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

Current State of Minitablet Product Design: A Review

Interest in minitablets (MTs) has grown exponentially over the last 20 years and especially the last decade, as evidenced by the number of publications cited in Scopus and PubMed. MTs offer significant opportunities for personalized medicine, dose titration and flexible dosing, taste masking, and customizing drug delivery systems. Advances in specialized MT tooling, manufacturing, and characterization instrumentation have overcome many of the earlier development issues. Breakthrough MT swallowability, acceptability, and palatability research have challenged the long-standing idea that only liquids are acceptable dosage forms for infants and young children. MTs have been shown to be a highly acceptable dosage form for infants, small children, and geriatric patients who have difficulty swallowing. This review discusses the current state of MT applications, acceptability in pediatric and geriatric populations, medication adherence, manufacturing processes such as tableting and coating, running powder and tablet characterization, packaging and MT dispensing, and regulatory considerations.

Point Prevalence Survey of Acute Hospital Patients with Difficulty Swallowing Solid Oral Dose Forms

The safe administration of solid oral dose forms in hospital inpatients with swallowing difficulties is challenging. The aim of this study was to establish the prevalence of difficulties in swallowing solid oral dose forms in acute hospital inpatients. A point prevalence study was completed at three time points. The following data were collected: the prevalence of swallowing difficulties, methods used to modify solid oral dose forms to facilitate administration, the appropriateness of the modification, and patient co-morbidities. The prevalence of acute hospital inpatients with swallowing difficulties was an average of 15.4% with a 95% CI [13.4, 17.6] across the three studies. On average, 9.6% of patients with swallowing difficulties had no enteral feeding tube in situ, with 6.0% of these patients receiving at least one modified medicine. The most common method of solid oral dose form modification was crushing, with an administration error rate of approximately 14.4%. The most common co-morbid condition in these patients was hypertension, with dysphagia appearing on the problem list of two (5.5%) acute hospital inpatients with swallowing difficulties. Inappropriate modifications to solid oral dose forms to facilitate administration can result in patient harm. A proactive approach, such as the use of a screening tool to identify acute hospital inpatients with swallowing difficulties, is required, to mitigate the risk of inappropriate modifications to medicines to overcome swallowing difficulties.

Problems experienced when swallowing solid oral dosage forms in older Japanese patients with dysphagia: A cross-sectional study

AIMS

We aimed to assess the difficulty in taking solid oral dosage forms (SODFs) among older people with dysphagia and clarify the relationship between difficulty in swallowing SODFs and swallowing function.

METHODS AND RESULTS

Outpatients from a dysphagia clinic aged ≥65 years were asked yes-or-no questions about the applicability of eight items regarding difficulty in taking SODFs. Additionally, a videofluorographic swallowing study (VFSS) was performed to assess their swallowing function. The Kruskal-Wallis test and Spearman's rank correlation coefficient were used to analyze the relationship between difficulty in taking SODFs and swallowing function.

RESULTS

Among the 93 participants, the average number of SODFs consumed was 5.8 ± 3.1. In the questionnaire, the average number of "yes" answers was 2.2 ± 2.2, and 65 patients (71.0%) answered "yes" to at least one question. Additionally, no significant relationship was observed between the perceived difficulty in swallowing SODFs and VFSS findings.

CONCLUSION

Approximately 70% of participants reported subjective difficulty in taking SODFs, showing that patients uniformly reported perceived difficulty in taking SODFs regardless of actual swallowing function. The results of this study suggest that patients must be questioned thoroughly about their SODFs use, regardless of the objective severity of their dysphagia.

A qualitative study of imaginary pills and open-label placebos in test anxiety

BACKGROUND

The efficacy of open-label placebos (OLPs) has been increasingly demonstrated and their use holds promise for applications compatible with basic ethical principles. Taking this concept one step further an imaginary pill (IP) intervention without the use of a physical pill was developed and tested in a randomized controlled trial (RCT). To explore participants' experiences and views, we conducted the first qualitative study in the field of IPs.

METHODS

A reflexive thematic analysis (RTA) of semi-structured interviews with test anxious students (N = 20) was nested in an RCT investigating an IP and OLP intervention. In addition, open-ended questions from the RCT were evaluated (N = 114) to corroborate the RTA and pill characteristics were included to more accurately capture the IP experience.

