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Crushing tablets – issues to consider
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CE 21/10/2010
Crushing tablets – issues to consider
Learning objectives
After completing this activity, pharmacists should be able to:
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•
•
•
•
Identify patients who may have swallowing difficulties
List common medicines which should not be crushed
Counsel patients about the risks of crushing tablets
Advise patients, doctors and Aged Care Home staff about safety and procedures
to crush tablets
Utilise resources to provide options for medications where crushing is not
advised
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The competency standards addressed by this activity include (but may not be limited to)
3.1.2, 3.1.3, 3.1.4, 3.1.5, 3.2.1, 3.2.2, 4.2.1, 4.2.2, 4.2.3, 4.3.3, 7.1.5.
Jenny Gowan
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•
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The importance of asking questions to patients and their advocates about
swallowing difficulties must be given greater priority to prevent adverse
effects
All pharmacists when dispensing extended release oral dose forms to older
persons should check whether the patient can swallow them whole or not.
Opening a capsule or crushing a tablet before administration will in most
cases render its use to be ‘unlicensed’.
Crushing tablets to make them easier to swallow could make them less effective or cause a
greater risk of toxicity and potential adverse effects. Many older people find it difficult to
swallow medicines whole and patients or their carers in the home setting commonly crush drugs
to make them easier to take. The importance of asking questions about swallowing difficulties
linked with their medical conditions must be given greater emphasis by doctors, and pharmacists.
Causes of dysphagia (swallowing difficulty).
Age related changes are the most common cause (e.g cranial neuropathies from diabetes, stroke,
Parkinson's disease) followed by neuromuscular disorders (eg, multiple sclerosis). 1,2,3 Medical
conditions which cause oral mucosal disease eg xerostomia (especially Sjogren’s syndrome), oral
mucositis and oral candidiasis will also impact on swallowing difficulties.4 Iatrogenic causes also
contribute from drugs which cause xerostomia eg anticholinergics and diuretics, recreational
drugs eg marijuana, heroin plus agents for chemotherapy and radiation therapy to the head and
neck. Hyposalivation is a major cause of delayed and impaired swallowing.
Dysphagia should not be confused with globus sensation, which is the sensation of the constant
‘lump in the throat’ although there is no actual difficulty swallowing food. Other conditions can
cause confusion and patients present with dysphagia include dementia, depression, diabetes, other
drug- induced causes, anaemia, thyroid disorders, spinal dysfunction and urinary tract
infections.1,2 Gastrointestinal reflux disease can also impact on swallowing and in severe cases
Crushing tablets – issues to consider
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CE 21/10/2010
may lead to strictures causing severe dysphagia. These patients should be referred and may
benefit from the use of a proton pump inhibitors (PPIs).3
Referral to a speech pathologist may be of great benefit in assessment and strategies for
swallowing. Assessment of nutritional requirements is also required. Many patients suffer from
dry mouth which can make swallowing very difficult. Pharmacists can advise patients to have a
few sips of water first or to use a thicker fluid to swallow tablets with. [l1]Substances such as
apricot puree, jam, honey, custard and yoghurt can be used in most cases. Medications which
should not be taken with calcium must not be given with custard or yoghurt as per Australian
Pharmaceutical Formulary (APF) listings.5
Legal implications of crushing
In some cases the practice of altering the form of medication may result in reduced effectiveness,
a greater risk of toxicity or an unacceptable presentation in terms of taste or texture.
Pharmacists should note that, once a marketed product has been altered (eg crushed), it is
no longer being used in accordance with the manufacturer’s ‘Product Information’ and
may be considered an ‘off-label’ product.5 Prescribers and administrators of the drugs may be
liable if adverse effects occur due to crushing.
Crushing medication in Aged Care Homes is a common occurrence 6 and each medication must
be checked by the GP and pharmacist before unqualified staff crush medication. Authorisation
must be clearly stated on the drug chart with specific directions eg swallow whole with a large
glass of water or tablets to be given one by one or directions for crushing given. A consistent
approach must be used by all staff qualified or not who are giving out medications. The
pharmacist should be consulted. In many cases an alternative dose form may be able to be found
eg, liquid, lozenges, dispersible tablets, patches or inhalers or tablets dispersed in water. In some
cases medications should be discontinued and deprescribing principles used to ensure optimum
quality of life for a frail older person.
