Download medication administration in patients with swallowing difficulties

MEDICATION ADMINISTRATION IN PATIENTS WITH SWALLOWING DIFFICULTIES/DYSPHAGIA
Preference - Crush tablets or open capsules first; then use licensed and therapeutic alternative after this and special use should be last resort due to cost
implications
TO SEARCH:HOLD DOWN CONTROL AND PRESS F THEN TYPE ITEM REQUIRED. For more information please ring pharmacy or ring
manufacturers.
SPECIAL
THERAPEUTIC
LICENSED
DETAILS
CAN INJECTION
DRUG
CRUSH
AVAILABL
ALTERNATIVE?
BE USED ORALLY? ALTERNATIVE?
OR
E (PRICE)
OPEN?
(£)
(CORRECT
AS JUNE
2011)
ABACAVIR
Yes
Manufacturer states no reason
why crushing tablets would
create stability concerns as long
as administered immediately.
Liquid available
ACARBOSE
Yes
Can chew tablets with first
mouthful of food. Tablets do
not disperse easily in water but
require gentle agitation for
approx 5 minutes. Suspension
can be flushed down 8Fr NG
tube
Consider changing to
insulin if appropriate
ACEBUTOLOL
Yes
ACETAZOLAMIDE
Non-MR can
be dispersed
in water
ACENOCOUMAROL
Yes
Change to other betablocker available in liquid
if absolutely necessary
If taking MR capsules convert
to normal release. These
disintegrate quickly in 10ml
water which settles quickly and
flushes down 8Fr NG tube
without blockage but rinse all
through to ensure total dose
given
Disperse in 10ml water within 5
minuts to give dispersion which
flushes via 8Fr NG tube without
blockage
Injection can be taken
orally or enterally – see
handbook. May be stored
in fridge for up to 24
hours
600mg tablets
(100) £21
Tablets are effervescent 600mg Injection solution diluted
to 50mg/ml can be given
BUT special
orally or enterally. Very
bitter. blackcurrant
Orange syrup, orange
juice or coke used
ACETYLCYSTEINE
See over
ACICLOVIR
Dispersible
tablets
ACITRETIN
Open
capsules
immediately
before use
and take
contents with
food
No
Not water-soluble and are
degraded by light. WARNING:
not to be handed by women of
childbearing potential.
Syrup available
One-Alpha injection
administered orally or via
feeding tube
Yes - injection
ALFUZOSIN
Non-MR can
be dispersed
in water
Convert MR to standard release
(commence at 2.5mg tds as risk
of hypotension)
ALIMEMAZINE
Yes
ALLOPURINOL
Yes
Blue film-coating can be
washed off tablets to make
them easy to crush. Disperse in
1-2 minutes
Disperse in 10ml water for 5
minutes to form dispersion that
flushes down 8FR NG tube
without blockage
ALVERINE
Yes
AMANTADINE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
Syrup available
AMILORIDE
Yes
Syrup available
AMINOPHYLINE
Do not crush
MR
ALFACALCIDOL
Syrup available
5mg/5ml x
75ml £59
Syrup available
Convert to mebeverine if
necessary
Powder has anaesthetic effect
on lips and oral mucosa
Theophylline liquid
AMIODARONE
Yes
Very bitter taste – mix with fruit
juice or jam if neccessary
100mg/5mg x
100 ml £76
AMITRIPTYLINE
Yes
Bitter taste. MR capsules can be
emptied out but swallow
granules whole. Tablets do not
disperse but can be crushed
and disperse in 10ml water.
Syrup available
AMLODIPINE
Yes
Give immediately as light
sensitive. Disperse in 10ml of
water in 2 minutes to give
dispersion that settles – flushes
down an 8Fr NG tube without
blockage.
Syrup available
ANASTROZOLE
Yes
Can be chewed if possible.
WARNING: not to be handed by
women of childbearing
potential. Tablets disperse in
10ml water to give clear
dispersion that lfushes down
8Fr NG tube without blockage.
ARTHROTEC®
No
ASASANTIN RETARD
No
ASCORBIC ACID
Yes
NSAID plus gastro
protection
Dispersible aspirin and
liquid
dipyridamole.Granules
may be given whole, not
chewed NB may clog
tube.
ATOMOXETINE
Yes
ATENOLOL
Yes
ATORVASTATIN
Yes
Open capsules
Syrup available
Rinse residual tablet material
down NG/PEG tube (does not
disperse completely). Be aware
that the insoluble powder may
cause blockage. Or can
sprinkle on cold, soft food.
ATROPINE
Injection may be given
orally and enterally
50mg/5ml x
150ml £12
AZATHIOPRINE
Yes but…
Tablet can be crushed but
should not be done on ward
due to risk of exposure
AZITHROMYCIN
No
Syrup available. Problems
with feeds
BACLOFEN
Yes
Syrup available
BALSALAZIDE
No
Manufacturer advises that the
capsules are NOT opened as
the drug contains an AZO (DYE)BOND and can badly stain skin,
teeth etc that it comes into
contact with
BENDROFLUMETHIAZIDE
Yes
Disperse in 2 minutes when
placed in 10ml water & give
fine dispersion
BENZTROPINE
BETAHISTINE
Use alternative treatment
if necessary e.g.
sulasalazine – see liquid
available
Syrup available
Injection may be given
orally and enterally
although manufacturer
cannot recommend.
Yes
When crushed finely the
powder mixes easily with water
and flushes down 8Fr NG tube
Other thiazides –
Indapamide. Loop
diuretics – furosmide and
bumetanide oral solutions
available
BEZAFIBRATE
Yes if Non-MR Risk of tube blockage with MR –
change to non-MR and can be
dispersed in 10ml water and
shake for 5 minutes to form
coarse dispersion that may
block fine-bore tubes but can
be flushed through 8Fr NG tube
BICULTAMIDE
Very insoluble Crush finely and suspend in
water. . WARNING: not to be
handed by women of
childbearing potential
BISACODYL
No
Do not crush EC – irritant effect
on stomach
BISOPROLOL
Yes
Risk of tube blockage due to
film coating. But do disintegrate
rapidly in 10ml water to form
fins suspension that flushes
down 8Fr NG tube without
blockage.
BROMOCRIPTINE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
NB Parlodel® tablets are
autocatalytic and will begin to
disintegrate as soon as they are
broken up- administer
immediately. Mix contents with
water when powder if wetted;
forms fine dispersion that
fushes easily via 8Fr NG tube
without blockage
Suppositories available
Atenolol liquid
BUDESONIDE
Yes
Opening capsules may cause
the drug to be released in the
wrong part of the intestine. Do
not open MR capsules. May mix
granules with fruit juice.
Granules may stick to the side
of enteral feeding tube.
BUMETANIDE
Yes
BURINEX A
Yes
Administer as separate
components as liquid
BUSPIRONE
Yes
Take 5 minutes
CABERGOLINE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
Tablets do not disperse readily
in water but if shaken in 10ml
water for 5 minutes will give
clear solution which flushes via
8Fr NG tube without blockage.
CALCIUM CARBONATE
Yes
Calcichew, Cacit and Tiraloc
disperse in water. Same applied
for Vitamin D components also
e.g. Cacit D3 granules.
CALCIUM FOLINATE
Yes
Injection may be given
Injection can also be given
orally or enterally
orally or enterally. Tablets
disperse in 10ml water within 5
minutes and given via 8Fr NG
tube without blockage.
CALCIUM RESONIUM
No
When mixed with water
resulting paste too think to
administer via feeding tubes.
Syrup available
Syrup available- CalciumSandoz
Enema available
CANDERSARTAN
Yes
Insoluble in water – administer
immediately
CAPECITABINE
Yes see next
column
Dissolve without crushing tablet
in small amount of warm water.
Takes approx 15 minutes
CAPTOPRIL
Yes
Tablets disperse in 10ml water
within 2 minutes to give
suspension that flushes down
8Fr NG tube.
Consider changing to
ACEI
Can also be given S/Ldose should be halved
and given twice as
frequently e.g., 12.5 mg
tds=6.25 mg 6 times a
day
Normal tablets
are special –
2mg x 100 £23
25mg/5ml x
100ml £27
5mg/5ml £65
CARBAMAZEPINE
No
Suppositories or liquid available.
125mg rectal dose is equivalent
to 100mg oral dose. Maximum
dose by rectal route is 250mg
qds. If patient has been taking
MR tablets give the same total
daily dose divided into three or
four doses.
PEG/NG – enteral feeds may
affect carbamazepine
absorption – leave two-hour
gap before and after dose,
especially with Isocal® and
Ensure plus®. NB also risk of
adsorption onto PVC feeding
tubes. If this is long term use,
then measure levels and adjust
dose accordingly. Liquid should
be mixed with equal volume of
water just prior to
administration and flushed
down tube well to minimise
adsorption onto tubes.
