Two techniques to make swallowing pills easier

Esophageal transit of solid oral dosage forms - impact of different surface materials characterized in vitro and in vivo by MRI in healthy volunteers

Acceptable swallowability and complete esophageal transit are decisive for the safe and effective administration of solid oral dosage forms. This applies in particular to the main user group of medicines, older adults, who often suffer from swallowing difficulties. It is well known that surface properties play an important role in this respect. In the past, this has led to the development of numerous coating formulations for tablets with improved swallowability. However, in vitro and especially in vivo data investigating a positive effect of different coating materials is limited. Therefore, we investigated coating materials being based on polyvinyl alcohol, hydroxypropyl methylcellulose, and a copolymer of methacrylate in respect to their influence on swallowability and esophageal transit of a tablet formulation. They were compared to uncoated tablets as well as to hard gelatin capsules. Three in vitro assays suitable for routine use in pharmaceutical development were performed: i.) Wettability test in artificial saliva; ii.) Swelling measurement in artificial saliva; iii.) Measurement of the adhesion between surface materials and a simulated mucosa surface. All three assays resulted in a differentiation of the surface materials. The coated tablets showed favorable behavior compared to uncoated tablets and hard gelatin capsules. To test the effect of the different materials in vivo, an intervention study was conducted. 36 adults were included and the likeliness of prolonged esophageal transit of (un-)coated tablets as well as a hard gelatin capsule of the same weight was objectively evaluated by means of magnetic resonance imaging. While hard gelatin capsules showed highest rates for prolonged esophageal transit, the tendency for adhesion was reduced for uncoated tablets, and least for coated tablets, i.e., prolonged esophageal transit in 22.2 %, 11.1 %, and ≤5.6 % of the cases, respectively. Further differentiation of the coating materials was not possible. Subjective evaluations of each participant with respect to subjective swallowability and esophageal transit did not correlate well with the objective measurements by means of magnetic resonance imaging. The use of coatings in general has a positive influence on esophageal transit. However, the selection of coating type seems to be of greater importance in respect to patients' oral perception of the dosage forms compared to their influence on the probability for prolonged esophageal transit.

Experiences, acceptability and barriers to calcium supplementation during pregnancy in Dar es Salaam, Tanzania

Calcium supplementation in pregnancy is recommended in contexts with low dietary calcium intake to reduce the risk of pre-eclampsia and its complications. The World Health Organisation suggested high-dose calcium supplementation (1500-2000 mg/day), divided into three doses and taken at different times from daily iron-folic supplements. We conducted a mixed methods evaluation study to assess experiences, acceptability and barriers to high-dose calcium supplementation from the perspectives of pregnant women and antenatal health care providers at two public health facilities in Dar es Salaam, Tanzania. Descriptive statistics and thematic analysis were used to characterise acceptability, barriers and overall experiences of using high-dose calcium supplementation. Pregnant women in the cohort were aged 19-41 years, with 32.4% being primiparous. The proportion of pregnant women who liked calcium supplements 'a lot' decreased from 50.2% at the first visit to 31.8% at the last antenatal follow-up visit. Adherence was 71.3% (interquartile range: 50.5%, 89.3%), with only 24.0% of the participants taking 90% or more of the required supplements. Although participants expressed positive attitudes towards using calcium supplements, they also voiced concerns about the large size, side effects, the potential to forget and the burden of taking calcium supplements three times per day. Antenatal health care providers also affirmed the high burden of taking calcium supplements in addition to iron-folic acid supplements. Participants expressed the acceptability of using calcium supplements during pregnancy, but adherence to three doses per day posed challenges to pregnant women. Reducing the number of calcium supplement doses per day may improve adherence.

Optimization of solid oral dosage form administration to patients with swallowing difficulties: An integrative review

AIM

To appraise and synthesize research investigating optimizing the administration of solid oral dosage forms (SODFs) to adults with swallowing difficulties.

DESIGN

An integrative review.

METHODS

An electronic search was conducted on Medical Literature Analysis and Retrieval System Online (Public Medline interface), Elsevier SciVerse Scopus and Scientific Electronic Library Online (updated February 2023). Restriction regarding the publication date was not considered for the inclusion of records. Studies addressing risks, general aspects, recommendations about patient postural adjustments, swallowing techniques, swallowing aids and aspects of concealment of SODFs were included.