Pharmacies supplying Aged Care Homes or packing Dose Administration Aids (DAAs)
Pharmacies packing Dose Administration Aids for Aged Care homes should be given a list of
residents who require medications crushed to ensure medicines are not packed that should not be
crushed. Consideration of a fixed field on dispensing programs where the pharmacist has to
ask a consumer about allergies, adverse drug reactions (ADEs) or need to crush medications
could assist in reduction of unwanted adverse medication events. The list should be audited at
regular intervals and added to resident admissions or change of status of existing residents.
In Aged Care Homes a list of medications, which must not be crushed or chewed is usually
provided by the pharmacist, but further education is required and team work to ensure
unqualified staff giving out medicines do not crush tablets in the interest of a faster medication
round. ‘Do not crush’ labels are available.
Safety, stability and absorption concerns
In addition to the legal implications involving modifying medicines there are important safety,
stability and absorption considerations.
Occupational Health & Safety: Crushing or breaking of products that are carcinogenic or
teratogenic may cause a hazard to health workers because of aerolisation of particles eg
azathioprine, methotrexate, cyclosporin.7 Compounding pharmacies should also be aware of
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similar risks when working with tablets that may require suspending. Where possible antibiotic
mixtures are preferred instead of capsules eg amoxycillin, amoxycillin/clavulanic acid,
flucloxacillin etc .7, 8
Stability: Some drugs such as nifedipine are highly light sensitive and should be used without
delay after crushing. 9
Absorption issues: Many medications have an outer coating that can protect the stomach or
ensure slow release of the drug, and changing it can alter its effectiveness. Crushing MS Contin
(morphine, controlled release) tablets, Tegretol CR (carbamazepine controlled release) tablets
and Isoptin SR ( verpamil controlled release) tablets may result in a significant risk to patient
safety[l2]. 9-13 Modified release drugs with an outer coating, such as morphine or verapamil slow
release, can be damaged if they are broken up, causing the patient to receive the full dose quicker
than expected, and subsequently little or no dose for a period of time.
Many medications are formulated to release drug in a controlled manner over a defined dosing
period, usually 12 or 24 hours. Crushing these medications may result in an unintended
large bolus dose.
Procedures for crushing:
Guidelines for crushing medications in Aged Care Homes have been developed (5, 7, 10, 11).
[l3]Equipment for crushing medications should conform to these principles:
• permits complete recovery of powdered material
• if shared among residents it should be washed and dried after use for each resident or
liners such as patty pans used in the mortar and over the pestle.
The use of the mortar and pestle or plastic screw type crushers increases the possibility of
different types of drugs being mixed together. Nursing staff present with overuse injuries
reportedly due to the use of mortar and pestles. This has lead to the development of many metal
crushers available commercially to assist nursing staff.[l4]
When tablets and capsules have been authorised as safe to be are to be given at the same time:
• Crush tablets first
• Open the capsule and add the powder or pellets contained therein to the crushed tablets to
prevent crushing sustained release or enteric-coated pellets.
Mix with a small amount of food that the resident likes (e.g. jams, fruit purees)
Ensure that crushed tablets or capsule contents are given to the resident as soon as possible after
altering and mixing with any food or liquid to avoid reduce medication degradation and minimise
risk of medication incidents.5, 7 Similar protocols should be followed in the home.
Table 1 offers a list of some common medications which should not be crushed.
Table 1: Medicines that should not be crushed - some examples 5-14
Category
Generic name (some brand names)
Analgesics
Hydromorphone (Jurnista)
1
Morphine sulfate (Kapanol, MS Contin, MS Mono)
1
Some options
Use IR form
Use IR forms,
liquid or open
capsules and
disperse
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CE 21/10/2010
disperse
pellets or
IM/SC/IV inj
Oxycodone (OxyContin, OxyNorm)
Oxycodone/naloxone (Targin)
1
Use IR forms
or inj
Paracetamol (Panadol Back & Neck, Panadol Extend, Panadol
Osteo)
1
Use IR or
liquid
1
Use IR or oral
drops
available
1
Use oral
suspension
Tramadol (Duotram XR, GA Tramadol SR, Tramahexal SR,
Tramal SR, Tramedo SR Zydol SR)
Antibiotics
Cefaclor (Ceclor CD, Karflor CD, Keflor CD, Ozcef )
Amoxycillin & clavulanic acid (Augmentin Duo, Augmentinn Duo
forte, Clamoxyl Duo, Clamoxyl Duo forte )
1, 2
Doxycycline (Doryx, Doxsig, Doxyhexal, Doxylin,Vibramycin )
3
Erythromycin (EES, Eryc)
Nitrofurantoin (Macrodantin)
1
Use oral
suspension
Capsules may
be opened and
pellets
sprinkled
Capsules may
be opened and
pellets
sprinkled or
use liquid
preferably
3
Use
suspension
Desvenlafaxine (Pristiq)
1
Use alternative
agent
Mirtazapine (Avanza,Axit, Mirtazon)
6
Use Avanza
soltabs on
tongue
Paroxetine (Aropax,Extine, Paxtine)
1
Aropax may
be broken in
half
Venlafaxine (Efexor XR)
1
Use IR
Carbamazepine (Tegretol CR)
1
Use IR, liquid
or break
tablets in half.
