Speech Buff Blog - Summaries of Peer- Reviewed Articles

***Disclaimer: No medical advice is provided here. This article is intended for informational and educational purposes only. Never make changes to your medications without first consulting your doctor or another primary care provider.***

Is my medication causing my difficulty swallowing?  

Your medication may be associated with your difficulty swallowing. Dysphagia, the medical term for swallowing difficulty, could be a side effect of your medicine, could be associated with the intended actions of your medication, or could be associated with swelling of the esophagus known as esophagitis. These medication effects, as well as changes in taste and smell, are known to affect how much a person eats, drinks, or swallows. (2) 

Signs and symptoms of Dysphagia and Medication-Induced Dysphagia

The signs and symptoms of swallowing difficulty that people should look out for before, during, or after swallowing are the following: losing food out of the front of the mouth, difficulty starting the swallow, pocketing food, oral residue, coughing, throat pain (pharyngitis or globus sensation), pain in the esophagus (esophagitis or globus sensation), pain when swallowing (odynophagia) watery eyes, choking, coughing, difficulty swallowing saliva, a feeling of food being stuck somewhere in the throat or esophagus (globus sensation), food being stuck at the entrance of the stomach, constipation, vomiting or regurgitation, waking up with a burning sensation in your throat, and gastroesophageal reflux disease (which may feel like heartburn).   Signs and symptoms of dysphagia may not be limited to the ones listed above.  

Trouble swallowing food and drink can be isolating, frightening, and life-threatening. Be sure to speak with your primary care provider if you are experiencing any of the signs and symptoms listed above, or if you think you may be having trouble swallowing for other reasons.

Dysphagia may not be listed as a side effect

Dysphagia may not be one of the side effects listed for medications. It also may not be included in the information sources that pharmacists access. However, other listed side effects of medications such as reduced general alertness, changes in awareness, feeling tired, dry mouth (xerostomia), gastrointestinal movement problems such as esophageal achalasia, (difficulty opening the muscle that allows food from the esophagus into the stomach) constipation, heartburn, and throat pain may also impact a person’s ability to swallow. (2) 

“Over 60% of medications prescribed in Gallagher and Naidoo’s rehabilitation/ extended care setting were identified as having gastrointestinal effects, including reflux and pharyngitis,” clinical signs that can lead to dysphagia. (2) Psychotropics, drugs that affect mental state, may increase confusion or could be associated with sedation. (3) Feinberg stated that drugs affecting confusion and attention have a profound effect on voluntary swallowing, especially with regard to oral preparation and transit. (3) 

Important Note

Clinicians should strive to reduce or remove medications that affect mental status. Medications associated with confusion “should be identified before treating patients with dysphagia.” (3) 

Drugs that lead to weight loss and coughing

Other medications may lead to weight loss and coughing, two of the “warning signs” of dysphagia. “Angiotensin-converting-enzyme (ACE) inhibitors may induce a cough or excessive throat clearing in as many as 10% of patients.” (2)

Extrapyramidal Symptoms (EPS) and Medication-Induced Dysphagia

Some of the drugs that contribute to swallowing difficulty have side effects known as extrapyramidal symptoms (EPS). EPS reactions to medications may include “opisthotonus (muscle spasm causing backward arching of the head, neck, and spine); trismus (lockjaw); torticollis (contraction of the neck muscles that causes the head to twist to one side); retrocollis (repetitive neck contractions that cause neck extension); aching and numbness of the limbs; motor restlessness; oculogyric crisis (spasmodic movement of the eyeball(s) into a fixed position); hyperreflexia (overactive reflexes); dystonia (involuntary muscle contraction); protrusion, discoloration, aching and rounding of the tongue; tonic spasms (brief, painful, unilateral muscle contractions) of the masticatory muscles; tight feeling in the throat; slurred speech; dysphagia [oral, oropharyngeal, laryngeal, pharyngeal, pharyngoesophageal, and esophageal]; akathisia (inability to remain still); dyskinesia (involuntary writhing movement of the face, arms, legs or trunk); parkinsonism (slow movement, rigidity, and tremor); and ataxia (poor coordination of voluntary and involuntary movements).” (4)

Classes of Medications that Cause Xerostomia and Dysphagia

Antiparkinsonian agents, antidepressants, antipsychotics, antihistamines, analgesics, tranquilizers, and antihypertensives are classes of the over 400 medications that the National Institute of Dental and Craniofacial Research found that cause dry mouth in 2006. (2) The physician’s desk reference (PDR) lists at least 160 drugs with dysphagia as an adverse side effect. (3) Some of these medication classes are antimicrobials, anti-hypertensives, analgesics, and anti-parkinsonian medicines. (3) 