RESULTS

Fifty-three records published between 2002 and 2021 were included. The main administration risks were aspiration, asphyxia and solid oral dosage form-induced oral/oesophageal mucosal lesions. The most frequent general aspect reported was administering one oral dosage form at a time. The sitting position was the most patient postural adjustment mentioned. The most frequently reported solid oral dosage form swallowing technique was the lean-forward method for capsules. Solid oral dosage form swallowing aids cited: tongue and throat lubricant and solid oral dosage form coating device, swallowing cup and swallowing straw.

CONCLUSION

The literature data on administering SODFs for adults with swallowing difficulties were appraised and synthesized. Some aspects, for example, not administering SODFs simultaneously, can make swallowing safer. Postural adjustments and solid oral dosage form swallowing aids are important to avoid administration risks. Swallowing SODFs can be easier if learned by techniques. Liquid and food are helpful as vehicles, and several of these have been listed.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

By optimizing the contributing factors of administering oral pharmacotherapy, the nurse can use appropriate practices to improve patient safety. Additionally, knowing and establishing the administration aspects are reasonable steps for standardizing care for patients with swallowing oral dosage form difficulties.

IMPACT

This study addressed administering SODFs to adult patients with swallowing difficulties. The administration of SODFs to adult patients with swallowing difficulties can be optimized if only one oral dosage form at a time is administrated and if patient postural adjustments, swallowing techniques and swallowing aids are used. This investigation will impact the care of patients with swallowing difficulties.

REPORTING METHOD

The authors declare they adhered to the relevant EQUATOR guidelines and report following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 Statement.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Influence of Solid Oral Dosage Form Characteristics on Swallowability, Visual Perception, and Handling in Older Adults

Swallowability, visual perception, and any handling to be conducted prior to use are all influence factors on the acceptability of an oral dosage form by the patient. Knowing the dosage form preferences of older adults, as the major group of medication end users, is needed for patient-centric drug development. This study aimed at evaluating the ability of older adults to handle tablets as well as to assess the anticipated swallowability of tablets, capsules, and mini tablets based on visual perception. The randomized intervention study included 52 older adults (65 to 94 years) and 52 younger adults (19 to 36 years). Within the tested tablets, ranging from 125 mg up to 1000 mg in weight and being of different shapes, handling was not seen as the limiting factor for the decision on appropriate tablet size. However, the smallest sized tablets were rated worst. According to visual perception, the limit of acceptable tablet size was reached at around 250 mg for older adults. For younger adults, this limit was shifted to higher weights and was dependent on the tablet shape. Differences in anticipated swallowability with respect to tablet shapes were most pronounced for tablets of 500 mg and 750 mg in weight, independent of the age category. Capsules performed worse compared to tablets, while mini tablets appeared as a possible alternative dosage form to tablets of higher weight. Within the deglutition part of this study, swallowability capabilities of the same populations were assessed and have been reported previously. Comparing the present results with the swallowing capabilities of the same populations with respect to tablets, it shows adults' clear self-underestimation of their ability to swallow tablets independent of their age.

Identifying and addressing pill aversion in adults without physiological-related dysphagia: A narrative review

Solid oral dosage forms (SODFs) (often called pills by patients) are the default formulation to treat medical ailments. Beneficial therapeutic outcomes rely on patients taking them as directed. Up to 40% of the population experience difficulties swallowing SODFs, resulting in reduced adherence and impaired therapeutic efficacy. Often associated with children, this also presents in adults with dysphagia, and without any organic dysphagia (non-physiological-related or functional dysphagia). This review aims to identify and appraise current interventions used to screen for and overcome pill aversion in adults with functional dysphagia. A comprehensive search of the literature was conducted. Articles reporting pill aversion in adults aged ≥18 years with no underlying cause, history of, or existing dysphagia were included. Study quality was determined using the STROBE tool for observational studies. A narrative synthesis of the findings was prepared. We identified 18 relevant cohort studies, which demonstrate that pill aversion is a global problem. Perceived ease of and/or SODF swallowability appears to be influenced by female gender, younger age, co-morbidities (e.g., depression), and physical SODF properties. Patients often modify their medicines rather than raise this issue with their healthcare team. Screening for pill aversion is haphazard but controlled postural adjustments, coating SODFs and behavioural interventions appear to be successful solutions. SODF swallowing difficulties are a barrier to effective medication use. Healthcare professionals must recognise that pill aversion is a problem requiring identification through effective screening and resolution by training interventions, appropriate formulation selection or specialist referral.

