Strattera ® (atomoxetine)

Strattera® (atomoxetine): Swallowing of capsules

Difficulty swallowing can be a barrier to medication compliance in children. Suggestions from studies are available that evaluated behavior and techniques to assist in swallowing capsules.

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Behaviour and Techniques to assist in swallowing of Capsules

Difficulty swallowing can be a barrier to medication compliance with the pediatric population. Suggestions from studies that evaluated behavior and techniques to assist in swallowing capsules included leaning the head slightly forward rather than back and the use of small sweet items to graduate to swallowing larger capsules.1-3

Swallowing of Capsules

One barrier to medication adherence in pediatric populations is difficulty swallowing pills. Some children do not have the prerequisite skills for effective pill swallowing (sustained attention or oral motor abilities), while others may have developed conditioned anxiety associated with repeated negative experiences (aversive taste or gagging) when trying to swallow pills.1

Studies have established that it is easier to swallow a capsule with the head leaned slightly forward rather than back.2,3 Capsules whose specific gravity usually is less than 1 will float on water. It is suggested that if patients tilt their heads back while swallowing capsules, they will swallow the water first, leaving the capsule in the mouth or lodged in the throat. In contrast, tilting the head forward will help to transport the floating capsule to the hypopharynx and the esophagus, thus increasing the probability of successful swallowing.3

Behavioral techniques have been used successfully to teach children with chronic medical conditions and developmental disabilities to swallow pills (Behavioral Techniques That Have Been Used Successfully).1,4-6

Behavioral Techniques That Have Been Used Successfully1

Behavioral Technique

Description

Verbal instruction

Verbal prompting to open the mouth wide and stick out the tongue. The adult then places the capsule on the back of the child’s tongue, immediately offering a preferred drink and verbally prompting the child to drink and swallow.

Positive reinforcement

Let the child pick a reward (eg, a toy from a prize bag) to earn as a reward for compliance. The child is informed that he/she will receive the selected toy once the capsule has been swallowed. Another example of a reward is giving the child a sticker when he/she has succeeded.

Verbal praise

The child should be given enthusiastic verbal praise (“You did it!”) if the capsule has been swallowed successfully, together with their reward (toy/sticker).

Corrective feedback

If the child only partly succeeded (ie, accepted the pill but did not swallow), he/she should still be praised for their efforts. Tell the child what he/she did well and inform them of what needs to be done in order to get their reward.

Consistent time, location, and caregiver

It is important to develop and practice a medication administering routine that is consistent and thus becomes familiar to the child.

A study involving 8 children with attention deficit/hyperactivity disorder or autistic disorder evaluated the use of the behavioral training techniques described above to increase cooperation with pill swallowing. Cake decorations of gradually increasing sizes were used as mock pills. The children were presented initially with the smallest size to reduce any behavioral distress from past experiences. The process

  • created a neutral, safe environment for learning
  • allowed the child to experience success in swallowing the smallest candy size, and
  • facilitated positive behavioral momentum for remaining trials when larger sizes would be introduced.1

Another study evaluated the effectiveness of a capsule swallowing training curriculum specifically developed to promote acceptance of oral medication.5 This study involved the participation of 4 multi-handicapped children, each requiring daily intake of oral medication. Training consisted of

  • verbal instruction
  • demonstration
  • reinforcement for swallowing sweets/capsules progressively larger in size
  • ignoring mildly inappropriate behavior, and
  • gradually providing less guidance and structure.5

In each case, the curriculum produced routine, independent swallowing of prescribed capsules/tablets.5

Label Information - Warning to not open the Capsule

The capsules are not intended to be opened.7

Atomoxetine is an ocular irritant. In the event of the capsules content coming in contact with the eye, the affected eye should be flushed immediately with water, and medical advice obtained. Hands and any potentially contaminated surfaces should be washed as soon as possible. 7

Strattera oral solution

Strattera 4 mg/ml oral solution might be an alternative option of administration for patients with difficulties swalllowing capsules.

References

1Beck MH, Cataldo M, Slifer KJ, et al. Teaching children with attention deficit hyperactivity disorder (ADHD) and autistic disorder (AD) how to swallow pills. Clin Pediatr. 2005;44(6):515-526. http://dx.doi.org/10.1177/000992280504400608

2Macleod S. Swallowing of capsules. Australas Psychiatry. 2005;13(1):86-87. http://dx.doi.org/10.1111/j.1440-1665.2005.02157_4.x

3Schiele JT, Quinzler R, Klimm HD, et al. Difficulties swallowing solid oral dosage forms in a general practice population: prevalence, causes, and relationship to dosage forms. Eur J Clin Pharmacol. 2013;69(4):937-948. http://dx.doi.org/10.1007/s00228-012-1417-0

4Pelco LE, Kissel RC, Parrish JM, Miltenberger RG. Behavioral management of oral medication administration difficulties among children: a review of literature with case illustrations. J Dev Behav Pediatr. 1987;8(2):90-96. http://dx.doi.org/10.1097/00004703-198704000-00005

5Babbitt RL, Parrish JM, Brierley PE, Kohr MA. Teaching developmentally disabled children with chronic illness to swallow prescribed capsules. J Dev Behav Pediatr. 1991;12(4):229-235. http://dx.doi.org/10.1097/00004703-199108000-00003

6Ghuman JK, Cataldo MD, Beck MH, Slifer KJ. Behavioral training for pill-swallowing difficulties in young children with autistic disorder. J Child Adolesc Psychopharmacol. 2004;14(4):601-611. http://dx.doi.org/10.1089/cap.2004.14.601

7Strattera Summary of Product Characteristics

Date of Last Review: November 20, 2019


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