Pharmacological Treatment of Dysphagia in Stroke

Abstract

The pharynx is important for a normal swallow and it has been suggested that pharmacological agents may play a role in the management of pharyngeal dysphagia, but none have been formally evaluated. A pilot double-blind, placebo-controlled study was undertaken in 17 hospitalized patients with persistent dysphagia 2 weeks after stroke. Patients were randomized to treatment with slow-release nifedipine 30 mg orally (n = 8) or placebo (n = 9) following specialist swallowing assessment and videofluoroscopy to exclude severe dysphagia. Videofluoroscopy was repeated after 4 weeks of treatment. Fourteen patients (active 6, placebo 8) completed the study. Two patients died (active 1, placebo 1) and 1 patient in the active group had to be withdrawn because of progressive heart failure. Initial assessment showed impairment in the pharyngeal phase with delayed triggering of swallow, poor laryngeal elevation, and prolonged pharyngeal transit times in all patients. Silent aspiration was seen in 4 patients (active 2, placebo 2). Improvement in swallowing was seen in 8 patients (active 5, placebo 3) at the end of 4 weeks. There were significant changes in the pharyngeal transit time (mean -1.34 second; 95% C.I. -2.56, -0.11) and swallow delay (mean -1.91 seconds; 95% C.I. -3.58, -0.24) in the active group suggesting improvement in the initiation of pharyngeal contractions and reduction in the time taken for the bolus to transverse the pharynx. A similar change was not seen in the placebo group. It is suggested that pharmacological agents such as nifedipine may have a role in the management of stroke-related dysphagia and merit further investigation.

Dysphagia in Aging

“…A small pilot study (n = 17), double-blind, placebo-controlled reported that nifedipine 30 mg orally resulted in improvement in swallowing in 8 patients (5 medication, 3 placebo) at the end of 4 weeks. 174 The exact mechanism of action resulting in improved swallow in these patients remains speculative. For those with permanently impaired swallowing, a feeding gastrostomy or jejunostomy may be the only option and should not be delayed if nutrition is becoming compromised.…”

Evidence-based stroke rehabilitation: an expanded guidance document from the european stroke organisation (ESO) guidelines for management of ischaemic stroke and transient ischaemic attack 2008

“…In those studies that have addressed this issue, quality of life was not improved by PEG (143). The use of calcium channel blockers to aid swallow has no convincing evidence base (144).…”

Swallowing and Stroke

“…Those randomised to the treatment arm demonstrated improvements in mean pharyngeal transit times (–1.34 s, 95% CI –2.56, –0.11) and mean swallow delay (–1.91 s, 95% CI –3.58, –0.24) [79]. It is unclear whether this was a local effect (pharyngeal muscle being striated) or a global improvement in neurological function [76]. …”

“…Anecdotal reports have suggested that both cisapride and nifedipine may aid those with mild-to-moderate dysphagia. Perez et al [76]studied 17 patients in a randomised placebo-controlled study of moderately dysphagic patients. At 2 weeks following stroke onset, those patients with difficulties swallowing, but able to take things orally, were randomised between a treatment arm (nifedipine LA 30 mg once daily) and placebo.…”

“…Various workers have examined the use of palatal devices (orthoses) [74]and electrical stimulation of the larynx [75], but few studies have examined the recovery of the swallow in the acute phase. Two studies have attempted to do so – one pharmacologically [76]and one using TCMS [77]. …”