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

Application of a screening tool to understand the medication habits of patients with swallowing difficulty: a prospective observational study

BACKGROUND

Difficulty swallowing solid oral dose forms can result in non-adherence and thus can negatively impact patient outcomes. It can be challenging for healthcare professionals to readily identify patients who present with this difficulty within the hospital setting.

AIM

To apply the "Swallowing Difficulties with Medication Intake and Coping Strategies" (SWAMECO) questionnaire at admission to hospital to elucidate the medication habits of patients when taking medication at home.

METHOD

This prospective observational study took place in acute urban teaching hospital in Ireland in July 2023. Eligible adults completed the SWAMECO, describing their difficulty and the coping strategies used. Data on age, sex, medicines and disease states, as per International Classification of Diseases and Related Health problems (ICD-10) were collected.

RESULTS

Self-reported prevalence of swallowing difficulties was 10% (41/409) of whom, 14 patients (median age; 67 years (range 40-86 years), 78.6%; female) completed the SWAMECO. The majority reported having a sensation of medication getting stuck in the pharynx. Swallowing difficulty caused anxiety for some patients and contributed to non-adherence. The most common coping strategy was splitting tablets. Paracetamol was the most frequent solid oral dose form associated with swallowing difficulty and hypertension was the most diagnosed condition. Alternative formulations were available for over half (56%) of the solid oral dose forms prescribed.

CONCLUSION

The SWAMECO can provide valuable information by identification of patients with swallowing difficulty. This may facilitate clinical pharmacist intervention to ensure safe administration of oral medicines and to enhance patient adherence by providing tailored solutions.

Study on Lyophilised Orodispersible Tablets from Plant-Based Drinks as Bulking Agents

Background/Objectives: Oral administration of active pharmaceutical ingredients (APIs) is the most commonly used route of administration. As dysphagia is a prevalent problem, the size of the swallowed dosage form could negatively influence patient adherence. Orally disintegrating tablets (ODTs) are beneficial dosage forms because they disintegrate within a few seconds in the oral cavity without water. Lactose is one of the most commonly used excipients in the pharmaceutical industry; it served as the central concept of a recent publication on the formulation of milk-based ODTs despite lactose malabsorption being widespread worldwide. Consequently, the plant-based alternative market has grown exponentially and has become a prevailing food trend, with various alternatives to choose from. For this reason, the development of a nonsteroidal anti-inflammatory drug (NSAID)-containing ODT with plant-based drinks (PBDs) was assessed for its innovative potential. Methods: Different PBDs were investigated and compared to traditional and lactose-free milk. The liquids' viscosity, pH, and particle size were determined, and an electronic tongue was used for the sensory evaluation. The various ODTs were prepared with the freeze-drying method, and then the qualitative characteristics of the dosage form were investigated. Results: Our different measurements show that different plant beverages differ from each other and that these differences have an impact on the technological processing. According to the HPLC-DAD measurements, all values were in the required range. Conclusions: These measurements suggest that the soya drink is the most similar to traditional cow milk and would be the most appropriate choice among the investigated plant-based drinks to be used as a carrier system for an ibuprofen-containing ODT.

Challenges and Opportunities in Managing Geriatric Depression: The Role of Personalized Medicine and Age-Appropriate Therapeutic Approaches

The global aging population has experienced rapid growth in recent decades, leading to an increased prevalence of psychiatric disorders, particularly depression, among older adults. Depression in the geriatric population is often compounded by chronic physical conditions and various psychosocial factors, significantly impacting their quality of life. The main question raised in this review is as follows: how can personalized medicine and age-appropriate therapeutic approaches improve the management of geriatric depression? This paper explores the epidemiology of geriatric depression, highlighting the influence of gender, race, and socioeconomic status on its prevalence. The classification and diagnosis of geriatric depressive disorders, based on ICD-11 and DSM-5 criteria, reveal the complexity of managing these conditions in older adults. Personalized medicine (PM) emerges as a promising approach, focusing on tailoring treatments to the individual's genetic, clinical, and environmental characteristics. However, the application of PM in this demographic faces challenges, particularly in the context of pharmaceutical forms. The need for age-appropriate drug delivery systems is critical, given the prevalence of polypharmacy and issues such as dysphagia among the older patients. This study emphasizes the importance of developing patient-centric formulations to enhance the effectiveness of personalized therapy in geriatric patients.

Patient Acceptability and Preferences for Solid Oral Dosage Form Drug Product Attributes: A Scoping Review

Background

There is no consistent framework for patient-centric drug product design, despite the common understanding that drug product acceptability and preferences influence adherence and, therefore, drug product effectiveness. The aim of this review was to assess current understanding of patient acceptability and preferences for solid oral dosage form (SODF) drug product attributes, and the potential impact of these attributes on patient behaviors and outcomes.

