Pharmacists can advise patients and prescribers about medication that may be adversely affecting the patient's ability to swallow. This can include one or more of the following categories:

Drugs that induce xerostomia or dry mouth can compromise a patient's ability to swallow; this may include drugs commonly prescribed to older people including diuretics such as triamterene or amiloride, tricyclic antidepressants, other antidepressants such as fluoxetine or moclobemide, antihistamines including chlorphenamine or promethazine, antimuscarinic drugs such as hyoscine or ipratropium, antipsychotics including chlorpromazine or haloperidol, opiates and certain beta blockers such as carvedilol.

Drugs that reduce gastro-intestinal motility can affect a person's ability to swallow. This would include some antidepressants, drugs with an anticholinergic effect, opioids and calcium channel blockers.

Drugs that reduce lower oesophageal sphincter pressure can also increase the risk of dysphagia, including theophylline, calcium channel blockers, nitrates and progesterone.

Drugs that cause direct mucosal injury can lead to symptoms of dysphagia. Drugs associated with this form of injury include antibiotics such as tetracycline, doxycycline or clindamycin, NSAIDs, bisphosphonates such as alendronate, potassium chloride, quinidine and ferrous sulphate.

Medication reviews should be conducted on a regular basis and should follow a standard structured process to maximise care, reduce any potential risk and also address any issues with compliance. The NO TEARS tool may be used for this purpose:

Need and indication - confirm that the treatment is still required and the indication relevant.
Open questions - this generates an opportunity to explore patient compliance.
Tests and monitoring - does the patient require any specific monitoring tests?
Evidence/guidelines - have the reasons for starting, continuing or stopping the medication changed?
Adverse events - has the patient developed any adverse effects from the medication?
Risk reduction or prevention - are there other risk factors and will the medication affect these?
Simplification and switches - have new formulations become available that are more cost effective or licensed?

Where dysphagia is acute in origin it may be possible to temporarily stop medication until the patient is able to swallow again.

Where patients are assessed as not being able to use the oral route it is likely that they will be receiving nutritional support either through a nasogastric or enteral feeding tube. Advice on whether a medicine can be given via a feeding tube can be found in the Handbook of Drug Administration via Enteral Feeding Tubes (Pharmaceutical Press) and/or the NEWT guidelines.

Where patients are assessed as having limited ability to swallow there are three possible courses of action:

• The pharmacist, together with the prescriber, should review the on-going need for each medication. This is to confirm that each medicine is effective, still appropriate for the patient and that the benefit of administration outweighs any potential risk.
• Identification of another route of administration avoiding the oral route.
• Identification of a different formulation that the patient is able to swallow.