RESULTS

Four key themes were identified: (1) attitude towards the intervention, (2) applicability of the intervention, (3) experience of effects, and (4) characteristics of the imagination. The IP intervention was well-accepted, easily applicable, and various effects, pill characteristics and appearances were described. While many participants did not desire a physical pill, either due to the absence of the imagination component or aversion to pills, the approach was considered to be cognitively and time demanding, which in turn, however, encouraged the establishment of a therapeutic ritual that protected against the increase in test anxiety during the preparation phase. OLP findings were comparable, and especially the importance of a treatment rationale was stressed in both groups, counteracting an initial ambivalent attitude. The RTA findings were supported by the open-ended questions of the RCT.

CONCLUSION

IPs appear to be a well-accepted and easily applicable intervention producing a variety of beneficial effects. Thus, the IP approach might serve as an imaginary based alternative to OLPs warranting further investigations on its application to harness placebo effects without a physical pill.

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.

Beyond the Eckardt Score: Patient-Reported Outcomes Measures in Esophageal Disorders

PURPOSE OF REVIEW

To provide an overview of patient reported outcome measures (PROMs) and summarize their role in assessing undifferentiated dysphagia and common esophageal disorders, including achalasia, eosinophilic esophagitis (EoE), and gastroesophageal reflux disease (GERD).

RECENT FINDINGS

Given the subjective nature of swallowing disorders, accurate diagnoses often rely on capturing the patient experience. As a result, the number of PROMs used to characterize esophageal symptoms is increasing with a recent particular emphasis on EoE. Overall, esophageal-focused PROMs are used to interpret patient symptoms and quality of life, diagnosis, and symptom changes over time. There are limitations with each instrument, including factors affecting validity, reliability, accessibility, patient participation, and logistical implementation. PROM instruments can be helpful tools in the diagnosis and treatment of esophageal disorders. Instruments should be chosen based on factors such as target population and setting, including research, clinical, and quality improvement efforts. Future research should address how best to implement PROMs and integrate the obtained data with patient care.

Patient preferences for systemic sclerosis treatment: A descriptive study within an Italian cohort

Objectives:

The aim of this study is to ascertain systemic sclerosis patients’ preferences regarding the formulations of the medications they use.

Methods:

We undertook questionnaires and interviews aimed at understanding systemic sclerosis patients’ preferences with respect to the medications they used.

Results:

Among 160 systemic sclerosis patients, we found that the majority does not have difficulty taking their medication. However, preferences were identified (81.25% – 65/80 – preferred oral meds and 47.50% – 38/80 – disliked rectal/vaginal meds), as well as some systemic sclerosis patients have significant difficulties using their medications. In fact, factors such as swallowing and fine finger motion difficulties were frequent, while intravenous/intramuscular/subcutaneous medicines were usually not preferred because they are felt as inconvenient (intravenous = 33.4% and subcutaneous/intramuscular = 10%) or painful (intravenous = 37.50% and subcutaneous/intramuscular = 10%)

Conclusion:

Most systemic sclerosis patients are able to take their medication despite having some difficulties. However, as there were clear preferences, we could improve patients’ adherence to drug therapy if taking these preferences into account.

Managing gastrointestinal complications in patients with systemic sclerosis

Objective

We sought to critically evaluate the literature published over the past 3 years on the management of gastrointestinal complications in systemic sclerosis (SSc). We emphasize interesting and important new findings to bring the reader up-to-date. We also discuss controversial discoveries and hypotheses currently of interest.

Methods

We conducted a literature search on PubMed over the last 3 years using the key words "systemic sclerosis," "gastrointestinal," "scleroderma," and "treatment." We also screened clinicaltrials.gov for ongoing trials relevant to the gastrointestinal complications of SSc. Reference lists from recent reviews on the management of gastrointestinal complications of SSc to identify articles that might have been missed in the initial search.

Results

103 publications and ongoing clinical trials were identified. We eliminated all case reports and review articles. Ultimately we had 58 articles remaining and we prioritized what we found to be the strongest and/or novel findings to discuss in this review.

Conclusions

Advances in the management of gastrointestinal disease in SSc continue to evolve. The application of novel therapies and the repurposing of existing therapies for the management of gastrointestinal involvement are shaping the therapeutic arsenal so that we can more effectively manage these complex patients.

Translation to English, cross-cultural adaptation, and pilot testing of the self-report questionnaire on swallowing difficulties with medication intake and coping strategies (SWAMECO) for adults with polypharmacy

OBJECTIVES

To translate the SWAMECO from German into English; to complete content and face validity with healthcare professionals (HCPs) and with patients from the target population that is, community-dwelling adult patients taking three or more medicines for three or more months.

DESIGN

The process followed guidance from Sousa et al and included translation and cross-cultural adaptation, and cognitive testing among selected HCPs and patients. As the SWAMECO questionnaire is a screening instrument, pilot testing was performed in the target population.