Patients and Methods

A scoping review was conducted. Embase, Ovid MEDLINE®, and PubMed® were searched for full-text articles published between January 2013 and May 2023. Following screening and assessment against predefined inclusion criteria, data were analyzed thematically.

Results

Nineteen studies were included. Four overarching domains of drug product attributes were identified and summarized in a framework: appearance, swallowability, palatability, and handling. Each domain was informed by specific drug product attributes: texture, form, size, shape, color, marking, taste, mouthfeel, and smell. The most frequently studied domains were swallowability and appearance, while the most studied attributes were size, shape, and texture. Smell, marking, and mouthfeel were the least studied attributes. Texture intersected all domains, while form, shape, and size intersected appearance, swallowability, and handling. Swallowability and size appeared to be the key domain and attribute, respectively, to consider when designing drug products. Few studies explored the impact of drug product attributes on behaviors and outcomes.

Conclusion

While existing studies of drug product attributes have focused on appearance and swallowability, this review highlighted the importance of two less well-understood domains-palatability and handling-in understanding patients' acceptability and preferences for SODF drug products. The framework provides a tool to facilitate patient-centric design of drug products, organizing and categorizing physical drug product attributes into four overarching domains (appearance, swallowability, palatability, and handling), encouraging researchers to comprehensively assess the impact of drug product attributes on patient acceptability, preferences, and outcomes.

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.

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.

VIDEOFLUOROSCOPIC EVALUATION OF THE IMPACT OF CAPSULE SIZE AND SUBJECT'S AGE AND GENDER ON CAPSULE SWALLOWING

BACKGROUND

People recurrently have difficulties swallowing solid medications, which can be associated with the size of the medication and the age and gender of individuals.

OBJECTIVE

To evaluate the impact of capsule size and adults' age and gender on oral and pharyngeal capsule transit during capsule swallows.

METHODS

Videofluoroscopy was used to measure capsule oral and pharyngeal transit during swallows in 49 healthy individuals (17 men and 32 women), with a mean age of 46 years (ranging from 23 to 88 years). Smaller capsules were filled with 0.50 mL of barium sulfate, and larger capsules were filled with 0.95 mL of barium sulfate; the volume of liquid ingested with the capsules was also quantified in each ingestion. The measurements included the oral preparation time, oral transit time, swallowing reaction time, time to laryngeal vestibule closure, laryngeal vestibule closure duration, pharyngeal transit time, and upper esophageal sphincter opening duration.

RESULTS

The capsule size did not influence either the oral or pharyngeal transit time. Increased liquid volume was ingested with larger capsules and by people older than 40 years. The oral transit time was shorter in older adults (60-88 years), and the time to laryngeal vestibule closure was longer in women.

CONCLUSION

The size of large capsules did not make a difference in oral or pharyngeal transit when compared with smaller capsules. The capsule size and the participant's age influenced the volume of liquid ingested - larger capsules and older individuals required a larger volume. The capsule oral transit was faster in individuals older than 60 years.

BACKGROUND

•Swallowing is influenced by the characteristics of what is being swallowed.

BACKGROUND

•There was no difference in swallowing capsules containing 0.50 mL or 0.95 mL.

BACKGROUND

•Larger capsules need more liquid ingestion to make swallowing easier.

BACKGROUND

•Individuals older than 40 years need a greater volume of liquid to swallow capsules than younger adults.

Effect of Taste Additives on the Palatability of Activated Charcoal: a Systematic Review

INTRODUCTION

Activated charcoal is a decontaminating agent used for acute intoxication. It can be mixed with taste additives to overcome its poor palatability. Our purpose was to evaluate the taste additives used to improve activated charcoal's palatability.

METHODS

We conducted a systematic review of comparative studies on taste additives used to improve activated charcoal's palatability. We searched PubMed, Embase, Web of Science, Cochrane, and CINAHL. We included controlled trials and observational studies that evaluate the effect of at least one taste additive, compared with activated charcoal alone. Our primary outcome was palatability. Our secondary outcomes included treatment adherence, adsorption efficacy, and adverse events. The risk of bias was assessed using the Quality Assessment Tool for Quantitative Studies.

RESULTS

Among 38 eligible articles, seven observational studies and three crossover clinical trials met our inclusion criteria. The risk of bias was found to be high for seven studies and intermediate for three others. The preferred flavoring agents were cola and chocolate milk for children, and sweetening agents for adults. All taste additives studied seemed to improve activated charcoal's palatability, except for yogurt (n = 1). The addition of bentonite, sorbitol, carboxymethylcellulose, or yogurt showed no impact on the in-vivo adsorption capacity of activated charcoal, whereas the results were inconclusive for chocolate. No meta-analysis was performed due to insufficient data.