Phenytoin (Dilantin)
1
Antidepressants
Antiepileptics
Use liquid or
chewable
tablets – not
bioequivalent
Use liquid or
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Valproate (Epilim)
1
Epilim
crushable
tablets
Antiglycaemic agents
Gliclazide (Diamicron MR, Glyade MR, Oziclide MR))
1
Use IR form
(Diamicron
60mg MR
may be cut in
half)
Metformin (Diabex XR, Diaformin XR, Metex XR)
1
Use IR form
Antihistamines
Dexchlorpheniramine ( Polaramine Repetabs
6mg),
Dexchlorpheniramine/pseudoephedrine (Demazin 12 hour relief
Repetabs
Fexofenadine/pseudophedrine (Telfast Decongestant)
Loratadine/pseudoephedrine (Clarinase 24 hour relief SR)
Antineoplastic & Immunomodulating agents
Altretamine (Hexalen), azathioprine (Imuran, Thioprine),
busulphan (Myleran), capecitabine (Xeloda), chlorambucil
(Leukeran) cyclophosphamide (Cycloblastin ), cyclosporin
(Neoral), levamisole (Ergamisol), etoposide (Vepesid), everolimus
(Afinitor, Ceriicam), hydroxyurea (Hydrea), idarubicin (Zavedos),
melphalan (Alkeran), mercaptopurine (Purinethol), methotrexate
(Ledertrexate, Methoblastin), temozolomide (Temodal) and others
Anti- Parkinson’s Disease
Levodopa controlled release (Sinemet CR, Madopar HBS))
Pramipexole (Sifrol ER)
Antiplatelet agents
Aspirin enteric coated (Astrix 100 capsules, Cartia)
1
Use IR or
liquid.
1
Use IR
1
1
Use IR
Use IR
6
5
Use injectable
forms if
possible. OH&S
safety issues if
crushing. Obtain
professional
advise from an
oncology
pharmacist .
1
Use IR,
1
Astrix capsules can be opened -pellets not to be crushed or chewed
Dipyridamole SR (Asasantin SR, Persantin SR)
Use Astrix tabs,
Cardiprin or
soluble aspirin .
1
Open capsule,
sprinkle pellets,
crush aspirin
hypersensitivity]
3, 5
Use syrup, or
injections
Olanzapine (Zyprexa)
3
Can be crushed
but irritation to
skin, eyes. Use
wafers
Paliperidone (Invega)
1
Use alternative
agent
Quetiapine (Seroquel XR
Cardiovascular medications
1
Antipsychotics
Chlorpromazine (Largactil) [also may cause contact
Use IR
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Carvedilol (Dilatrend)
1
Break tablets
in half
Fluvastatin ( Lescol XL80mg )
1
Use lower
strength capsule
Isosorbide mononitrate (Imdur, Duride, Imtrate, Isomonit,
Monodur)
1
Break 60mg
tablets in half,
or use patches
1
Use IR
1
Use another
Calcium
Channel
Blocker[l5]
NB 120mg tablets must not be broken in half; 60mg are scored and slow release
properties are not affected
Indapamide 1.5mg (Dapa-Tabs, Natrilix SR)
Felodipine (Felodur SR, Plendil ER, ; with ramipril - Triasyn)
Metoprolol ( Toprol -XL)
1
Use IR
Nifedipine (Adalat, Adalat Oros, Adefin, Adefin XR, Nifecard,
Nifehexal, Nyefax)
Nimodipine (Nimotop)
2
Use IR
2
Use infusion
Verapamil (Anpec SR, Cordilox SR, Isoptin SR,, Veracaps SR)
1
Glyceryl trinitrate( GTN) sublingual (Anginine)
Isosorbide dinitrate (Isordil Sublingual 5mg )
2
Electrolyte
Potassium chloride SR (DuroK, Slow-K, Span-K)
3
Use IR
Use GTN
spray
Use
Chlorvescent
[l6]
Effervescent
tabs
Endocrinology
Alendronate (Alendro, Fosamax, Fosamax Plus Once weekly,
Fosamax Plus D-Cal
3
Suggest
ceasing
Clodronate ( Bonefos capules, tablets )
[Capsules must be swallowed whole, tablets may be halved]
3
Uses
alternative
Risedronate (Actonel, Actonel Combi, Actonel Combi D)
3
Consider
dispersal in
water
6
Use
suppositories .