CARBIMAZOLE
Yes
Tablets disperse in 10ml and
shaken vigorously for 5 minutes
0 give via 8Fr NG tube without
blockage
CARBOCISTEINE
No
CARVEDILOL
Yes
CEFALEXIN
No
CEFUROXIME
Yes
Disperse in water and
administer however should be
avoided as risk of sensitisation
CELECOXIB
No
Capsule contents have low
aqueous solubility and poor
stability, but can be removed
just prior to administration. May
be added to cold or roomtemperature apple sauce if
swallowing difficulties
CELIPROLOL
Yes
CETIRIZINE
No
CHLORAL HYDRATE
No
Syrup available
30mg/5ml x
100ml £7
Liquid available
Disperses in 1-5 minutes
immediately before
administration as small particles
will form in water
Liquid available
Tilomed brand disintergrate if
shaken in 10ml water for 5
minutes.
Liquid and injection
available
Change to rofecoxib liquid
Liquid available
Consider alternative in
elderly patient e.g.
benzos, - temazepam
200mg/5ml x
200ml £2
200mg/5ml x
50ml £15
500mg/5ml x
200ml £8
CHLORDIAZEPOXIDE
Yes
CHLOROQUINE
Yes
CHLORPHENAMINE
No
CHLORPROMAZINE
No
CHLORTALIDONE
Yes
Take care to give all, as it will
sediment quickly.
CICLOSPORIN
Yes
Do not give via tubes as it will
adsorb to the plastic
CILAZAPRIL
Yes
Flush tube well after dose –
may block
CIMETIDINE
Yes
Incompatible with feeds – stop
one hour before and after.
Dilute with same volume of
sterile water and flush post
dose
CINNARIZINE
Yes
Disperse in 10ml water and
flushes easily via 8FR Ng tube
Liquid available – do not
give at same time as
antacids
Crush to ensure film-coating is
broken. Very bitter taste
Injection can be given
orally.
Liquid available. Acid
solution. Direct
interaction of drug and
feed causing coagulation
in the tube. Dilute with
equal volume of water
Suppositories, injection
and liquid available
Concentrate for infusion
and liquid available
Liquid and injection
Injection can be given
enterally. May be reduced available.
absorption when
cimetidine administered
directly into jejunum.
Change to Promethazine
Hydrochride
CIPROFIBRATE
Yes
CIPROFLOXACIN
Yes – disperse
in 30-60ml of
sterile water
and take
Ciprofloxacin absorption may be
reduced by up to 25% by
interaction with Jevity®,
Ensure® and Resource® and
also chelated by ions in tap
water.
Liquid available
Stop feed for 1 hour before and
2 hours after dose. Consider
increasing dose if feed needs to
be continued.
Use distilled water for dissolving
tablets/flushing tubes.
CITALOPRAM
Yes
CLARITHROMYCIN
Yes
CLINDAMYCIN
Yes
The powder is poorly soluble so
care should be taken to not
block tube. 8 drops of the
liquid is equivalent to 20mg
tablet. REF. Can add water to
required number of drops. Flush
tube well to prevent clogging.
Oral drops available
Liquid available, may clog
tube so dilute with same
volume of water prior to
administration
Unpleasant taste and odour –
try masking with flavoured
syrup e.g. blackcurrant, cherry.
Suspension has been
discontinued in the UK
but can be imported
through IDIS from other
countries
75mg/5ml x
80ml £9
Capsules open easily and
powder pours from capsule
when squeezed; care must be
taken to ensure entire contents
are emptied out. Mixes easily
with water and flushes via 8Fr
Ng tube without blockage
CLOBAZAM
5mg/5ml x
150ml £35
Yes
5mg/5ml x
100ml £3
CLOMETHIAZOLE
No
CLOMIPRAMINE
Yes (non-MR Small capsules – mix with water
capsules only) and flush down 8Fr NG tube
without blockage.
CLONAZEPAM
Yes
Liquid available
Consider changing to
alternative tricyclic
Injection solution may be
given orally or enterally
after dilution with 1ml
water for injection.
Excipients include
ethanol, glacial acetic
acid, benzyl alcohol and
propylene glycol.
Liquid and injection
available. Do not mix
suspension with water - it
will create an emulsion
and the active ingredient
will precipitate out.
125mcg/5ml x
150ml £130
2mg/5ml x
150ml £46
500mcg/5ml x
150ml £39
CO-AMILOFRUSE
Yes
CO-AMILOZIDE
Yes
Give components
separately as liquids
CO-AMOXICLAV
Yes
Liquid and dispersible tablets
available. 250/62 syrup is
designed for children - for
dysphagic adults use dispersible
tablets.
NG/PEG –if syrups are used,
thin with an equal quantity of
water before putting down tube
(avoids ‘crusting’ of tube with
syrup).
CO-APROVEL
No
CO-BENELDOPA (Madopar
®' preparations) SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION
No
Give separate components and
see on here
Dipsersible tablets available.
Administer immediately once
dissolved.
Do not empty the MR capsule the capsule shell is part of the
MR mechanism.
NB dispersible tablets have a
quicker onset and shorter
duration of action and cannot
be substituted for normal
release without a review of
therapy. Give at different time
to feed as may interfere with
absorption of levodopa. Do not
open capsules
CO-CARELDOPA (Sinemet
®preparations) SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION
CO-CODAMOL
Yes
Administer immediately once
dissolved. Do not crush M/R
products
Yes
dispersible
available
CO-DANTHRAMER
Liquid available - now
very limited indications
for this drug
CO-DYRAMOL
No
CODEINE
Yes
Liquid available or convert
to soluble/liquid
components
Dispersion occurs slowly
Liquid available
30units/1ml x
100ml £100
COLECALCIFEROL
See Calcium
and Vitamin D
CO-PHENOTROPE
Yes
CO-TENIDONE
CO-TRIAMTERIZDE
Yes however
should
suspend in
Yes
CO-TRIMOXOZOLE
No
COLCHICINE
Yes
Disperses in 2 minutes when
placed in 10ml water to give
coarse dispersion that breaks
up further when drawn into
syringe. Flushes down 8Fr Ng
tube without blockage.
CO-PROXAMOL
Yes
COVERSYL
No
Suggest using alternative
analgesic e.g. co-codamol
8/500 soluble
CYCLIZINE
Yes
CYCLOPENTHIAZIDE
Yes
CYCLOPHOSPHAMIDE
No
CYPROPHEPTADINE
Yes
CYPROTERONE
Yes
DANTROLENE
Yes
DAPSONE
Yes
DEFLAZACORT
Yes
Disperse in water and flush
down 8Fr NG tube without
blockage.
Liquid and dispersible
tablets available
Switch to perindopril and
indapamide
Powder may be mixed with food Injection available and
or syrup (to mask bitter taste) can be given enterally but
manufacturers do not
for administration.
recommend.
Injection can be used to
prepare solution for oral
use. It has been used
enterally.
Powder may be emptied from
capsule and mixed - with
orange juice or other acidic
liquid.
Protect from light, use
immediately
Disintegrates in water and
flushes down 8Fr NG tube
without blockage
50mg
suppositories x
12 £46
50mg/5ml x
100ml £56
DEFERIPRONE
No
DEMECLOCYCLINE
Yes
Liquid available
Remove capsule contents, mix
with water and flush down
tube.
Contents do not disperse in
water and tube blockage has
been reported. Flush well
Consider whether the patient is
fluid restricted as this is often
the case if this drug is being
used to treat SIADH
Irritant to the mucosa- DO NOT
open for oral administration
Absorption reduced by calciumWithhold feed 1 hour before
and 2 hours post dose
Nasal or sublingual route
available
DESMOPRESSIN
Yes
Disintegrates within 5 minutes
in 10 ml water and give via 8Fr
Ng tube
DEXAMETHASONE
Yes
Disintegrates within 5 minutes Can dilute and administer Liquid available.
in 10 ml water and give via 8Fr the injection orally or
enterally.
Ng tube. Settles quite quickly
DIAZEPAM
Yes
PEG/NG – syrup/crushed tablets
not recommended as drug may
adsorb onto tubing. APS brand
disperses within 2 minutes in 10
ml water and give via 8Fr Ng
tube
DICLOFENAC
No
Tablets are E/C or M/R and
should not be crushed.
Injections should be limited to
max. 2 days treatment. Some
MR capsules can be emptied
and the contents given, but for
some brands the capsule shell
is involved in the slow release
mechanism so cannot be
emptied.