SETTING

Three community pharmacies in and around Cork (Ireland) recruited patients for interviews and pilot testing.

PARTICIPANTS

Community-dwelling patients with ≥3 oral medications for ≥3 months, aged ≥18 years.

OUTCOME MEASURES

Answers to the SWAMECO questionnaire; clarity of each question, each instruction and each response format.

RESULTS

Issues related to cultural and conceptual differences were resolved by rewording some items. Ten HCPs and 11 patients completed the questionnaire and gave their feedback and opinions on criteria according to Fitzpatrick et al. Revisions included rewording; deleting of two questions; using of colour to signpost that is, where to skip questions that were not applicable to the participants; and replacement of the A-14 medication adherence scale with three validated items. Of the 66 patients enrolled for pilot testing, eight (12.1%) indicated swallowing difficulties. Difficulties with ingesting foods or liquids correlated with swallowing difficulties (p=0.001). All patients perceived discomfort (mean 6.9 on a Visual Analogue Scale from 0 to 10). Patients with swallowing difficulties were significantly more likely to report modifying their medicines (p=0.004) and having poorer medication adherence (p=0.028) than those who had no swallowing difficulties.

CONCLUSIONS

The version of the SWAMECO questionnaire in English contains 28 items and is ready for use in adults with polypharmacy.

Understanding the knowledge, attitudes and beliefs of community-dwelling older adults and their carers about the modification of oral medicines: A qualitative interview study to inform healthcare professional practice

BACKGROUND

Oral medicines are commonly modified (e.g. tablets split/crushed) to meet the dosing and swallowing requirements of older adults. However, there is limited research investigating the opinions of community-dwelling patients and carers about medicine modification.

OBJECTIVES

The aim of this study was to investigate the views of community-dwelling older adults and their carers about oral medicine modification.

METHODS

Semi-structured, face-to-face interviews were conducted with community-dwelling older adults and carers of older adults who experienced difficulty swallowing medicines, or who required medicines to be modified. Participants were recruited from purposively selected community pharmacies using a combination of purposive, convenience and snowball sampling. Interviews were audio-recorded, transcribed verbatim and analysed thematically. The Francis method governed when data saturation had been reached.

RESULTS

Twenty-six interviews (13 patients, 13 carers) were conducted (76.9% female, median length 11 min (IQR 8-16 min)). Four themes emerged from the data: variation in medical needs and preferences; balancing acceptance and resignation; healthcare professional engagement and; opportunities for optimising formulation suitability. The heterogeneity of medical conditions experienced by community-dwelling older adults resulted in a variety of modifications being required. Patients and carers are accepting of their medications and formulations. However, when challenges arise, they tend to feel resigned to coping within the constraints of the current medication regimen, resulting in a lack of focused communication with healthcare professionals. Thus, healthcare professionals were unaware of their difficulties and unable to offer advice or solutions.

CONCLUSION

Healthcare professionals must engage proactively with this group. Whilst a holistic approach to medication management is ideal, the disadvantage is that no single healthcare professional may identify this as their responsibility. Whilst the input and expertise of all healthcare professionals will be required, as medication experts, the pharmacy profession should take ownership and become the champion of, and for, the patient.

Community pharmacy Medicines Use Review: current challenges

With a growing aging population, the appropriate, effective, and safe use of medicines is a global health policy priority. One concern is patients' non-adherence to medicines, which is estimated to be up to 50%. Policymakers seek to reconfigure medicine management services and consider community pharmacy as especially well-placed to improve medicine use. In England and Wales, a commissioned medication review service called "Medicines Use Reviews (MURs)" was made available in through the National Health Service (NHS) in 2005. This involves a patient-pharmacist consultation to improve patients' knowledge and the use of medicines and to help reduce avoidable waste. However, over a decade since their introduction, questions remain over the extent to which the MUR policy has successfully been embedded in practice and translated into more effective use of medicines. The MUR intervention continues to hold many challenges ranging from poor public awareness and acceptance of MURs, organizational constraints, and issues over interprofessional collaboration. Many of these challenges are not exclusive to the MUR service, or even to the community pharmacy setting. Nevertheless, by identifying and exposing such challenges, an opportunity exists for policymakers and commissioners to seek to improve this service to patients. This narrative review explores the current challenges that face MURs. Damschroder et al's consolidated framework for implementation research is employed to help organize these challenges from patient and professional perspectives across multiple contexts. Over the past decade, MUR policy and practice has continued to evolve, being shaped by research, organizational and professional influences, and policy. Reforms to the service suggest that the MURs are becoming more responsive to patients' need and preferences. It is intended that this review will create impetus and scope for further debate, service reconfiguration, and ultimately service improvement.