AZ, a 73-year-old female, presents to the Pharmacotherapy clinic for assistance with patient education regarding new medications that were added to her home regimen after her recent hospitalization. She was admitted for an acute myocardial infarction (MI) and, as a result, a drug-eluting stent (DES) was placed in her right coronary artery. While going through her medications, her daughter, who accompanied her to the appointment today, expresses that AZ has been experiencing some difficulty swallowing recently.

PMH: Hypertension, Hyperlipidemia, Alzheimer’s Disease (AD), MI

Vitals: BP 129/74 mmHg, HR 71 bpm, RR 15 bpm, Temp 98.6˚F

Labs:

Na 140 mEq/L, K 4.3 mEq/L, Cl 102 mEq/L, SCr 0.7 mg/dL

TC 205 mg/dL, HDL 38 mg/dL, LDL 104 mg/dL, TG 129 mg/dL

Current medications:

Nitrostat 0.3 mg PRN (prescribed at hospital discharge)

Ecotrin Low Strength 81 mg QD (prescribed at hospital discharge)

Crestor 20 mg QD (previously on 10 mg, increased to 20 mg at hospital discharge)

Prilosec 20 mg QD (prescribed at hospital discharge)

Kapspargo Sprinkle 25 mg QD (prescribed at hospital discharge)

Brilinta 90 mg BID (prescribed at hospital discharge)

Cozaar 50 mg QD

Aricept 10 mg QD

Due to her reported dysphagia, which of AZ’s new medications can be crushed/opened for ease of administration? Select all that apply.

 A. Nitrostat

B. Ecotrin

C. Prilosec

D. Kapspargo

E. Brilinta

Answer with Rationale

Dysphagia, or swallowing difficulty, is a significant concern in progressive dementia, including AD. It can occur as a mix of both neurological changes and environmental distractions, such as loud noises from TV/radio during mealtimes, etc. Signs & symptoms of dysphagia include pain when swallowing, coughing or choking when eating or drinking, regurgitation (including nasal regurgitation), etc. Without proper intervention, consequences usually include unintended weight loss, malnutrition, as well as dehydration. It can also lead to more serious complications, such as aspiration pneumonia, which can become fatal in this patient population. Safe administration of medications for adults with swallowing impairment often involves mixing crushed tablets or contents from opened capsules with a small amount of pureed food (applesauce or pudding) or liquid (water).

Answer A is incorrect. Nitrostat is a sublingual (SL) dosage form of nitroglycerin. SL tablets cannot be chewed, crushed, or swallowed whole. Tablets must be place under tongue & allow to dissolve. Alternatively, SL tablets can be placed in the buccal pouch.

Answer B is incorrect. Ecotrin is an enteric-coated dosage form of aspirin. Crushing enteric-coated tablets may result in the drug being released too early, destroyed by stomach acid, or irritating the stomach lining. In an emergent situation where a patient may be having an acute coronary syndrome, immediate-release aspirin should always be given to ensure rapid absorption. 

Answer C is correct. Prilosec delayed-release capsules may be opened and contents mixed with 1 tablespoon of applesauce. Swallow immediately with a glass of cool water; mixture should not be chewed, crushed, warmed, or saved for future use.

Answer D is correct. Kapspargo sprinkle capsules may also be opened and contents mixed with 1 teaspoon of applesauce, pudding, yogurt, etc. to be used within 60 minutes (do not store for future use). Of note, many generic formulations of metoprolol succinate XL as well as Toprol XL are scored and can be split in half if scored but not crushed. 

Answer E is correct. Brilinta tablets may be crushed and mixed with water to create a suspension for oral use for patients unable to swallow whole. If suspension is administered orally, refill glass with water, stir and drink.

Generic/Brand: Nitroglycerin (Nitrostat), Aspirin (Ecotrin), Rosuvastatin (Crestor), Omeprazole (Prilosec), Metoprolol succinate (Kapspargo), Ticagrelor (Brilinta), Losartan (Cozaar), Donepezil (Aricept)

NAPLEX Core Competencies Covered:

• 1.2 – From patients: treatment adherence, or medication-taking behavior; chief complaint, medication history, medical history, family history, social history, lifestyle habits, socioeconomic background
• 1.5 – Signs or symptoms of medical conditions, healthy physiology, etiology of diseases, or pathophysiology
• 2.2 – Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied
• 3.5 – Drug route of administration, dosage forms, or delivery systems
• 5.5 – Instructions or techniques for drug administration