Injection has been given
enterally, however
manufacturers do not
recommend. Drug loss
may occur if administered
through long PVC tubes
as it is significantly
absorbed onto PVC. It
may also contribute to
blockage of tubes
Liquid available but may
absorb into plastic tubing.
Suppositories available as
well as IM or IV preps.
10mg/5ml x
200ml £29
2.5mg/5ml x
500ml £14
Liquid, dispersible tablet,
suppositories , injection
and emulgel available
50mg/5ml x
150ml £30
DICYCLOVERINE
Yes
DIGOXIN
Yes
Liquid available
Bioavailability of liquid differs
from that of the tablets i.e.
65% for tablets vs. 75% for
liquid. The company
recommends that dose changes
are not generally necessary –
monitor levels after change. Do
not dilute liquid.
Liquid and Injection
available
IM NOT recommended.
Contact pharmacy for
information on IV use. If
converting from IV to oral give
20% reduced dose
Leave a two hour gap in the
feed before and after
administering the dose.
DIHYDROCODEINE
Yes (but not
MR)
DILTIAZEM
No but see
next column
Liquid available
Preparations that are once or
twice daily all MR, so
crushing/dissolving is not
recommended; an alternative
calcium channel blocker should
be considered. Three times
daily formulation is not mr and
can be crushed. May crush
Tildiem 60mg tablets & flush
down tube with water.
If patient on SR prep then
convert to plain 60mg tablets.
Due to differences in
bioavailability of the MR preps
give 60mg TDS and adjust
accordingly
Tildiem LA Capsules- open and
sprinkle content in water or mix
in soft food. However due to
size of micropellets may block
feeding tubes1. DO NOT crush
the pellets
Do not crush M/R forms (e.g.
Tildiem retard)
• Adizem SR/XL -capsule
contents can be mixed in water
or soft food. DO NOT crush the
pellets. Due to size of pellets
may block feeding tubes
• Patient should stay dedicated
to one brand due to differing
bioavailabilities
• Alternatively change to
amlodipine
DIPYRIDAMOLE
Yes (Non MR Crush or disperse tablet in
only)
water (Persantin). Sugar coated
so may block tube. Flush well
after dose.
Dispersion occurs slowly
Persantin Retard may be
opened and contents taken in
soft food or suspended in water
Granules should not be crushed
or dissolved in hot water
May block tube
Dipyridamole/aspirin capsules
(Asasantin) may be opened and
the contents given in a small
quantity of liquid or food.
Care should be taken to not
crush the granules as the
dipyridamole component is a
sustained release granule. Do
not dissolve in hot water.
Anecdotal reports that the
granules may block PEG or NG
Tablets may be crushed, but
taste is unpleasant-this may be
masked by mixing with an
acidic beverage e.g. orange
juice.
Diluted injection can be
administered orally or by
feeding tube. Should be
given on empty stomach
therefore enteral feeds
should be withheld for
one hour before and one
hour after dose.
Liquid dipyridamole
available.
DISODIUM
ETIDRONATE(also included
in Didronel PMO pack)
Yes
DOCUSATE
No
Liquid available
DOMPERIDONE
Yes
Liquid (high sorbitol
content and may cause
diarrhoea) and
suppositories available
DONEPEZIL
PEG/NG – feed should be
stopped for 2 hours before and
2 hours after administration of
etidronate as drug interacts
with calcium in feed.
DO NOT use Aricept Evess for
feeding tube administration as
these tablets will only dissolve
in an environment where
digestive enzymes are present
ie the mouth. They will not
dissolve in water.
DOSULEPIN
Yes
Crushing tablets/emptying
capsules not recommended as
powder is local anaesthetic –
avoid hot drinks after. Can
sprinkle on small amount of
food.
DOXAZOSIN
Yes
Tablets may be crushed and
mixed/washed down with
distilled water as the chloride
ions in tap water will precipitate
out the active drug. REF.
Sudden hypotensive effect
when crushed tablets given by
enteral route – monitor patients
BP
Consider other
antidepressant
25mg/5ml x
500ml £29
When converting from MR to
plain halve the dose and titrate
upwards according to response
Do NOT crush MR preparations.
DOXEPIN
Yes
Can open capsule and mix the
powder with water. The
resulting solution has a bitter
taste which is difficult to mask.
DOXYCYCLINE
Yes
Can remove capsule contents to
flush down tube. They should
NOT be opened for oral
administration as the hyclate
salt present is irritant to the
oesophagus. Doxycycline binds
to calcium ions and may have
reduced
Doxycycline binds to calcium
ions and may have reduced
absorption when given via
enteral feeding tubes.
Consider other
antidepressant
Dispersible tablets
available
Prescribe at higher end of
standard dosage range. Can be
put in thick and easy. But break
in feeding not necessary
DULOXETINE
Yes
DUTASERIDE
Open capsules and mix with
apple juice or sauce. Entericcoated beads inside should not
be chewed or crushed. Give
immediately. NG – no
information, try opening
capsule and flushing NG tube
with apply juice.
Do NOT empty capsules, may
irritate GI tract
DYDROGESTERONE
Yes
EFAVIRENZ
NO
Liquid available –
conversion necessary
ENALAPRIL
Yes
Give immediately after crushing
and mixing with water.
Disintegrates within 5 minutes
in 10 ml water and give via 8Fr
Ng tube
ENTACAPONE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
Caution: Tablet powder will
stain orange, so avoid spillage
on clothes etc., and contact
with lips etc. May also stain
tube. Wear gloves. May be
added to jam, honey or orange
juice.
Consider other ACEI.
2mg/5ml x
100ml £62
PEG/NG tubes: tablet powder
mixes in water but does not
dissolve fully, so ensure all
residue is rinsed thoroughly
down tube. See guidelines at
end of table
EPLERENONE
Yes
EPROSARTAN
Yes
ERGOCALCIFEROL
No
Crush and suspend in water.
Can also mix with apple sauce
Change to ACEI
Daily supplements with
Calcium and Vitamin D or
injection.
1500units/1ml
x 20ml £3
3000units/1ml
x 120ml £122
3000 units/1ml
x 20ml £21
ERYTHROMYCIN
No
ESCITALOPRAM
Yes
ESMOPRAZOLE
No
Liquid available
Powder is poorly soluble so care
should be taken to not block
tube.
MUPS formulation so will
dissolve, but leave EC beads.
Lansoprazole Fastabs® best for
use down tubes.
Citalopram drops
Alternative PPI
ETHAMBUTOL
Yes
ETHOSUXIMIDE
No
ETIDRONATE
Yes
Liquid available
Stop feed 2 hours before and
after dose. Flush line well with
plain water post dose
Avoid antacids and mineral
supplements 2 hours before
and after administration.
ETOPOSIDE
No (cytotoxic)
Injection - Unpleasant
taste. Can be given
enterally or in orange
juice for oral
administration. A conc. of
0.4mg/ml or less avoids
the risk of precipitation
EXEMESTANE
Yes
EZETIMIBE
Yes
FAMCICLOVIR
Yes
FAMOTIDINE
Yes
FELODIPINE
No
Drug is formulated in a MR
matrix, so crushing is NOT
advised - conversion to
alternative drug may be
necessary
FENOFIBRATE
Yes
Can given capsule contents in
orange
FERROUS SULPHATE
No
Crush tablet and give via tube if
necessary
Disintegrates within 5 minutes
in 10 ml water and give via 8Fr
Ng tube
Tablets do not disperse in water
easily. Hard to crush but will
crush with persistence and will
suspend in water and give via
8Fr Ng tube
Ranitidine (40mg
famotidine = ranitidine
300mg)
Amlodipine
Liquid available. Change
to Sytron (sodium
feredetate) 10ml=200mg
FeSO4.
FEXOFENADINE
Yes
Change to other
antihistamine available as
liquid
FINASTERIDE
Yes
Tablets may be crushed and
dispersed in water, however
tablet powder should NOT be
handled by pregnant women, or
those with any possibility of
being pregnant. Disintegrates
within 5mins 10 ml water and
give via 8Fr Ng tube
FLAVOXATE
Yes
Ensure all drug is rinsed out of
crusher and administered.
Bitter taste. Tablets hard to
crush but can be ground to fine
powder which mixes well with
water and give via 8Fr Ng tube
FLECAINIDE
Yes
Tablets may be
crushed/injection used orally
(same dose)-may have a local
anaesthetic effect. Do not mix
with tap water due to chelation
of ions. Use distilled water
.Disintegrates within 5 minutes
in 10 ml water and give via 8Fr
Ng tube
Injection has been
administered enterally
undiluted. This should be
used in emergency, and
monitor for
clinical/adverse effects. If
giving via enteral feeding
tube, always flush with
deionised water, do not
mix with alkali solutions,
sulphate, phosphate,or
chloride ions. Do not mix
drug with medications
prior to administration
25mg/5ml x
500ml £47
FLUCLOXACILLIN
Yes
PEG/NG – ideally, stop feed for
1 hour before and after dose of
flucloxacillin, as food impairs
drug absorption.
