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Identifying Swallowing Issues

Adherence and Administration Challenges in the General Population

As you know, adherence to a prescribed treatment regimen can be challenging for various types of patients, even those without epilepsy. In fact, one literature search, which reviewed articles from the US and other countries, cites that generally speaking, “the compliance rate of long-term medication therapies was between 40% to 50%.”11. Jin J, Sklar GE, Min Sen Oh V, Chuen Li S. Factors affecting therapeutic compliance: A review from the patient’s perspective. Ther Clin Risk Manag. 2008;4(1):269–286.

There are many reasons why patients with or without epilepsy miss doses or fail to take their medication as prescribed. Some of these are patient awareness issues, such as forgetfulness or poor understanding of treatment. Others include socioeconomic factors (such as age, education, and income status), physical difficulties, regimen complexity, and treatment side effects.11. Jin J, Sklar GE, Min Sen Oh V, Chuen Li S. Factors affecting therapeutic compliance: A review from the patient’s perspective. Ther Clin Risk Manag. 2008;4(1):269–286.

Administration challenges can also be an issue in the general patient population. Simply put, many patients—including those who don’t have epilepsy—have difficulty swallowing oral forms of medication, which can lead to a variety of adverse events and treatment noncompliance.22. US Food and Drug Administration. Size, shape, and other physical attributes of generic tablets and capsules. Washington, DC: US Department of Health and Human Services; 2015.

One survey found that

50%

of all US participants
reported difficulty
swallowing tablets and
capsules (N=1002)3*3. OTC Company News. Hermes highlights need for better formats. http://www.hermes-pharma.com/fileadmin/data/download/Hermes_highlights_need_for_better_formats_OTCBulletin_250714.pdf. Published July 2014. Accessed July 10, 2016.
An estimated

16.5

million

people in the US
have dysphagia4*4. Robbins J, Langmore S, Hind JA, Erlichman M. Dysphagia research in the 21st century and beyond: Proceedings from Dysphagia Experts Meeting. August 21, 2001. J Rehabil Res Dev. 2002;39(4):543-548.
*Statistics represent patients in the general population and not specifically those with epilepsy.

Administration issues are often due to the size and shape of tablets and capsules, which affect the transit of the product through the pharynx and esophagus. Larger tablets and capsules have been shown to have a prolonged esophageal transit time. This can lead to disintegration of the product in the esophagus and, in some cases, can cause injury.2,2. US Food and Drug Administration. Size, shape, and other physical attributes of generic tablets and capsules. Washington, DC: US Department of Health and Human Services; 2015.5,5. Tablets and capsules that stick in the oesophagus. Drug Ther Bull. 1981;19(9):33–34.66. Channer K, Virjee JP. The effect of size and shape of tablets on their esophageal transit. J Clin Pharmacol. 1986; 26:141–146.

Liquid dosage forms are generally regarded as more appropriate for children. But they may also pose issues, such as taste, smell, portability, and stability.77. Liu F, Ranmal S, Batchelor HK, et al. Patient-centred pharmaceutical design to improve acceptability of medicines: similarities and differences in paediatric and geriatric populations. Drugs. 2014;74(16):1871–1889.

In addition to the issues above, the challenge of using liquid formulations in older patients, particularly those with dysphagia, is aspiration, which is caused by inadequate protection of the airway during swallowing.77. Liu F, Ranmal S, Batchelor HK, et al. Patient-centred pharmaceutical design to improve acceptability of medicines: similarities and differences in paediatric and geriatric populations. Drugs. 2014;74(16):1871–1889.

While some patients may be nonadherent due to administration challenges, the extent of the issue may not be completely apparent as patients do not always bring up or discuss the issue with their healthcare providers.88. 40% of American adults report experiencing difficulty swallowing pills [press release]. New York, NY: PR Newswire; January 15, 2004.

Recognizing Administration Challenges for Your Patients with Epilepsy

To identify your patients with epilepsy who are missing doses or failing to take their medication as prescribed, it may be helpful to ask a few simple questions, such as:

  • Do you find it challenging to take your medications?
  • Do you struggle to take or swallow medication due to its size, shape, taste, or smell?
  • Do you gag when taking medication?
  • Do you have to add medication to food in order to take it?
  • Do you ever skip or avoid taking medication because it’s hard to take?

It may help to ask parents, spouses, and other caregivers these types of questions too, to uncover administration challenges they may encounter.

Worth Remembering

There are many reasons why patients skip doses or avoid their medicine. Discussing these reasons with patients may uncover swallowing issues and other administration challenges, which patients may not mention on their own.