Swallowing difficulties: supporting adherence

Managing swallowing difficulties

Before considering the options outlined here, an assessment of whether the patient still needs the medication should be carried out. Healthcare professionals may find the SPS resources on polypharmacy useful when undertaking medication review.

It is important to understand the clinical context and issues to consider when providing safe pharmaceutical care for patients with swallowing difficulties. Swallowing difficulties (SPS page) contains all our advice on using medicines safely and effectively in this group of patients.

Alternative formulation of the same medicine

Some patients may benefit from having their medication in a different formulation, such as a liquid instead of capsules or tablets if one is available. A medication review is an ideal time to discuss this with the patient. Licensed medicines are preferred over unlicensed specials. Special consideration should be given to the potentially high costs of unlicensed medicines. 

Further information on the options available can be found in Swallowing difficulties (SPS page) and Using unlicensed medicines (SPS page).

Support with swallowing pills

Patients may find it hard to swallow pills.

Videos on good swallowing techniques may help. The NHS has published patient videos on good swallowing techniques for adults.

KidzMed is an e-learning module for healthcare professionals from NHS England’s elearning for healthcare (login required), covering how to teach children and young people how to swallow pills.

If tablets or capsules are the only formulations available and the patient has minor difficulty swallowing them, then a pill-swallowing aid may be helpful. These are cup-shaped structures which are used to contain the pills and make swallowing easier. They encourage a natural drinking position and there are also options that fit into the neck of a water bottle. There are many options available. Search online for ‘pill swallowing aid’.

Devices to support preparing medicines

There must be someone willing and able to use the device. In order to make a safe and appropriate choice about which device to choose, identify:

• who will be giving the medicine (the patient themselves or a carer)
• their manual dexterity
• their ability to follow instructions to administer the medicine correctly

Tablet cutters

Consideration should be given to whether it is safe to cut tablets. Tablets that are scored with a line or indentation down the middle are usually acceptable to split in half.

The following are examples of medicines that should not be cut (this list is not exhaustive):

• enteric-coated tablets or tablets that are slowly released in your body
• orally-disintegrating tablets
• irregularly shaped tablets
• tablets that are too small to be split evenly
• capsules (some can be opened and sprinkled on food for easier swallowing)
• chemotherapeutic agents
• some combination medicines (one tablet that contains two or more medicines)
• oral contraceptive tablets
• any tablets that contain medicines with a narrow therapeutic index

There are a range of tablet cutters widely available to purchase. Search ‘tablet cutters’ online. They cut a range of tablet sizes but are not suitable for capsules. Some devices are a tablet cutter and crusher in one.

Some devices double as a pill box but all generally require a good level of manual dexterity to operate and contain sharp blades.

Tablet crushers

There is a wide range of portable tablet crushers available to purchase. Search ‘tablet crushers’ online. Other options include using a pestle and mortar to grind the tablets to a fine powder.

Tablet crushers generally require less manual dexterity than tablet splitters. They are usually operated using a twisting motion, in a similar way to a salt grinder. Care is needed to ensure all contents are emptied out, so the correct dose is taken.

Not all tablets can be crushed. Enteric-coated, sustained release and cancer medicines are not suitable for crushing. Some tablets also have a bad taste or are a mucosal irritant so are unsuitable for swallowing when crushed but may be suitable for use via a feeding tube.

Further information can be found in Advising how to crush or disperse tablets and open capsules (SPS page).

Pharmacies providing split tablets

Pharmacies may be able to provide patients with halved or quartered tablets if they cannot use a tablet cutter. The patient should be assessed by a member of the pharmacy team as having a need for these.

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