Liquid and injection
available
FLUCONAZOLE
Yes
Interacts with Jevity® - stop
feed for one hour before and
one hour after.
Liquid and injection
available
FLUDROCORTISONE
Yes
Disintegrates within 2 minutes
in 10 ml water and give via 8Fr
Ng tube
FLUOXETINE
Yes
Prozac liquid available. Dilute
with the same volume of sterile
water and flush post dose
• Open capsule and disperse in
water or fruit juice – do
immediately prior to
administration
• Dissolves slowly- 5 minutes
• Irritant to eyes and skin. Wear
protective clothing
FLUPENTHIXOL
Yes
FLURBIPROFEN
Yes (open
capsules, do
not crush
tablets)
FLUTAMIDE
Yes
FLUVASTATIN
Yes
Flush well post dose.
Disintegrate if shaken in water
for 5 minutes and give via 8Fr
Ng tube
Do not crush beads as may
block tube
Tablets may be crushed and
given mixed with milk or fruit
juice
May be difficult to remove all
capsule contents. Do not put
MR down tubes.
Consider alternative SSRI
FLUVOXAMINE
Yes
No information on enteral tube
admin
FOLIC ACID
Yes
No information on enteral tube
admin
FORCEVAL
Yes
Capsule contents may be
administered by snipping end of
capsule off and withdrawing
contents (gelatinous), but will
not be whole dose. Also tastes
foul, so giving in jam etc. would
be a good idea!
Consider alternative liquid
multivitamin
FOSINOPRIL
Yes
No information on enteral tube
admin
Change to other ACEI
FUROSEMIDE
Yes
No information on enteral tube
admin
FUSIDIC ACID
No
FYBOGEL
No
Do not put down tube due to
the risk of congealing and
blocking the tube.
GABAPENTIN
Yes
Mixing with Ribena® or other
strong-flavoured liquid may
mask the very bitter taste of the
powder. Use immediately due
to hydrolysis. Powder may also
be sprinkled on cold, soft food.
REF Open capsules and mix
with 10ml water, mixes easily
and flushes down 8Fr NG tube
GALANTAMINE
Yes
GANCICLOVIR
No
Will disperse in 5 minutes when
places in 10ml water which can
flush down 8Fr NG tube
Carcinogenic and teratogenic
Liquid available
Injection and liquid
available
Liquid available - 500mg
sodium fusidate tablets
are approximately
equivalent to 750mg
fusidic acid suspension
Liquid available
GLIBENCLAMIDE
Yes
Give just before the start of a
feed. REF Monitor blood
glucose levels as may be more
effective crushed
GLICLAZIDE
Yes
Watch for associated increase
in bioavailability (monitor blood
glucose carefully). REF
Preferably swith to insulin for
better glycaemic control
GLIMEPIRIDE
Yes
May take 5 minutes to disperse
– DO NOT CRUSH
GLIPIZIDE
Yes
Disperses readily in water once
finely crushed.
GLYCERYL TRINITRATE
No
GLYCOPYRRONIUM
Yes
5mg/5ml x
150ml £118
Buccal, S/L Spray,
patches
Tablets are
special 1mg x
100 £64
Injection given orally
2mg x 100 £99
GRANISETRON
Yes
GRISEOFULVIN
No
Give injection orally or
give IV
Change to alternative
drug such as terbinafine
125mg/5ml x
100 £30
500mg tablets
£52
HALOPERIDOL
Yes
HYDRALAZINE
Yes
Liquid and injection
available
Crushing tablets leads to more
rapid absorption of drug and
possible rapid fall in BP \caution – review choice of
therapy? Absorption is
decreased in the presence of
food – leave a one hour gap
before and after the dose.
Reconstitued injection can
by given orally or
enterally
HYDROCHLORTHIAZIDE
Yes
Disperse in water
HYDROCORTISONE
Yes
Will disperse in 5 minutes when Injection available and
placed in 10ml water which can can be given orally or
enterally. Contains
flush down 8Fr NG tube
significant amount of
phosphate
HYDROXYCHOLOQUINE
Yes
HYDROXYUREA
Yes
Caution: care with handling avoid contact of drug powder
with skin, mucous membranes,
inhalation etc. - drug is
cytotoxic.
HYDROXYZINE
Yes
May be difficult to crush as
sugar coated. Risk of tubeblockage so flush well.
HYOSCINE N
BUTYLBROMIDE
Yes
Injection may be used orally.
Tablets are sugar coated so
may be hard to crush. REF
HYOSCINE
HYDROBROMIDE
Yes
Tablets can be sucked and will
be absorbed through oral
mucosa.
IBUPROFEN
No
Can however crush and
disperse brufen tablets
IMATINIB
Yes
Disperse in water or apple juice
– at least 50ml of fluid for
100mg tablet
IMIPRAMINE
Yes
If giving down tube, put some
syrup down first to decrease
adsorption on tubing.
INDAPAMIDE
Yes
Do not crush MR preps
10mg/5ml x
100ml £105
Liquid available
Injection available and
may be used orally or
enterally. Content of
ampoule may be stored in
fridge for up to 24 hours
once opened.
Injection solution may be Patches and injection
given orally and enterally available
Liquid and brufen
granules available
Liquid available
Consider alternative
tricyclic antidepressant
INDOMETHACIN
Yes
MR capsules may be emptied
and the granules swallowed
whole. MR capsules irritant on
stomach – do not open.
Can sprinkle on soft food to
mask taste.
INDORAMIN
Yes
IRBESARTAN
Yes
ISONIAZID
Yes
ISOSORBIDE
MONONITRATE
Yes
Normal release tablets can be
crushed and will dissolve but do
not crush MR. Release
properties may change so
monitor patient.
ISOTRETINOIN
No
Capsules can be cut or pierced
and mixed in food or stirred
into warm milk. Can also freeze
and cut into halves or quarters
ISRADIPINE
Yes
Low solubility
ITRACONAZOLE
Stop feed 2 hours pre and post
Open
capsules and dose but possible reduced
absorption
dissolve
contents.
IVABRADINE
Yes
Also fix with yoghurt or soft
food
KETOCONAZOLE
Yes
Stop feed 2 hour before and
after dose
Suppository available
Crush and suspend in water Will
disperse in 5 minutes when
placed in 10ml water –larger
particles break up when draw
into syringe and can flush down
8Fr NG tube
Will disperse in 5 minutes when
placed in 10ml water which can
flush down 8Fr NG tube
25mg/5ml x
100 £14
Consider changing to ACE
inhibitor
50mg/5ml x
500ml £26
GTN patch
Liquid available
LABETOLOL
No
It is not recommended to crush
due to film coating and rapid
oxidisation. The injection
solution can be used orally,
mixed with orange juice to
mask taste. REF can be
dispersed in water if tablets are
ground down enough but may
block tube.
LACIDIPINE
Yes
Very insoluble in water
therefore crush tablets and
flush down tube
LAMIVUDINE
No
Use liquid in order to avoid
exposure of operator to active
constituents of crushed tablets.
LAMOTRIGINE
Yes
Dispersible tablets available and
even non-dispersible will
dissolve once crushed.
Dispersible tablets can be
chewed.
LANSOPRAZOLE
Yes see next
column
Granules may be emptied from
the capsule and swallowed
(without crushing or chewing)
with water or in soft food e.g. a
spoonful of apple sauce.
Injection can be used
orally or enterally if
necessary. Injection can
also be given with fruit
juice or squash to disguise
bitter taste.
Consider alternative
calcium channel blocker
Liquid available
Granules from capsule (do not
crush may be flushed down
tubes (except v. fine bore
tubes) preferably with apple
juice (manufacturer
recommends 40ml; this reduces
adhesion of granules compared
to water).
Fastabs® are best for tubes, as
the microspheres are smaller
than in the capsules. Dissolve
in apple juice or orange juice,
put down tube and then flush
again with the fruit juice. (Juice
is better than water as it makes
the granules less sticky)
PEG/NG- sachets not suitable
for tube administration, as the
suspension is too viscous.
Fast tabs are not absorbed
sublingually – not supposed to
be broken up in the mouth and
the drug is not absorbed there.