Oral bioavailability of microdoses and therapeutic doses of midazolam as a 2-dimensionally printed orodispersible film in healthy volunteers

PURPOSE

The use of two-dimensional (2D) printing technologies of drugs on orodispersible films (ODF) can promote dose individualization and facilitate drug delivery in vulnerable patients, including children. We investigated midazolam pharmacokinetics after the administration of 2D-printed ODF.

METHODS

Midazolam doses of 0.03 and 3 mg were printed on an ODF using a 2D drug printer. We investigated the bioavailability of the two midazolam doses with ODF swallowed immediately (ODF-IS) or delayed after 2 min (ODF-DS) by comparing their pharmacokinetics with intravenous and oral midazolam solution in 12 healthy volunteers.

RESULTS

The relative bioavailability of ODF-IS 0.03 mg was 102% (90% confidence interval: 89.4-116) compared to oral solution and for 3 mg 101% (86.8-116). C_max of ODF-IS 0.03 mg was 95.5% (83.2-110) compared to oral solution and 94.3% (78.2-114) after 3 mg. Absolute bioavailability of ODF-IS 0.03 mg was 24.9% (21.2-29.2) and for 3 mg 28.1% (23.4-33.8) (oral solution: 0.03 mg: 24.4% (22.0-27.1); 3 mg: 28.0% (25.0-31.2)). Absolute bioavailability of ODF-DS was significantly larger than for ODF-IS (0.03 mg: 61.4%; 3 mg: 44.1%; both p < 0.0001).

CONCLUSION

This trial demonstrates the tolerability and unchanged bioavailability of midazolam printed on ODF over a 100-fold dose range, proving the suitability of ODF for dose individualization. Midazolam ODF-IS AUC_0-∞ in both doses was bioequivalent to the administration of an oral solution. However, C_max of the therapeutic dose of ODF-IS missed bioequivalence by a clinically not relevant extent. Prolonged mucosal exposure increased bioavailability. (Trial Registration EudraCT: 2020-003984-24, August 10, 2020).

Pregnant and breastfeeding women's prospective acceptability of two biomedical HIV prevention approaches in Sub Saharan Africa: A multisite qualitative analysis using the Theoretical Framework of Acceptability

HIV infection during pregnancy and breastfeeding has implications for maternal health. Between May- November 2018, we explored prospective acceptability of two novel HIV Pre-exposure Prophylaxis (PrEP) products, oral pills and vaginal rings, through focus group discussions with 65 pregnant and breastfeeding women in Malawi, South Africa, Uganda, Zimbabwe. Qualitative analysis was completed, guided by the Theoretical Framework of Acceptability (TFA). First, a deductive thematic analysis was applied to relevant coded data, into the seven TFA constructs (Affective Attitude; Burden; Ethicality, Intervention Coherence; Opportunity Costs; Perceived Effectiveness; Self-efficacy). Next, an iterative analysis was completed to generate themes within each of the TFA constructs. Women’s positive attitudes towards daily oral PrEP highlighted the familiarity of taking pills, understanding the purpose of taking pills, and the perception that it is an effective method to protect mothers and babies from HIV during pregnancy and breastfeeding. Women emphasized the ease of using the ring given its monthly duration that lowers burden on the user, its discreetness and invisibility once in place. The TFA analysis highlighted how acceptability of both methods could be enhanced by focusing on perceptions of the end users (i.e. the women) and not just the products themselves. This approach provided insights into how to refine the intervention materials and plans for implementation.

Solid Oral Dosage Forms Use in Adults with Neurological Disorders and Swallowing Difficulties: A Scoping Review

Swallowing difficulties affects the deglutition of solid oral dosage forms (SODFs) and it is a common problem among neurological disorders. Interventions may improve the use of SODFs in healthcare settings. The aim of this study was to map the available research about the interventions aiming the effective and safe use of SODFs in adults with neurological disorders and swallowing difficulties and to identify potential literature gaps in this scientific field. A scoping review was carried out based on Joanna Briggs Institute guidelines and reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews, in PubMed, Scopus, and SciELO databases (March 2021). Peer-reviewed observational studies assessed the effectiveness and safety of SODFs in adults with neurological disorders and swallowing difficulties in the healthcare organizations setting were included. 11 studies were included (three case reports, two mixed-methods intervention studies, and six analytic studies). The frequency of women ranged from 49 to 67%, and the age from 57 to 91 years. Most studies (n = 7) included elderly patients, Parkinson (n = 6) and dementia (n = 3). Medication review was the most frequently reported intervention, 35% (9/26). In most studies, interventions were targeted to patients during hospitalization (n = 7) and performed by physicians (n = 8). At least 20 different outcomes were evaluated in the studies. Implementing specific protocols for using SODFs aimed at the swallowing difficulties of this population is not a common practice. Additional studies on interventions aimed at optimizing SODFs are needed to support the safety and efficacy of oral therapy in this patient group.