CONCLUSION

Strategies to improve activated charcoal's palatability seem to enhance the taste. Descriptive data are in favor of a limited impact on activated charcoal's adsorption capacity when adding binding agents or sweeteners.

TRIAL REGISTRATION ON PROSPERO

This review is registered as PROSPERO CRD42019135092.

Impact of Tablet Size and Shape on the Swallowability in Older Adults

Older adults represent the major target population for oral medications, due to the high prevalence of multimorbidity. To allow for successful pharmacological treatments, patients need to adhere to their medication and, thus, patient-centric drug products with a high level of acceptability by the end users are needed. However, knowledge on the appropriate size and shape of solid oral dosage forms, as the most commonly used dosage forms in older adults, is still scarce. A randomized intervention study was performed including 52 older adults (65 to 94 years) and 52 young adults (19 to 36 years). Each participant swallowed four coated placebo tablets differing in weight (250 to 1000 mg) and shape (oval, round, oblong) in a blinded manner on three study days. The choice of tablet dimensions allowed for a systematic comparison between different tablet sizes of the same shape, as well as between different tablet shapes. Swallowability was assessed using a questionnaire-based method. All tested tablets were swallowed by ≥80% of adults, independent of age. However, only the 250 mg oval tablet was classified as well swallowable by ≥80% of old participants. The same was true for young participants; however, they also considered the 250 mg round and the 500 mg oval tablet as well swallowable. Furthermore, swallowability was seen to influence the willingness to take a tablet on a daily basis, especially for an intake over longer time periods.

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.

Bioequivalence of Esaxerenone Conventional Tablet and Orally Disintegrating Tablet: Two Single-Dose Crossover Studies in Healthy Japanese Men

We assessed the bioequivalence of a single dose of 5-mg of esaxerenone administered as an orally disintegrating tablet (ODT) with the conventional oral tablet in healthy Japanese men. This single-center, open-label, randomized, two-drug, two-stage crossover, single-dose study was conducted in two parts. In study 1, both formulations were taken with water. In study 2, only the ODT formulation was taken without water. The primary outcome was the evaluation of bioequivalence of the ODT and conventional tablet using the pharmacokinetic (PK) parameters maximum plasma concentration (C_max ) and area under the plasma concentration-time curve to the last quantifiable time (AUC_last ). Plasma concentrations were measured using a validated liquid chromatography/mass spectrometry method and PK parameters were calculated by noncompartmental analysis. The ratios of the geometric least-squares mean (2-sided 90% confidence intervals [90%CIs]) for ODT with (study 1) and without (study 2) water to the conventional tablet were 1.03 (1.00-1.07) and 1.01 (0.96-1.06) for C_max and 1.03 (1.00-1.07) and 0.96 (0.94-0.98) for AUC_last , respectively. The 90%CIs fell within the predefined bioequivalence range of 0.80-1.25. Treatment-emergent adverse events were similar between both formulations. In conclusion, esaxerenone 5-mg ODT taken with or without water was bioequivalent to a single 5-mg conventional oral tablet.

Topical Medicine Potency of Musa paradisiaca var. sapientum (L.) kuntze as Oral Gel for Wound Healing: An In Vitro, In Vivo Study

OBJECTIVE

 Topical application of ambonese banana (Musa paradisiaca var. sapientum (L.) kuntze) stem sap gel (GEGPA) on the socket wound area showed an increase in the expression of platelet-derived growth factor-BB, while decrease in the expression of matrix metalloproteinase-2 and 9. The aim of this study is to achieve standard formulation of GEGPA through stability, viscosity, distribution area, and drugs release for oral gel wound healing.

MATERIALS AND METHODS

 This is an in vitro and in vivo study with the randomized posttest only control group design. The gel was formulated according to the composition of each group by adding hydroxypropyl methylcellulose (HPMC), Lexgard, propylene glycol, and cold water to obtain 100 g of gel. Observations were made through the following tests: stability, viscosity, distribution area, drug release, and histopathological analysis of tooth extraction wound healing.

STATISTICAL ANALYSIS

 Data were analyzed using a one-way analysis of variance (α = 0.05) with GraphPad Prism-8 statistical software.

RESULTS

 The study showed that the GEGPA formulation was stable against changes in consistency, color, smell, homogeneity, and pH value. There is a significant difference between groups with respect to viscosity (p = 0.0001), adhesion (p = 0.004), dispersion (p = 0.000), and fibroblast cell numbers on days 3 and 5 (p = 0.007 and p = 0.001). There is no interaction between the active ingredients and the gel base of all formulations. Formulation 3 had better properties in terms of viscosity, broad distribution, and drug release compared with other groups. Application of GEGPA to tooth extraction wounds showed a significant proliferation of fibroblast cells on days 3 and 5.