LEFLUONOMIDE
Yes
Monitor patient for signs of
exaggerated or diminished
effects. Will disperse in 5
minutes when placed in 10ml
water which can flush down 8Fr
NG tube
LERCANIDIPINE
Yes
Light sensitive so use
immediately
LEVETIRACETAM
Yes
Tablets can be crushed and
sprinkled into soft food such as
apple puree or yoghurt but do
have bitter taste. Liquid can
also be added to food. 500mg
tablets will disperse in 5
minutes when placed in 10ml
water which can flush down 8Fr
NG tube
LEVODOPA
Yes
Only sparingly soluble with
insoluble excipients. Will stain
skin, teeth, tongue and tube.
See handbook for further
details on brand.
LEVOFLOXACIN
Yes
Bitter taste with metallic
aftertaste. Stop feed 2 hours
pre and post dose. If administer
via tube consider changing to
another quinolone as takes few
minutes to dissolve. This forms
milky dispersion which can flush
down 8Fr NG tube
Liquid available
Injection and liquid
Consider alternative
antipsychotic
Injection can be given
orally and enterally. Note
that excipients degrade to
products which
theoretically may induce
asthma attacks when
given enterally. No
reports of attacks ever
having been induced this
way have been recorded
by the manufacturers and
the risk is considered to
be small
LEVOMEPROMAZINE
Yes
Will disperse in 2 minutes when
placed in 10ml water which can
flush down 8Fr NG tube but
may block finer tubes.
LEVOTHYROXINE
Yes
Long half life so can be omitted
for up for 5 days. Will disperse
in 5 minutes when placed in
10ml water and shaken, this
can flush down 8Fr NG tube
Liquid and injection (dose
conversion necessary)
available
LINEZOLID
Yes
Monitor for side effects
Liquid available but may
be too thick for feeding
tubes.
LISINOPRIL
Yes
12.5mg/5ml x
100ml and
50ml both £42
2.5mg/5ml x
100ml £47
5mg/5ml x
100ml £23
LITHIUM
No
Withhold feed 1 hour before
and 2 hours post dose
Liquid available but dose
conversion necessary.
Monitor blood levels
closely. 520mg/5ml as
lithium citrate -equivalent
to 200mg of lithium
carbonate.
LOFEPRAMINE
No
Has very bitter taste and hard
to crush as film coating
Liquid available
LOPERAMIDE
No
Caution in stoma patients.
Liquid available but large
sugar content so caution
in diabetics. Flushes down
NG tube without
resistance.
LORATADINE
Yes
LORAZEPAM
Yes
Can also be used sublingually
but needs moist mouth
LOSARTAN
Yes
Mix with 10ml water to form
fine suspension which flushes
down 8Fr NG tube without
blockage
LOXAPINE
Yes
Crushed tablets should be
dissolved in water and given
immediately
MAGNESIUM
Yes
Capsule contents can be mixed
with soft food
Liquid available
Injection can be given
S/L.
Liquid available
Consider alternative
anxiolytic
4mmol
chewable
tablet x 50 £16
5mmol/5ml x
200ml £60
Normal tablets
x 100 £39
MEBENDAZOLE
No
Liquid available
MEBEVERINE
Yes but only
non-MR
Fairly soluble in water. Change
MR to normal release tablets or
liquid. Stop feed for 30 minutes
pre and post dose
MEDROXYPROGESTERONE
Yes
Dissolves slowly approx 5
minutes. Suspension will flush
via 8Fr NG tube without
blockage.
MEFENAMIC ACID
Yes
Only suspend contents in water
– virtually insoluble. Can mix
with food or jam
MEGESTROL ACETATE
Yes
Tablets may be crushed and
given in water, fruit juice or
jam. May take 5 minutes for
tablets to dissolve.
MELATONIN
Yes
Tablets may be crushed and
mixed with yoghurt, fruit juice
or jam.
Liquid available
Depo-Provera has been
used orally, although little
data available.
Suspension available
All specials
Circadin tablets should not be
crushed as controlled release.
MELOXICAM
Yes
MEMANTINE
No
MENADIOL
Yes
MERCAPTOPURINE
No
Disperse in 10ml water within 5
minutes and flushes down 8Fr
NG tube without blockage.
Suppositories also
available. Use
suppositories for the
shortest time possible
Alternative NSAIDS
Oral drops available.
5mg=10 drops
5mg/5ml x
50ml £80
Do not crush as cytotoxic. Place
tablet in water, however
unstable in aqueous solutions.
Use immediately.
Suspension available
MESALAZINE
No
Tablets should not be crushed.
If colon only affected a rectal
preparation could be tried, or
patient could be converted to
sulphasalazine, which comes in
a liquid.
Suppositories foam
enema, sachets
Pentasa® brand tablets
disperse very quickly in water;
however, this leaves small
beads in the liquid which must
be swallowed or put down the
tube intact. These are better
than the sachets, which have
larger granules. See enteral
feeding book for more
information.
METFORMIN
Yes
May block tube and may
increase availability
METHOTREXATE
No
Cytotoxic therefore do not
crush. Place in water and
disperse. In rheumatoid
conditions consider S/C or I/M.
Sachets available and
much cheaper than liquid
Injection can be diluted
with water and
administered orally.
Extended expiry can be
given if preservative used.
Can be given enterally
although manufacturers
cannot recommend.
Absorption from injection
gives similar plasma
concentration to tablet
formulation.
10mg/5ml x
50ml £52
20mg/5ml x
100ml £73
METHOTRIMEPRAZINE
Yes
Tablets disperse in water.
Injection has been use orally.
METHYLDOPA
Yes
May block tube as tablet
coating may not dissolve.
Interacts with Ensure®, Ensure
plus® and Osmolite® - stop
feed for two hours before and
one hour after. REF
METHYLPREDNISOLONE
Yes
Tablets will disperse in water.
Do not crush M/R tablets
METHYLPREDNISOLONE
Yes
METOCLOPRAMIDE
Yes
Suspension available
Injection
The manufacturers are
aware that SoluMedrone® has been mixed
with orange juice and
water when given orally
because it has an
unpleasant taste which
almost nothing will
disguise. If orange juice is
used, it must be added
just before taking due to
its low pH
Dispersion occurs slowly.
Injection can be used
enterally
Injection and liquid
available
METOLAZONE
Yes
Tablets can be crushed but be
aware that the increased
bioavailability may lead to
increased postural hypotension.
May need to be shaken for 5
minutes. Can flush via 8Fr NG
tube without blockage. Do not
crush MR formulations.
METOPROLOL
Yes
Do not crush MR formulations
METRONIDAZOLE
Yes
Injection can be given orally.
Liquid also available but do not
use in C.diff. or NJ/jejunostomy
patients. Administer 1 hour
before food to allow break
down.
METYRAPONE
Yes
Capsule can be cut open and
the contents administered if
necessary.
Syrup available
MEXILITINE
Yes
Open capsules and dissolve
contents in distilled water. Can
flush down feeding tube.
MIANSERIN
Yes
Tablets may be crushed, but
difficult. Mix with plenty of
water.
MIDAZOLAM
MINOXIDIL
Injection can be given
orally. It has also been
administered enterally. It
has a very unpleasant
taste. When the injection
is being given to patients
with swallowing
difficulties, it should be
given at least 30 minutes
before food as it has a
local anaesthetic action in
the mouth
Injection can be given
orally. The injection has a
bitter taste so should be
diluted with apple or
blackcurrant juice,
raspberry or cherry syrup,
chocolate sauce or cola
Yes
Disperse in water within 2
minutes to give dispersion
which flushes via 8Fr NG tube
without blockage.
10mg/5ml
buccal syrup x
5ml £40
12.5mg/5ml x
100 £86
MIRTAZPINE
Yes
Bitter taste and local
anaesthetic effect
MISOPROSTOL
Yes
Tablets may be crushed (and
dispersed in water if necessary)
IMMEDIATELY before use.
Caution: powder should not be
handled by pregnant women.
Change to lansoprazole if for
this indication
MOCLOBEMIDE
Yes
Solution flushes down 8Fr NG
tube without blockage
MODAFINIL
Yes
Use suspension immediately
MONTELUKAST
Yes
Give immediately as unstable in
water. Granules can be mixed
in soft food or place directly
onto the tongue and swallow.
Dispersible tablets
available but may block
tubes.
Tablets are
special
MORPHINE M/R
TABLETS/CAPSULES
Try the MR capsules (Zomorph)
which can be opened and the
granules sprinkled on soft food
or washed down with liquid.
NB if using MXL® capsules the
liquid used should be enteral
feed, not water. This is due to
the high lipophilicity of the
granules which would lead to
tube blockage. MR tablets
should not be crushed.
Sachets are not always suitable
for use down tubes due to high
viscosity. The MST® sachets,
once reconstituted with 10ml
water, will pass down a Ryles
tube (4.75mm internal
diameter) and NG tubes of
1.05mm internal diameter or
more.