Influence of the geometry of 3D printed solid oral dosage forms on their swallowability

3D printing can be used to realise a wide variety of geometries of oral dosage forms. In this work, the swallowability of 3D-printed dosage forms with comparable size and different shape using fused deposition modelling (FDM) from isomalt was investigated in a controlled, randomised crossover study design. To produce the required number of dosage forms, a commercial 3D printer was modified with regard to product safety and production time. The modifications carried out permit the printing of 4 pharmaceutical forms simultaneously as well as the printing of rigid filaments. Six 3D-printed placebo objects and two compressed placebo reference objects were tested by 12 subjects in a blinded design. A questionnaire was used to assess swallowability, foreign body sensation at the moment of swallowing, persistent foreign body sensation after swallowing and pain after swallowing. Furthermore, the amount of additional water drunk after administration was documented. With the modified printer, the required 576 test objects could be printed within a few days with good reproducibility. In all questions, the best results were obtained for the printed and compressed oblong tablets, followed by the printed and compressed round tablets, the football and the sphere. The worst results were obtained for the pyramid closely followed by the cuboctahedron. The study shows that the variety of shapes of oral dosage forms made possible by 3D printing needs to be tested in swallowability studies, as not every shape is also easy to swallow.

Effect of the rheological properties of the liquid carrier on the in vitro swallowing of solid oral dosage forms

Solid oral dosage forms (SODF) are the most popular oral drug delivery forms, but they can be difficult to swallow, especially for patients suffering from swallowing disorders. This study investigated the dynamics of different combinations of liquid carriers and SODF during the oral phase of swallowing using an in vitro model. The rheological properties of the carriers were characterized using shear and extensional rheometry, and their effect on bolus velocity, bolus shape, post-swallow residues, and SODF position within the bolus was evaluated. The latter has been identified as a novel and promising variable to discriminate between alternative formulations. When swallowed with water, capsules and tablets did not impact significantly the velocity of the bolus, but they lagged behind the liquid bolus, suggesting that low viscosity Newtonian fluids are not efficient carriers for SODF. Increasing the viscosity of the carrier at high shear rates improved the ability of the liquid to transport the SODF but also increased the amount of post-swallow residues. At equivalent shear viscosity, elastic and extensional properties of carriers influenced positively the position of the SODF in the bolus. Capsules and tablets were transported toward the front of these boluses, during the oral phase of swallowing, which is considered beneficial to avoid SODF sticking to the mucosa in the following stages of swallowing. Thin elastic liquids appear as an interesting option to promote safe swallowing of capsules and tablets. Clinical studies are, however, necessary to confirm this positive effect in healthy and dysphagic patients.

Individualization of attention-deficit/hyperactivity disorder treatment: pharmacotherapy considerations by age and co-occurring conditions

Attention-deficit/hyperactivity disorder (ADHD) is a neurodevelopmental disorder that manifests in childhood and can persist into adolescence and adulthood. Impairments associated with ADHD can impact quality of life, social interactions, and increase the risk of morbidity and mortality; however, for many patients, effective treatment can lessen these effects. Pharmacotherapy with stimulants or nonstimulants is recommended in conjunction with psychosocial therapy for most patients. Determining the optimal pharmacotherapy can be complex, and the clinician needs to consider many factors such as the patient's age, comorbidities, and lifestyle. Furthermore, the needs of the patient with ADHD will change over time, with specific challenges to consider at each stage of life. A variety of Food and Drug Administration (FDA)-approved stimulant and nonstimulant formulations are available with different modes of delivery and durations of effect. This armamentarium of ADHD medications can be used to individualize ADHD treatment for each patient's needs. This article combines current information from the literature and the first-hand experience of the authors to provide guidance on ADHD treatment options for patients of different ages and for some of the more common comorbidities.

