'recipes' are validated due to the cost of stability testing. Stability testing requires outsourcing special 'analytical labs' which have HPLC capability, which is difficult even to hospital pharmacies.

Psychiatric Medications that Can Be Compounded

Examples of medications that can be compounded

  • Citalopram (Celexa) 4 mg/ml
  • Clonidine (Catapres) 0.01mg/ml or 0.02mg/ml
  • Atomoxetine (Strattera) 6mg/ml (this one is quite challenging to flavour because of the underlying bitterness)
  • Aripiprazole (Abilify) 1mg/5ml or 5mg/5ml (Although the manufacturer indicates to not crush the tablets, they do not possess any long-acting coating plus the drug is available in a liquid form in the US)
  • Amitriptyline 10mg/ml or higher strength
  • Escitalopram (Cipralex) 2mg/ml or 8mg/ml
  • Fluoxetine (Prozac) Peppermint-Free 20mg/5ml (for children who refuse to take the mint-flavoured commercial product. We also compound a Prozac “no-sub” suspension using Prozac© capsules as our starting point);
  • Fluvoxamine suspension or any other immediate release tablet. There are situations where slow release capsules can be made into an immediate-release (IR) suspension.
  • Lamotrigine (Lamictal) 2.5mg/ml or 5mg/ml
  • Lithium Carbonate 10mg/ml or higher strength
  • Melatonin 1mg/ml flavoured suspension (peppermint-free as well)
  • Sertraline (Zoloft) 10mg/ml or could be higher
  • Trazodone 10mg/ml or higher strength
  • Venlafaxine IR (Effexor) twice daily suspension in various strengths

Where can one go to find a compounding pharmacy?

1) Hospitals. Many hospitals may have compounding pharmacies. All hospital pharmacies follow the same protocol, and insist that an extemporaneous product be validated for stability. If it has not been validated, a hospital will not make it. The reason that product validation is important is that it gives confidence that there remains a high level of potency towards the end of the assigned expiry date, and knowing what storage conditions are most appropriate. Pharmaceutical companies consider any treatment with extemporaneous products to be off label as outcomes have not been assessed.


    To make the product, the patient’s own medication supply is used, which the hospital does not assume liability for. Examples include: Hospital for Sick Children (Toronto, ON), IWK (Halifax, NS), BC Children’s (Vancouver, BC) and CHEO (Children’s Hospital of Eastern Ontario in Ottawa, ON).

    2) Retail pharmacies. Retail pharmacies that compound generally follow USP guidelines and arbitrarily assign expiry dates without validation. Unfortunately, this means that there is a potential for lack of response if the medication breaks down over time. In the worst case scenario then, the pharmaceutical will have degraded to the point it is as if you are giving a placebo. Thus, it is important to use medications as directed, and not let them become too old.

    References

    BJ Kaplan, RA Steiger, J Pope, A Marsh, M Sharp, SG Crawford. Successful treatment of pill-swallowing difficulties with head posture practice. Paediatr Child Health 2010;15(5):e1-e5.

    About This Document

    Reviewed by the CHEO Mental Health Promotion Committee at the Children’s Hospital of Eastern Ontario (CHEO). Special thanks to Marla Sullivan, Pharmacist, CHEO.

    Conflicts of Interest: None declared.

    License

    Under a Creative Commons License. You are free to share, copy and distribute this work as in its entirety, with no alterations. This work may not be used for commercial purposes. View full license at http://creativecommons.org/licenses/by-nc-nd/2.5/ca/

    Disclaimer

    Information in this fact sheet may or may not apply to your child. Your health care provider is the best source of information about your child’s health.

    Date Posted: Jul 17, 2019
    Date of Last Revision: Jul 17, 2019

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