Interacts with Jevity® and
Pulmocare – stop feed for two
hours before and one hour
after.
MOXIFLOXACIN
Yes
Tablets have a bitter taste.
400mg tablet will dissolve in
20mls of water. Stop feed one
hour before and 2 hours after
administration.
MOXONIDINE
Yes
Crush well to minimise risk of
blocking tube. Mix one tablet
with 50ml water and allow to
dissolve for 2 minutes. Solution
flushes down 8Fr NG tube
without blockage
MYCOPHENOLATE
Reconstituted injection
solution has been used
enterally with a dextrose
5% flush before and after
administration. Care
should be taken when
handling the powder
(teratogenic risk).
Contamination should be
removed promptly by
washing with soap and
water (eyes – plain water
NABILONE
Yes
Remove capsule contents and
disperse in water
NADOLOL
Yes
Crush and disperse in water
NAFTIDROFURYL
No
Do not open capsule- powder is
irritant and anaesthetic to
mouth/throat mucosa-ask Dr to
review need for this drug. If
drug absolutely necessary open
capsule and disperse contents
with water but drink large
amount of fluid following dose.
NALIDIX ACID
No
NAPROXEN
Yes but not
MR or EC
NATEGLINIDE
Yes
NEBIVOLOL
Yes
Administer solution
immediately. Doesn’t dissolve
very well – flush.
NEFOPAM
Yes
Dispersion occurs slowly, may
need to be shaken. Ensure
adequate rinsing of container.
NEFAZODONE
Yes
NEOMYCIN
NEOSTIGMINE
Yes
NEVIRAPINE
Yes
NICARDIPINE
Yes
The powder can be removed
from the capsule and dissolved,
preferably in orange juice
NICORANDIL
Yes
Dispersion occurs slowly (at
least 5 minutes). Use in care
with enteral feeding tube as
may cause blockage.
NICOUMALONE
Yes
Insoluble in water
Can take 5 minutes for tablet to
completely disperse
Suspension and
suppositories available
Give IM injection orally.
20mg IM = 60mg oral.
Special tablets
100mg x 60
£56
Yes
NIFEDIPINE
Yes
Do not crush MR tablets (NB
Adalat Retard® may be
crushed and dispersed in water,
as this does not affect the
release mechanism.) Adalat
LA® cannot be crushed.
Consider alternative
calcium channel blocker
Normal release capsules can be
bitten (by the patient) or
snipped (by staff if patient
unable to bite) open and the
liquid contents swallowed/given
sub-lingually. However,
nifedipine is very short acting in
this form and to avoid sudden
drop in BP, change to longer
acting calcium channel blocker
may be preferable. Please ask
NG/PEG tubes - Capsule
contents (oil) may be drawn up
in syringe and flushed down
tube with N-saline, not water,
but see notes above.
It is not advised to open
Coracten® preparations as the
capsules contain mini-tablets
which may be lost. There is
also a danger that the patient
may chew them and this would
release a greater dose. If it is
necessary to open the capsules
there is no difference in effect if
the mini-tablets are swallowed
whole. See handbook of drug
administration for more
information
NIMODIPINE
Yes
NITRAZEPAM
Yes
Use immediately as extremely
light sensitive. Give injection in
non-PVC or glass apparatus.
Also applied to tablets in
solution. For PEG/NG tubes,
ensure tablets are in fine
powder after crushing fragments of film coating can
block tubes.
Liquid available
20mg/1ml x
30ml oral
drops £17
NITROFURANTOIN
No
Large granules may block fine
bore tubes.
NIZATIDINE
Yes
May block tubes as excipients
are insoluble
NORETHISTERONE
Yes
Suspension flushes via 8Fr NG
tube without blockage
NORFLOXACIN
Yes
Flush well as poorly soluble.
Stop feed 1 hour before and 2
hours after. Unpleasant taste.
NORFLOXACIN
Yes
Do not disperse well in water –
give crushed tablets
NORTRIPTYLINE
No
OFLOXACIN
Yes
Do not disperse readily. Stop
feed for one hour before and 2
hours after administration.Use
de-ionised bottled water to
avoid drug chelation with ions
See notes under ciprofloxacin
for PEG/NG tubes.
OLANZAPINE
Yes
Normal tablets will dissolve, but
not as fast as velotabs
OLSALAZINE
Yes
Avoid mixing with acidic
solution (eg orange juice) as
active drug is alkaline. Disperse
in warm sterile water. Capsule
contents and dispersed tablets
will stain bright orange
OLMESARTAN
No
Change to another ACEI
Liquid available
Consider changing to
alternative H2 antagonist
Consider alternative
tricyclic
OMACOR
OMEPRAZOLE
Burning/bitter taste therefore
not recommended. Very difficult
to pierce and empty capsule. Oil
not compatible with most
plastics and oxidises quickly in
air. Could dissolve capsules in
hot, not boiling water, in a
china cup, and administer
immediately. Drink entire
contents as oil doesn’t dissolve
in water.
Dispersible
tablets
PEG/NG tubes :- Manufacturer
recommends one of two
methods of administration to
avoid tube blockages
Dissolve the tablet in 25ml
water in the syringe, invert
syringe to disperse drug pellets,
and immediately run 5-10ml
down tube. Invert syringe to
mix contents again, run a
further 5-10ml down tube.
Repeat until all the liquid has
been passed down the tube.
Rinse syringe and flush tube
with a further 25ml water. (This
method is intended to avoid
syringe and tube blockages by
compacted pellets)
Dissolve the tablet in the
syringe in 5ml water and add
5ml wholemilk yoghurt. Mix
gently and pass down the tube.
Flush with 10ml water to rinse
down any remaining drug
pellets.
NB: Lansoprazole Fastabs® are
best for tube use. REF
Liquid available – Maxepa Is it vital the patient has
it?
liquid £20 for 150ml
10mg/5ml x
50ml £138!
ONDANSETRON
No
Crush or disperse tablet in
water.
ORLISTAT
Yes
Open and stir into water or fruit
juice or flush contents down the
tube
ORPHENADRINE
Yes
OXPRENOLOL
Yes (not mr
forms)
OXYBUTYNIN
Yes (not mr
forms)
OXYCODONE
No
Do not open oxynorm capsules
due to possibility of powder
becoming airborne.
OXYTETRACYCLINE
No
Tablets may be crushed for
administration down tubes only.
It is not recommended that
they be crushed for oral
administration due to the risk of
oesophageal ulceration and
oesophagitis. Consider changing
to alternative such as
doxycycline. Also must stop
feed 1 hour before and 2 hours
after.
Injection has been used Injection, suppositories,
enterally. This may be
syrup or melt tablets.
preferable for
administration via enteral
tubes terminating in the
jejunum as the syrup
contains sorbitol. The
injection is acidic, so flush
well before and after each
dose to prevent
precipitation of the drug
when giving via enteral
feeding tube
Oral solutions available
Tastes very bitter
Liquid and patch available
Liquid form available.
PANCREATIC ENZYMES
Yes
Creon® - empty the granules
from the capsule. If giving with
an enteral feed, give half the
dose before the feed and half
after. If the patient has a
jejunal tube, crush the granules
(or dissolve in sodium
bicarbonate) and mix with feed.
Pancrex powder
PANTOPRAZOLE
No
Tablets must be swallowed
whole and may not be crushed.
Patient should be changed to
alternative e.g. lansoprazole or
omeprazole.
PARACETAMOL
No
For use through enteral tubes it
is better to use the soluble
tablets as the liquid is too thick
Suppositories and soluble
tablets
PAROXETINE
Yes
Powder is bitter and has
anaesthetic effect
Liquid available
PENICILLAMNINE
Yes
Take at least 5 minutes
PENICILLIN V
Yes
PEG/NG – If possible stop feed
for 1 hour before and 2 hours
after administration –
absorption is unpredictable with
enteral feeds – if not possible,
consider higher dose or
alternative antibiotic. REF
PERGOLIDE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
Slow to disperse. Can
administer in Jam or yoghurt.
PERINDOPRIL
Yes
Leave a feed gap of two hours
before and after dose.
PHENELZINE
Yes
Slow to disperse. Use
immediately. No information on
enteral tube administration
500mg/5ml x
200 £2
Other ACEI or A2RB
PHENOBARBITAL
Yes
Liquid available but may
be inappropriate in
children due to high
alcohol content
50mg/5ml
alcohol free x
50ml £8
50mg/5ml
normal liquid x
200ml £2
50mg/5ml x
60ml £3
50mg/5ml S/F
x 150ml £25
PHENOXYBENZAMINE
Yes
No information about whether
this may block tube
PHENYTOIN
Yes but
difficult to
crush and do
not disperse
readily in
water
Injection should be given
preferably by slow IV injection,
and patients should be ECG and
BP monitored. If given by IV
infusion an in-line filter must be
used.