Neonatal and pediatric oral drug delivery: Hopes and hurdles

The neonatal and pediatric populations have long been neglected concerning the development of oral dosage forms. For close to two decades, caregivers have had to adjust the doses of the off-label medicines and drugs for adults to suit the neonatal and pediatric needs. This is due to the lack of rules and regulations regarding neonates and pediatrics clinical trials while pharmaceutical industries see this as a non-lucrative approach. Despite such limitations, the administration of solid and liquid dosage forms to neonates and pediatrics necessitates the development of new technologies and even new strategies to meet the needs. Current approaches have not only focused on the development of suitable dosage forms but also the advancement of devices to enhance drug administration to pediatrics and neonates. Though current approaches have significantly added to the number of pediatric and neonatal oral dosage formulations on the market, there is still more room for improvement(s). While novel dosage forms including multiparticulates, orodispersible tablets/films, and chewable tablets have extensively been researched, some administration devices (e.g., nipple shield, pill swallowing cup, and solid dosage pen) have also been explored. Although a few of these products are in the market, the concerted efforts of regulation administrative bodies, pharmaceutical industry settings, and scientists in academia have been oriented to address all issues and advance the neonatal and pediatric-centric pharmaceutical products.

A Difficult Pill to Swallow: An Investigation of the Factors Associated with Medication Swallowing Difficulties

BACKGROUND

Many medications are available as solid oral dosage forms such as tablets and capsules; however, some people find these medications difficult to swallow.

AIM

To identify whether certain psychological, oral sensory, and oral motor characteristics contribute to medication swallowing difficulties.

METHODS

A sample of healthy adults from two academic institutions in Brisbane were assessed for their experiences with swallowing solid oral dosage forms, food preferences, and food neophobia. The gag reflex, oral cavity size, fungiform papillae count, and chewing efficacy were also evaluated followed by a capsule-swallowing task. Primary outcome was the incidence of medication swallowing difficulties. Secondary outcomes were the association of medication swallowing difficulties with psychological, oral sensory, and oral motor factors.

RESULTS

Of 152 subjects, 32% reported difficulty swallowing tablets or capsules whole. This group was significantly more likely to have had a memory of choking on medications compared to those without medication swallowing difficulties (OR = 7.25, p < 0.05). Current medication swallowing difficulties were significantly associated with a smaller mouth cavity size (OR = 2.98, p < 0.05), a higher density of taste receptors on the tongue (OR = 3.27, p < 0.05), and were higher among those who chewed a jelly candy to non-homogenous particle size (OR = 4.1, p < 0.05). Current medication swallowing difficulties were associated with lower confidence in swallowing large capsules (000 size: OR = 0.47, 00 size: OR = 0.39, p < 0.05). No associations were found between medication swallowing difficulties and the gag reflex or food neophobia.

CONCLUSION

A combination of heightened oral perception characterized by a small oral cavity and high taste sensitivity compounded by a past choking episode on medications may be precipitating factors for medication swallowing difficulties. These factors may be helpful in identifying individuals who are more likely to experience difficulty swallowing medications.

Better Medicines for Older Patients: Considerations between Patient Characteristics and Solid Oral Dosage Form Designs to Improve Swallowing Experience

Oral drug administration provided as solid oral dosage forms (SODF) remains the major route of drug therapy in primary and secondary care. There is clear evidence for a growing number of clinically relevant swallowing issues (e.g., dysphagia) in the older patient population, especially when considering the multimorbid, frail, and polymedicated patients. Swallowing impairments have a negative impact on SODF administration, which leads to poor adherence and inappropriate alterations (e.g., crushing, splitting). Different strategies have been proposed over the years in order to enhance the swallowing experience with SODF, by using conventional administration techniques or applying swallowing aids and devices. Nevertheless, new formulation designs must be considered by implementing a patient centric approach in order to efficiently improve SODF administration by older patient populations. Together with appropriate SODF size reductions, innovative film coating materials that can be applied to SODF and provide swallowing safety and efficacy with little effort being required by the patients are still needed. With that in mind, a literature review was conducted in order to identify the availability of patient centric coating materials claiming to shorten esophageal transit times and improve the overall SODF swallowing experience for older patients. The majority of coating technologies were identified in patent applications, and they mainly included well-known water soluble polymers that are commonly applied into pharmaceutical coatings. Nevertheless, scientific evidence demonstrating the benefits of given SODF coating materials in the concerned patient populations are still very limited. Consequently, the availability for safe, effective, and clinically proven solutions to address the increasing prevalence of swallowing issues in the older patient population is still limited.