enemas
Mesalazine (Mesasal, Pentasa, Salofalk),
4
Use granulesdisperse
Sulfasalazine (Pyralin EN, Salazopyrin EN)
4
[Whole risedronate tablets may be dispersed in 70mL water. Rinse cup & follow
with 125mL water. Patient to remain upright 30 minutes after dose .11]
Gastrointestinal
Docusate (Coloxyl), Docusate & senna Coloxyl & senna)
[frequently crushed if acceptable to patient]
Use non EC
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form
Proton Pump Inhibitors (PPI)
Esomeprazole (Nexium)
2
Disperse in ½
glass of water
Lansoprazole (Zoton, Zoton FasTabs)
2
Use Fastabs
Place on
tongue to
disperse.
Lanzoprazole (APO-Lanzoprazole)
2
Orally
disintegrating
Lanzoprozole (Lanzopran)
2
Open capsule
and sprinkle
granules on
apple sauce,
strained pears,
cottage cheese
or yoghurt
Omeprazole (Acimax, Losec, Omepral and others). [Meprazole is
2
Disperse in
water
Pantoprazole (Somac)
2
Use granules
Pantoprazole (APO-Pantoprazole, Chemmart pantoprazole,
Gastenz, Panto, Pantoloc, Pantoprazole Sandoz EC,
Pantoprazole GA, Salpraz)
2
Change to
another PPI
or use Somac
granules
Rabeprazole (Pariet)
2
Change to
another PPI
Iron products
Iron containing products (Ferro F, Ferrogradumet, Fergon, FGF,
Fefol)
3
Use elixir or
iron injections
1
1
3
Use IR form
or a different
NSAID if not
available or
suppositories.
not dispersible] Probitor capsules can be opened and pellets taken with fruit
juice or yoghurt – pellets must not be crushed
Non-steroidal anti-inflammatory agents (NSAIDs)
Ketoprofen Sustained release (Orudis SR, Oruvail SR)
Naproxen Sustained release (Naprosyn SR, Proxen SR)
Diclofenac enteric coated (Diclohexal, Dinac, Fenac, Voltaren)
Diclofenac and misoprostol - Arthrotec,
Other NSAIDs may cause an irritant effect
Pancreatic supplements
Pancrease, Cotazym, Creon
4
Respiratory
Theophylline controlled release (Nuelin SR, Theodur)
1
Some can be
opened and
taken with
liquid with
food
Some can be
opened and
taken with
Crushing tablets – issues to consider
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CE 21/10/2010
liquid with
food
Miscellaneous
Bupropion (Clorprax, Prexaton, Zyban SR)
1
Use another
antismoking
product
Darifenacin (Enablex Prolonged release)
2
Use
alternative
product
Finasteride (Proscar)
5
Teratogenic
Isotretinoin (Roaccutane)
3&5
Teratogenic
Methylphenidate (Concerta Extended Release,
Ritalin LA))
1
Sprinkle on
soft food
Pseudoephedrine SR (Sudafed 12 hour relief)
6
Tamsulosin (Flomaxtra)
1
No alternative
Zolpidem (Stilnox CR)
1
Use IR
Legend
•
•
Use IR form
1. Altered absorption characteristics
2. Medication instability
3. Local irritant effect
4. Failure to reach site of action
5. Occupation health and safety
6. Unacceptable/undisguisable taste
IR = immediate release; EC= enteric coated
NB List of brands and medications is not exhaustive. Some tablets may be cut in half but
not crushed. Check with Product information before recommending crushing, cutting or
dispersing and to establish the equivalency of dose forms eg when changing from a solid
dose form to a liquid, or different bioavailability. 9
For patients with percutaneous endoscopic gastronomy (PEG) tubes taste or texture are
not relevant, but different protocols must be followed for administration.13,15
Sources of further information
In Aged Care Homes a list of medications, which must not be crushed or chewed is usually
provided by supply pharmacists, often prepared by reputable companies specialising in DAAs.