90mg syrup is equivalent to
100mg capsule e.g. patient
previously on 300mg in
capsules should be given 45ml
syrup.
Chewable tablets
PEG/NG – Phenytoin absorption
is significantly reduced if
administered with enteral feeds.
Give phenytoin as a single daily
dose; stop feed two hours
before giving and do not restart
until 2 hours after dose.
Alternatively, this could be
managed by stopping feed
overnight e.g. between 10pm
and 6am, and giving phenytoin
at midnight. Interacts
especially with Osmolite®,
Isocal®, Ensure® and Jevity®.
Dilute syrup with equal volume
of water and flush tube before
and after drug administration.
Phenytoin is less effective if
given down NJ tube – consider
reviewing therapy. More
convenient if dose changed to
single daily dose.
PHYTOMENADIONE
Yes
Konakion MM Paed Injection
orally. Flush well after each
dose if giving via enteral
feeding tube
PIMOZIDE
Yes
Not very soluble in water
20mg/1ml x
5ml £11
PINDOLOL
PIOGLITAZONE
Yes
PIROXICAM
Yes
PIVMECILLINAM
Yes
PIZOTIFEN
Yes
POTASSIUM
Yes but only
Sando-K
Do not crush Slow K.
PRAMIPEXOLE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
Light sensitive so use
immediately
PRAVASTATIN
Yes
Use immediately
PRAZOSIN
Yes
Insoluble so ensure wash down
with water or mix with jam etc
PREDNISOLONE
Yes
Soluble tablets available. Do not
crush E/C. Plain tablets disperse
in water.
PREGABALIN
Yes
Unpleasant taste. Give
immediately after dissolved in
sterile water.
PRIMIDONE
Yes
Disperse in water (poorly
soluble)
PROCHLORPERAZINE
No
Yes
Monitor blood glucose levels
carefully if crushing tablets. For
better glycaemic control switch
to insulin.
Suppositories or IM. Melts
available
Probably more accurate to
change dose to equate to half
or quarter of tablet
Liquid available
Kay-Cee-L liquid
Other Statin
Liquid available
Buccal tablets, syrup,
effervescent granules
250mg/5ml xz
200ml £43
PROCYCLIDINE
Yes
Liquid available
PROGUANIL
PROMAZINE
Yes
PROMETHAZINE
Yes
Dispersion flushes via 8Fr NG
tube without blockage
PROPAFENONE
Yes
Local anaesthetic action and
bitter taste
PROPRANTHELINE
Yes
PROPRANOLOL
No
PROPYLTHIOURACIL
Yes
PSEUDOEPHEDRINE
No
PYRAZINAMIDE
Yes
PYRIDOSTIGMINE
Yes
No
Liquid available
Granules from MR capsules can
be swallowed whole. Flush
down tube or mix with soft
food.
Liquid, injection available
Can give injection orally;
it has been mixed in
raspberry syrup when
given orally. However
little information on it so
not recommended.
Liquid available.
Liquid available
500mg/5ml x
300ml £52
Leave a one hour feed gap
either side of dose.
Liquid available
5mg/5ml x
150ml £38
60mg/5ml x
150ml £37
PYRIDOXINE
Yes
Dispersion occurs slowly
10mg/5ml x
100ml £67
QUETIAPINE
Yes
Bitter taste therefore mix with
soft food. Flush down tube. Can
crush. Do not crush XL
formulation
QUINAPRIL
No
QUINIDINE
Yes
Do not crush m/r tablets
QUININE
Yes
Only crush if necessary and
going to need for long term.
Crush or disperse in 200ml
warm water as this will aim
flushing. May block the tube.
RABEPRAZOLE
No
E/c will be destroyed and stops
breakdown of product in
stomach acid
RALOXIFINE
Yes
Unpleasant taste. Care handling
and crushing – maybe
teratogenic. Discotinue if
immobile.
RAMIPRIL
Yes
Bitter taste. Place contents
directly on mouth or bread.
RANITIDINE
Yes
REBOXETINE
Yes
REPAGLINIDE
Yes
RIFABUTIN
Yes
Change to other ACEI
Change to other PPI
Injection may be given
enterally
Crushing will speed absorption
so monitor blood sugar
carefully. NB if patient has a
tube, note where it emerges in
GI tract, as absorption will be
faster in duodenum than
stomach.
Injection, dispersible
tablets, syrup (may cause
diarrhoea)..
RIFAMPICIN
No
Crush tablets/open capsules
can cause sensitisation. Stop
feed one hour before and 30
minutes post dose. Can crush
or disperse
Syrup available
Rifinah and Rifater.
RILUZOLE
Yes
Tablets may be crushed and
given, preferably in sugar/soft
food, as drug is not very soluble
in water. Crush and mix into
soft food
RISEDRONATE
No
Do not give via feeding tube.
Review need. 35mg tablets
disperse in 10ml water within 5
minutes to give fine dispersion.
RISPERIDONE
No
Quicklets available and
injection, liquid.
RIVASTIGMINE
Yes
Solution and patch
ROPINIROLE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
Mix with soft food and crush
and mix with water for use
down enteral feeding tubes.
ROSIGLITAZONE
Yes
May increase effect. Consider
sliding scale.
ROSUVASTATIN
Yes
Use immediately as light
sensitive
SALBUTAMOL
Yes
Do not crush MR preparations –
convert to liquid and give in 3-4
divided doses. Consider
changing to nebulised therapy
SECOBARBITAL
Yes
Open capsules and dissolve
contents in water, use
immediately and discard
remainder
Liquid
SELEGILINE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
Yes
Liquid available
SENNA
Yes
Liquid available
SERTRALINE
Yes
Tablets may be crushed but
powder is poorly soluble in
water (Lustral). Can mix with
food, e.g. jam. Powder tastes
bitter and has local anaesthetic
effect. Ensure all powder is
given if giving down tube
SEVELAMAR
No
Not recommended in feeding
tubes
SILDENAFIL
Yes
Tablets will disperse in water,
give immediately
Consider other drug
available in syrup e.g.
fluoxetine, citalopram oral
drops.
25mg/5ml x
100ml £83
5mg/5ml x
100ml £83
5mg/5ml x
50ml £23
SIMVASTATIN
Yes
Give immediately as light
sensitive and give via 8Fr NG
tube. Take significant time to
disperse.
SITAGLIPTIN
Yes
Readily soluble in water
SIROLIMUS
SODIUM BICARBONATE
Yes
SODIUM CHLORIDE
Injection can be given
orally or enterally
Injection may be given
orally or enterally
SODIUM
PHENYTLBUTYRATE
Injection may be given
orally
SODIUM CROMOGLICATE
Contents can be removed,
dissolved in hot water, then
diluted in cold water before
taking
SODIUM CLODRONATE
Yes
Open capsules and disperse
contents. Stop feed for two
hours before and after and take
care not to give any calcium,
milk etc in that period. Only
mix with water. Can be opened
and flushed via enteral feeding
tube.
SODIUM FUSIDATE
Yes
Fucidin syrup comes as fusidic
acid which is not as well
absorbed as sodium fusidate: 500mg in tablets = 750mg in
syrup
SODIUM PICOSULFATE
No
Liquid available
Liquid available
SODIUM VALPROATE
No
Epilim liquid may be
administered rectally. Contact
pharmacy for details. REF When
switching g from oral to IV, the
IV dose is the same as the oral
dose. Epilim chrono
formulations are
interchangeable with other
conventional or prolonged
release formulations of
equivalent daily doses.
SOLIFENACIN
Yes
Dissolves quickly in water,
however irritant to the eyes.
SOTALOL
Yes
SPIRONOLACTONE
Yes
Crushable tablets and
injection
Consider switching to
oxybutynin
Consider licensed beta
blocker preparations
Can take 5 minutes for tablet to
completely disperse. Will flush
down 8 FR NG tube without
blockage.
25mg/5ml x
125ml £45
50mg/5ml x
125ml £48
STALEVO
Yes
Suspend in water. Only
sparingly soluble with insoluble
excipients. Will stain skin, teeth,
tongue and tube. Max with
yoghurt, milk, honey, jam,
orange juice or water. Give
immediately. See Parkinson
information at end of
document.
STAVUDINE
no
Open capsules and mix into
water or food. Contents pour
freely, mix with water when
stirred and flush via 8Fr NG
tube without blockage.
STRONTIUM
No information regarding
administration via tube but no
reason why the product could
not be administered via this
route. Stop feed 2 hours before
and after administration.
SUCRALFATE
Yes
Stop feed for one hour before
and after dose due to the risk
of bezoar formation. Likely to
block tube and no suitable for
JEJ administration.