A novel technique for intraduodenal administration of drug suspensions/solutions with concurrent pH monitoring applied to ibuprofen formulations

Characterization of dissolution of solid suspended drug particles in vivo is important for developing biopredictive in vitro tests. Therefore, methods to gain deeper insights into particle dissolution in vivo are needed. The soft Bioperm intubation method, a well established tool for investigation of permeability, absorption, metabolism, and drug interactions at predefined locations in the gastroinstinal tract, was modified. The novel intubation method involved pump-controlled infusion of pharmaceutical suspensions as well as simultaneous pH monitoring. This technique was used in a proof of concept study in healthy humans. Plasma sampling and non-compartmental analysis allowed comparison of three different ibuprofen drug products, a solution and two suspensions with different particle size distribution, as well as two different infusion rates. Both a particle size effect and an effect of altering infusion rates on pharmacokinetic parameters were shown. Moreover, it was possible to monitor intestinal pH changes after intestinal infusion. Infusion of ibuprofen resulted in a pH drop that was quantified by the concept of Area Between Curves (ABC).

Dosage form modification and oral drug delivery in older people

Many people cannot swallow whole tablets and capsules. The cause ranges from difficulties overriding the natural instinct to chew solids/foodstuff before swallowing, to a complex disorder of swallowing function affecting the ability to manage all food and fluid intake. Older people can experience swallowing difficulties because of co-morbidities, age-related physiological changes, and polypharmacy. To make medicines easier to swallow, many people will modify the medication dosage form e.g. split or crush tablets, and open capsules. Some of the challenges associated with administering medicines to older people, and issues with dosage form modification will be reviewed. Novel dosage forms in development are promising and may help overcome some of the issues. However, until these are more readily available, effective interdisciplinary teams, and improving patient health literacy will help reduce the risk of medication misadventures in older people.

A spoonful of sugar helps the medicine go down? A review of strategies for making pills easier to swallow

Solid oral dosage forms such as tablets and capsules are generally the preferred method of drug delivery due to their convenience, cost, and acceptability. However, for many people, it can be a challenge to swallow solid oral medications, even those with healthy swallowing function. This review describes current strategies available to facilitate medication administration to otherwise healthy people with pill-swallowing difficulties. In general, restoring and maintaining the ability to swallow pills whole should ideally be the first choice in managing people with pill-swallowing difficulties. A number of strategies can potentially make it easier to swallow pills whole. These include postural adjustments, using pill-swallowing aids, and teaching pill-swallowing techniques. Where these are not successful or appropriate, then other approaches have to be considered using alternative formulations/routes of administration or deprescribing. If there is no other option, and it is not directly contraindicated for each specific medication dosage form, pills may be modified and mixed in foods and drinks to aid swallowing. In conclusion, people with pill-swallowing difficulties can benefit from a number of strategies designed to facilitate swallowing medications. However, these strategies should be further evaluated with regard to the evidence relating to both their efficacy and safety.

Effects of chin-up posture on the sequence of swallowing events

BACKGROUND

Chin-up posture is frequently used to manage oral dysphagia after head and neck cancer. This prospective study investigates the effects of chin-ups on the sequence of pharyngeal swallowing events.

METHODS

Twelve healthy young adults performed 45 consecutive swallows of 5 mL water across 3 phases on videofluoroscopy: 5 swallows in the neutral head position; 30 swallows during chin-up posture; and 10 swallows in the neutral head position. Swallowing kinematic and bolus flow measures for 9 swallowing events were recorded. Linear trends were analyzed across 30 chin-up swallows; pairwise comparison was used to compare the 3 phases.

RESULTS

Time to hyoid peak and laryngeal vestibule closure changed abruptly during chin-up swallowing compared to the initial neutral position. No measure changed across 30 chin-up swallows. Time of hyoid burst decreased upon returning to the neutral position.

CONCLUSION

Our findings indicate that chin-up posture challenges the pharyngeal sequence of events for both swallowing kinematics and bolus flow. © 2017 Wiley Periodicals, Inc. Head Neck 39: 947-959, 2017.