Antidepressants and Dysphagia

Antidepressants such as Celexa (citalopram), Effexor (venlafaxine), Etrafon (amitriptyline & perphenazine), Luvox (fluvoxamine), Paxil (paroxetine), Prozac (fluoxetine), Serzone (nefazodone), Wellbutrin (bupropion), and Zoloft (sertraline) are cited by the PDR as listing dysphagia as an adverse side effect. Rooney and Johnson (2000) found that Serzone or Wellbutrin were “better choices in the depressed patient with concomitant dysphagia.” (3)

Antipsychotic Medications and Dysphagia

Antipsychotic medications often have side effects that are associated with movement difficulties such as swallowing problems, esophageal complications such as difficulty with peristalsis (poor movement of the esophagus), pulmonary aspiration (breathing in materials other than air such as food, saliva, liquids, or stomach contents), and aspiration pneumonia (lung infection caused by aspiration). (1) Complications due to swallowing difficulty and aspiration include but are not limited to death, pneumonia, choking, weight loss, dehydration, malnutrition, and noncompliance with medications. (1) Antipsychotics such as Clozaril (clozapine), Risperdal (risperidone), Seroquel (quetiapine), and Zyprexa (olanzapine) are specifically cited by the PDR as listing dysphagia as an adverse side effect. (3) 

Other side effects of antipsychotics include xerostomia, appetite alterations, tardive dyskinesia (rhythmic, involuntary movements of mouth and facial muscles)...glucose intolerance, inattention, [and] taste alterations.” (3) “A dose-related association between antipsychotics and dysphagia has been well established.” (5) According to Rooney and Johnson (2000), Risperdal (risperidone) and Zyprexa (olanzapine) “should be avoided in the patient with dysphagia.” The benefits of any drugs prescribed for a patient, especially an elderly patient or a patient with dementia, should be weighed against side effects that may lead to dysphagia. (3)

Medication-Induced Dysphagia Treatment - Case Reports

Dysphagia treatment for medication-related swallowing difficulties may result in the reversal of the negative side effects.  Information from case reports provides suggestions for medication changes that may resolve swallowing trouble brought on by new or current medications. Keep in mind that these symptoms may develop even after taking a medication for longer periods of time with good tolerance to that medication. 

Following a 62-year-old woman’s switch from olanzapine to aripiprazole, her swallowing difficulty resolved along with an improvement in her appetite. (1) After a 65-year-old man’s development of drooling and resting tremors following 10 years of treatment with 50 mg of risperidone every two weeks, he presented with gradually worsening symptoms that led to 3 hospitalizations for aspiration pneumonia over the course of 2 months. (5) After switching the man from risperidone to 400 mg/day of quetiapine, his symptoms demonstrated improvement during the next three months. He was ultimately advanced to a regular diet without recurring pneumonia. (5) 

Another case report provided information on a 76-year-old man with Alzheimer's dementia who was treated with risperidone for irritability and aggression. He presented with choking along with abnormal oral and pharyngeal swallowing during a modified barium swallow study, a video X-ray swallowing test. Olanzapine was substituted for risperidone, and the patient’s swallowing difficulties improved. (1)  

Logemann (1998) found that antidepressants may worsen dysphagia severity in stroke patients. The usage of thioridazine and lithium in patients with schizophrenia has also been implicated in dysphagia. (Ruschena, et. al, 2003) Treatment with thioridazine should include “increased monitoring for the deterioration of swallowing and reflux prevention reflexes.” (Ruschena, et. al, 2003) Also, Antidepressants such as “amitriptyline and imipramine, exert significant blocking on Alpha-1 or serotonin receptors, and cause dysarthria (imprecise speech) with concomitant (coexisting) dysphagia.” (3)  

Medication-induced dysphagia treatment with anti-parkinsonian drugs

Dysphagia treatment for the EPS symptoms associated with medications may include possible control with anti-parkinsonian drugs such as benztropine mesylate in combination with reducing the dosage or reducing the dosage alone. (3) Dysphagia treatment with anticholinergics or amantadine has been reported to successfully treat medicine-related parkinsonism, although there may be an equal risk of aspiration, but not of dysphagia when using first or second-generation antipsychotics to treat these patients. (5)