The APF21 offers very useful guidelines for modification of oral formulations with specific
information included in the Clinical monographs.5 Product monographs, available in eMIMs offer
information as to products which should not be crushed.9 A very comprehensive practical guide,
low cost and regularly updated, is available electronically from Marianne Vincent at
Woollongong Hospital Pharmacy ([email protected]).11 This guide
also has a comprehensive section on solid dose forms that are dispersible in water. 11
References:
1. Beers M, Berkow R eds. The Merck Manual (18th ed). Merck Research Laboratories, 2007
available www.merck.com
2. Murtagh J. General Practice 2007 McGraw-Hill NSW
Crushing tablets – issues to consider
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3. Therapeutic Guidelines. Gastrointestinal Version 4. Therapeutic Guidelines Ltd Melbourne,
2006 in eTG 2010
4. Therapeutic Guidelines. Oral and Dental Version 1. Therapeutic Guidelines Ltd Melbourne,
2007 in eTG 2010
5. Sansom LN (Ed) . Australian Pharmaceutical Formulary and Handbook 21st edition,
Pharmaceutical Society of Australia, Canberra, 2009.
6. Nissen L, Haywood A, Steadman KJ. Solid Medication Dosage Form Modification at the
Bedside and in the Pharmacy of Queensland Hospitals J Pharm Pract Res 2009; 39: 129-34.
7. Alteration of Medication Dose Forms Project University of South Australia, Guidelines and
standard operating procedures for altering medication dose forms - A resource for staff in
residential aged care facilities. 2002, Canberra: APAC.
8. Haywood A, Glass B. Dosage form modification for the elderly. Australian Pharmacist 2009;
28 (11): 960-964.
9. eMIMs, CMPMedica Australia Pty Ltd September 2010.
10. Australian Pharmaceutical Advisory Council, Guidelines for medication management in
residential aged care facilities (3rd edition). 2002, Canberra: Commonwealth Department of
Health and Ageing.
11. Vincent Marianne. Do Not Crush Guide. Wollongong Hospital 2010
12. Rossi S. Australian Medicines Handbook, Adelaide, Australian Medicines Handbook Pty
Ltd, 2010
13. Rossi S. Drug Choice Companion: Aged Care, Adelaide, Australian Medicines Handbook Pty
Ltd, 2010
14. Simpson C. Crushing medications: an emerging guideline. Australian Nursing Journal 2005;
13 (1) Clinical Update 84.
15. North West Melbourne Division of General practice. GP Residential and aged care kit.
Impetus (previously NWMDGP) . Department of Health and Ageing Victoria 2004.
Questions based on the above article:
For each question please indicate the INCORRECT statement.
1. Indicate the incorrect statement:
(a) Patients with Parkinson’s disease may have difficulty in swallowing tablets.
(b) People taking drugs such as oxybutynin may get xerostomia and have swallowing difficulties.
(c) People with dementia should always have their tablets crushed.*
(d) Oral disorders such as oral candidiasis may cause difficulty in swallowing.
2. Indicate the incorrect answer:
(a) For people with swallowing difficulties if safe to crush, all medicines can be taken with
custard or yoghurt which makes it easier to swallow.
(b) For administration of medicines to people with dysphagia it is safer for staff to use
amoxycillin mixtures rather than sprinkle the contents of the capsule on soft food.
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CE 21/10/2010
(c) Rather than using a paracetamol mixture, paracetamol 500mg tablets can be crushed.
(d) OxyNorm® capsules although immediate release must not be opened, crushed or chewed.
3. Indicate the incorrect answer:
(a) Panadol Osteo® is a biphasic tablet and must not be crushed.
b) Imdur® tablets 60mg can be cut in half.
(c) Dilatrend tablets can be broken in half.
(d) Coloxyl & senna has a bitter taste and must not be crushed due to change in absorption.*
4. Indicate the incorrect answer
(a) Phenytoin liquid can be substituted for phenytoin capsules but dose adjustment may be
required.
(b) Some brands of morphine sulfate capsules can be opened and the pellets sprinkled on soft
food.
(c). All PPIs can be dispersed in water, as long as the pellets are not chewed as per the Product
Information.
(d) Calcium citrate tablets can be crushed.
5. Indicate the incorrect statement
(a) Colecalciferol is available in a tablet that can be crushed.
(b) Colecalciferol is available in adult dose form liquid that can be given via dropper.
(c) Tramadol is available in an adult dose form that can be given by dropper.
(d) Medications that can safely be crushed should always be given one by one.