Swallowing difficulties with medication intake assessed with a novel self-report questionnaire in patients with systemic sclerosis - a cross-sectional population study

OBJECTIVES

To assess subjective swallowing difficulties (SD) with medication intake and their practical consequences in patients suffering from systemic sclerosis (SSc) with a novel self-report questionnaire.

DESIGN AND SETTING

Based on a systematic literature review, we developed a self-report questionnaire and got it approved by an expert panel. Subsequently, we sent the questionnaire by post mail to SSc patients of the European Center for the Rehabilitation of Scleroderma Rheinfelden, Switzerland.

PARTICIPANTS

Patients were eligible if they were diagnosed with SSc, treated at the center, and were of age ≥18 years at the study start.

MAIN OUTCOME MEASURES

Prevalence and pattern of SD with oral medication intake, including localization and intensity of complaints.

RESULTS

The questionnaire consisted of 30 items divided into five sections Complaints, Intensity, Localization, Coping strategies, and Adherence. Of the 64 SSc patients eligible in 2014, 43 (67%) returned the questionnaire. Twenty patients reported SD with medication intake (prevalence 47%), either currently (11; 26%) or in the past that had been overcome (9; 21%). Self-reported SD were localized mostly in the larynx (43%) and esophagus (34%). They were of moderate (45%) or strong to unbearable intensity (25%). Modification of the dosage form was reported in 40% of cases with SD. Adherence was poor for 20 (47%) patients and was not associated with SD (p=0.148).

CONCLUSION

Our novel self-report questionnaire is able to assess the pattern of complaints linked to medication intake, that is, localization and intensity. It may serve as a guide for health care professionals in selecting the most suitable therapy option, enabling tailored counseling to reduce inappropriate medication modifications.

Medication adherence in patients with myotonic dystrophy and facioscapulohumeral muscular dystrophy

Myotonic dystrophy (DM) and facioscapulohumeral muscular dystrophy (FSHD) are the two most common adult muscular dystrophies and have progressive and often disabling manifestations. Higher levels of medication adherence lead to better health outcomes, especially important to patients with DM and FSHD because of their multisystem manifestations and complexity of care. However, medication adherence has not previously been studied in a large cohort of DM type 1 (DM1), DM type 2 (DM2), and FSHD patients. The purpose of our study was to survey medication adherence and disease manifestations in patients enrolled in the NIH-supported National DM and FSHD Registry. The study was completed by 110 DM1, 49 DM2, and 193 FSHD patients. Notable comorbidities were hypertension in FSHD (44 %) and DM2 (37 %), gastroesophageal reflux disease in DM1 (24 %) and DM2 (31 %) and arrhythmias (29 %) and thyroid disease (20 %) in DM1. Each group reported high levels of adherence based on regimen complexity, medication costs, health literacy, side effect profile, and their beliefs about treatment. Only dysphagia in DM1 was reported to significantly impact medication adherence. Approximately 35 % of study patients reported polypharmacy (taking 6 or more medications). Of the patients with polypharmacy, the DM1 cohort was significantly younger (mean 55.0 years) compared to DM2 (59.0 years) and FSHD (63.2 years), and had shorter disease duration (mean 26 years) compared to FSHD (26.8 years) and DM2 (34.8 years). Future research is needed to assess techniques to ease pill swallowing in DM1 and to monitor polypharmacy and potential drug interactions in DM and FSHD.

Formulation approaches to pediatric oral drug delivery: benefits and limitations of current platforms

Introduction: Most conventional drug delivery systems are not acceptable for pediatric patients as they differ in their developmental status and dosing requirements from other subsets of the population. Technology platforms are required to aid the development of age-appropriate medicines to maximize patient acceptability while maintaining safety, efficacy, accessibility and affordability.

Areas covered: The current approaches and novel developments in the field of age-appropriate drug delivery for pediatric patients are critically discussed including patient-centric formulations, administration devices and packaging systems.

Expert opinion: Despite the incentives provided by recent regulatory modifications and the efforts of formulation scientists, there is still a need for implementation of pharmaceutical technologies that enable the manufacture of licensed age-appropriate formulations. Harmonization of endeavors from regulators, industry and academia by sharing learning associated with data obtained from pediatric investigation plans, product development pathways and scientific projects would be the way forward to speed up bench-to-market age appropriate formulation development. A collaborative approach will benefit not only pediatrics, but other patient populations such as geriatrics would also benefit from an accelerated patient-centric approach to drug delivery.