Tardive Dyskinesia and Medication-Induced Dysphagia

EPS-related complications may continue after treatment is discontinued. Tardive dyskinesia (TD) is one of these complications.  Attempts at treating dysphagia with anti-parkinsonian drugs are ineffective at treating TD. (3) Increasing antipsychotic dosage or switching to a different antipsychotic medication can simply conceal developing TD. If medication is discontinued when the early signs of TD appear, it may not fully develop. (3)  

Medication-Induced Dysphagia Swallowing Strategies

Although there isn’t any evidence at this time for the usage of swallowing strategies as dysphagia treatment for this population, swallowing strategies used for Parkinson’s Disease (PD) may be helpful because of the similarities in the swallowing trouble caused by these medications and the swallowing deficits in PD. Thickening liquids, eating upright, using a chin tuck before and during swallowing, and encouraging control of bolus sizes (small bites, small sips, use of bolus control devices) may help to reduce aspiration in this population.

Polypharmacy and Dysphagia

Polypharmacy (taking many medications) increases the risk of drug interactions exponentially. The older population is more vulnerable to drug interactions due to changes in the body’s ability to metabolize (break down) medications resulting from changes in tissue sensitivity as well as chronic diseases. (2) Collaboration between pharmacists, doctors, nurse practitioners, nurses, speech therapists, and other health professionals is necessary to reduce the number of medications taken by patients and to evaluate medications for side effects when an older patient begins to present with dysphagia.

Xerostomia, Drooling, and Dysphagia

Xerostomia can cause reduced intake of dry, crunchy, or sticky foods. It can affect sensory perception, chewing, comfort while eating, swallow initiation, lubrication of the bolus (food ball), and amount of intake (2). Saliva assists with stomach acid neutralization so reduced saliva may cause an increase in stomach acidity and reflux (heartburn) into the esophagus. (2) Sjogren’s syndrome, bone marrow transplants, endocrine disorders, nutritional deficiencies, and trauma to the head and neck area may cause dry mouth (2). Radiation during [oropharyngeal cancer or other head and neck] cancer treatments can also cause temporary or permanent damage to glands that produce saliva (2). Alternatively, according to Stewart 2018, Medications causing excessive drooling can also lead to aspiration, problems swallowing, and aspiration pneumonia. (5) 

Positive Effects of Medications on Swallowing

Some medications have been found to have positive side effects on swallowing, as well. The drug atropine has been reported to reduce drooling (Logemann, 1998). Monte, et. al, 2004 found that Parkinson’s patients taking higher doses of levodopa demonstrated improved oropharyngeal swallowing efficiency during videofluoroscopy (an X-ray swallowing test). Fonda, et. al, 1995 found that adjusting the timing of levodopa administration improved a patient’s dysphagia. They found that administering levodopa one hour before the subject’s meals “positively affected the patient’s total swallow time for both liquids and solids, lessened the laryngeal tremor noted during the swallow, reduced the incidence of laryngeal penetration on solids and liquids, and eliminated aspiration on liquids.” (2)

 Thank you! I hope this helps with your practice!

Thank you for reading. If you are a medical professional or anyone else who finds incorrect or misrepresented information in this article, please write to me with corrections and references at speechbuff@gmail.com.  

***Disclaimer: No medical advice is provided. This article is intended for informational and educational purposes only. Never make changes to your medications without first consulting with your doctor or another primary care provider.***

References

1. Crouse, E. L., Alastanos, J. N., Bozymski, K. M., & Toscano, R. A. (2017). Dysphagia with second-generation antipsychotics: A case report and review of the literature. Mental Health Clinician, 7(2), 56–64. https://doi.org/10.9740/mhc.2017.03.056 

2. Gallagher, L. (2010). The impact of prescribed medication on swallowing: An overview. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 19(4), 98–102. https://doi.org/10.1044/sasd19.4.98 

3. Rooney, J. J. (2000). Professional practice: Potentiation of the dysphagia processes through psychotropic use in the long-term care facility. Perspectives on Swallowing and Swallowing Disorders (Dysphagia), 9(3), 4–6. https://doi.org/10.1044/sasd9.3.4 

4. Sifton, David W. (Ed.) (2000). The physicians' desk reference (54thed.). Montvale, NJ: Medical Economics Co.

5. Stewart, J. T. (2018). Covert dysphagia and recurrent pneumonia related to antipsychotic treatment. Journal of Psychiatry and Neuroscience, 43(2), 143–144. https://doi.org/10.1503/jpn.170147