CONCLUSIONS

 The formulation of M. paradisiaca var. sapientum (L.) kuntze extract with HPMC and propylene glycol obtained a gel preparation, GEGPA, that was organoleptically stable and met the topical gel standard for wounds in the oral cavity.

Performance of Tablet Splitters, Crushers, and Grinders in Relation to Personalised Medication with Tablets

Swallowing problems and the required dose adaptations needed to obtain optimal pharmacotherapy may be a hurdle in the use of tablets in daily clinical practice. Tablet splitting, crushing, or grinding is often applied to personalise medication, especially for the elderly and children. In this study, the performance of different types of (commercially available) devices was studied. Included were splitters, screwcap crushers, manual grinders, and electric grinders. Unscored tablets without active ingredient were prepared, with a diameter of 9 and 13 mm and a hardness of 100–220 N. Tablets were split into two parts and the difference in weight was measured. The time needed to pulverise the tablets (crush time) was recorded. The residue remaining in the device (loss) was measured. The powder was sieved to obtain a particle fraction >600 µm and <600 µm. The median particle size and particle size distribution of the later fraction were determined using laser diffraction analysis. Splitting tablets into two equal parts appeared to be difficult with the devices tested. Most screwcap grinders yielded a coarse powder containing larger chunks. Manual and especially electric grinders produced a finer powder, making it suitable for administration via an enteral feeding tube as well as for use in individualised preparations such as capsules. In conclusion, for domestic and incidental use, a screwcap crusher may provide sufficient size reduction, while for the more demanding regular use in hospitals and nursing residences, a manual or electric grinder is preferred.

Enabling modular dosage form concepts for individualized multidrug therapy: Expanding the design window for poorly water-soluble drugs

Multidrug dosage forms (aka combination dosage forms, polypills, etc.) create value for patients through reduced pill burdens and simplified administration to improve adherence to therapy. Enhanced flexibility of multidrug dosage forms would provide further opportunities to better match emerging needs for individualized therapy. Through modular dosage form concepts, one approach to satisfy these needs is to adapt multidrug dosage forms to a wider variety of drugs, each with a variety of doses and release profiles. This study investigates and technically explores design requirements for extending the capability of modular multidrug dosage form concepts towards individualization. This builds on our recent demonstration of independent tailoring of dose and drug release, which is here extended towards poorly water-soluble drugs. The challenging design requirement of carrying higher drug loads in smaller volumes to accommodate multiple drugs at their clinical dose is here met regarding dose and release performance. With a modular concept, we demonstrate high precision (<5% RSD) in dose and release performance of individual modules containing felodipine or naproxen in Kollidon VA64 at both a wide drug loading range (5% w/w and 50% w/w drug) and a small module size (3.6 mg). In a forward-looking design-based discussion, further requirements are addressed, emphasizing that reproducible individual module performance is predictive of dosage form performance, provided the modules are designed to act independently. Therefore, efforts to incorporate progressively higher drug loads within progressively smaller module volumes will be crucial to extend the design window further towards full flexibility of future dosage forms for individualized multidrug therapy.

Amorphous Solid Dispersion Tablets Overcome Acalabrutinib pH Effect in Dogs

Calquence^® (crystalline acalabrutinib), a commercially marketed tyrosine kinase inhibitor (TKI), exhibits significantly reduced oral exposure when taken with acid-reducing agents (ARAs) due to the low solubility of the weakly basic drug at elevated gastric pH. These drug-drug interactions (DDIs) negatively impact patient treatment and quality of life due to the strict dosing regimens required. In this study, reduced plasma drug exposure at high gastric pH was overcome using a spray-dried amorphous solid dispersion (ASD) comprising 50% acalabrutinib and 50% hydroxypropyl methylcellulose acetate succinate (HPMCAS, H grade) formulated as an immediate-release (IR) tablet. ASD tablets achieved similar area under the plasma drug concentration-time curve (AUC) at low and high gastric pH and outperformed Calquence capsules 2.4-fold at high gastric pH in beagle dogs. In vitro multicompartment dissolution testing conducted a priori to the in vivo study successfully predicted the improved formulation performance. In addition, ASD tablets were 60% smaller than Calquence capsules and demonstrated good laboratory-scale manufacturability, physical stability, and chemical stability. ASD dosage forms are attractive for improving patient compliance and the efficacy of acalabrutinib and other weakly basic drugs that have pH-dependent absorption.