SULFASALAZINE
Yes
Do not crush E/c.
SULINDAC
SULPIRIDE
Yes
Yes
Can be dispersed to form fine
dispersion which can be drawn
up and flushes via 8Fr NG tube
without blockage.
TACROLIMUS
See next
Open capsules and mix
contents with small amount of
water. Do not inhale and wear
maxk and gloves.
TAMOXIFEN
Yes
Tablets may be crushed and
given mixed with jam or
yoghurt.
Suspension available
Suppositories/enema for
lower-bowel disease.
Suspension available
Liquid available
Handle drug powder with care
(avoid dust being inhaled, on
skin etc. as far as possible – use
mask, gloves and eye
protection).
TAMSULOSIN
Yes
MR capsules - the granules may
be emptied out and mixed with
cold water, but swallow whole,
do not chew granules.(Small
granules, so should go down
NG or PEG tube too). May give
sudden hypotensive effect if
administered via PEG/NG. May
block feeding tubes – flush well.
TELMISARTAN
Yes
Tablets not very soluble but will
flush via 8Fr NG tube without
blockage. Absorb moisture after
crushing to give immediately.
TEMAZEPAM
Yes
TENOFOVIR
Liquid available
Disperse in 100ml water,
orange juice or grape juice and
take immediately. Disperse in 5
minutes and flush via 8Fr Ng
tube without blockage.
TERBINAFINE
Yes
TERAZOSIN
Yes
May take 5 minutes to disperse.
Insoluble excipients
TETRABENAZINE
Yes
Dispersion occurs slowly at
least 5 minutes
THALIDOMIDE
No
Manufacturers advise that
capsules should not be opened.
However, they do provide the
following information:
• Thalidomide is not very
soluble and may therefore block
NG tubes. It may be given by
NG by: Using a syringe suitable
for connecting to the NG tube,
remove the plunger and empty
the contents of the capsule into
the syringe. Add water or
enteral feed, replace plunger
and administer. Flush the
syringe and the NG tube until
the capsule contents have been
completely administered. To
avoid blockage administer only
1-2 capsules at a time.
• The contents of thalidomide
may be mixed with soft food
and given orally. Give
immediately as stability
unknown.
• When administering staff
should wear disposable gloves
and masks, and the empty
capsules should be disposed of
in a cytotoxic waste bin.
• Pregnant members of staff
should not handle the drug.
THEOPHYLLINE
Do not crush M/R tablets
60mg/5ml x
300ml £136
M/R capsules. The granules
can be emptied from the
capsule and swallowed (whole)
with soft food e.g., yoghurt.
DILUTE WITH
equal volume
of water
If converting to syrup from a
M/R product, dosage regime
will need to be adjusted –
monitor levels. Divide total daily
dose by 3 and give TDS.
Do not crush Nuelin SA, Slophylline capsules may be
opened and flushed through
tube. Do not crush granules
and may block tube, Flush well.
Absorption may be decreased
by 60-70% but increased
absorption has also been
reported. Aminophylline
injection has been given orally
and enterally.
Interacts with Osmolite®,
Ensure® and Ensure plus® so
stop feed for one hour before
and after
THIAMINE
Yes
THIOGUANINE
TIAGABINE
No
TIBOLONE
Yes
TIMOLOL
No
TIZANIDINE
Yes
Crush to fine powder for
NG/PEG tubes.
TOLBUTAMIDE
Yes
Crush and disperse in water
Yes
30 minutes before food
Suspension available
May take 5 minutes – gives fine
dispersion that flushes down
8Fr NG tube without blockage.
Suspend in water
Liquid available
Consider changing to
alternative beta blocker
TOLTERODINE
Yes
Normal release prep can be
crushed. XL capsules contain
uniform time-release beads and
can be opened and the intact
beads administered. Settles
quickly but draws up and
flushes via 8Fr Ng tube without
blockage.
TOPIRAMATE
Yes
Do not administer sprinkle
beads via tubes as these stick
and cause blockage. Sprinkle
Sprinkles® in liquid or on soft
food. Capsule contents stick to
plastic tubes so not suitable for
PEG/NG. Normal tablets can be
crushed too.
TORASEMIDE
Yes
Crush and disperse in water.
Slurry is formed so rinsing of
tube essential.
TRAMADOL
No
TRANDOLAPRIL
Yes
Remove capsule contents and
disperse in water. Bitter taste.
Soluble tablets are most
suitable for administration via
enteral tubes.
Capsule contents can be mixed
with fruit squash to mask bitter
taste or mixed in water to give
via PEG/NG.
May cause sudden hypotension
if patient dehydrated. Capsules
very small and difficult to open.
Consider alternative
Oxybutynin Elixir.
10mg/5ml x
100ml £42
25mg/5ml x
100ml £40
Injection, sachets,
orodispersbiel tablets
Consider changing to
alternative ACEI.
TRANEXAMIC ACID
Yes
Tablets disperse in 2-5 minutes. Can use injection orally or
enterally immediately
after dilution. Store in
fridge and use within 24
hours.
TRAZODONE
Yes-only open Bitter taste
capsules and
mix with
water
TRIFLUOPERAZINE
Yes
Do not crush MR tablets.
Spansules are s/r and cannot be
opened/crushed.
TRIHEXYPHENIDYL
Yes
Disperse tablet in water and will
flush down 8Fr NG tube without
blockage.
TRIMEPRAZINE
No
TRIMETHOPRIM
Yes
Stop feed for 30 minutes before
and after administration of
liquid. Well absorbed via enteral
feeding tubes
TRIMIPRAMINE
Yes
Open capsules and suspend in
water or crush and suspend
tablets in water. Has local
anaesthetic action
TROSPIUM
Yes
With disperse in 100ml water,
orange or grape juice. Bitter
taste.
Liquid available
Liquid available
Liquid available
Liquid available
Consider tricyclic
antidepressants
URSODEOXYCHOLIC ACID
Yes
Open capsules and suspend in
water. Do not disperse in water.
May block fine bore tubes.
Capsules (Ursofalk) can be
opened and contents sprinkled
on to food.
VALACICLOVIR
No but see
next
Quite difficult to crush and
powder does not suspend well,
therefore not advised. If
crushed and suspend in water,
dose must be given immediately
owing to the rapid rate of
hydrolysis. Can flush down 8Fr
NG tube without blockage but
must be draw into syringe
immediately. Check references
VALSARTAN
Yes
Tastes bitter
VANCOMYCIN
Yes
Liquid available
Change to ACEI
Injection can be used
orally for Clostridium
difficile- can also use via
nasogastric tube. Consult
pharmacy.
Capsule contents are gelformed and not suitable
for feeding tube
administration.
125mg/5ml x
300ml £60
Normal
release YES
Mix with jam and or liquid
M/r -NO
Capsule contents (MR granules)
may be emptied out and given
in smooth food e.g. yoghurt –
granules not to be crushed or
chewed. To convert from M/r to
normal release, total daily dose
is given as two divided doses
and adjusted as necessary.
VERAPAMIL
Yes
Only crush normal release
tablets. Bitter taste and local
anaesthetic action in mouth. Do
not crush MR tablets. Doses
should be divided throughout
the day. Ordinary tablets may
be crushed and dissolved in
water but a drink of juice
should be given afterwards to
remove bitter taste/local
anaesthetic effect. The beads
from the MR capsules may be
given, swallowed whole. May
block tube. Stop feed 1 hour
before and post dose.
VIGABATRIN
Yes
Disperse contents of sachet in
water as well as crushing
tablets and dispersing in water.
Can put contents of sachet
down 8Fr NG tube without
blockage.
VENLAFAXINE
Mirtazepine Orodispersible
Tablets
Liquid available
Injection may be given
orally or enterally. Give
on an empty stomach;
withhold enteral feeds for
one hour before and one
hour after each dose
VITAMIN B COMPOUND
Yes
Ensure full dose is given as
active substance present in very
low concentrations
VITAMIN E
No
Liquid available
VORICONAZOLE
No
Liquid available – take 1
hour before food or 1
hour after.
WARFARIN
Yes
Stop feed 1 hour before and 12 hours post dose. Monitor INr
closely as crushing may
increase absorption.
Liquid available
Liquid available
Vitamin K content of Osmolite®
and other feeds may antagonise
anticoagulant effect of warfarin.
ZAFIRLUKAST
Yes
May be difficult to crush, may
result in increase peak levels.
ZESTORETIC
Yes
ZIDOVUDINE
No
Syrup available
ZINC SULPHATE
No
Effervescent tablets and
injection available
ZOPICLONE
Yes
If for N/G or PEG tube use,
crush as finely as possible, mix
with water and give QUICKLY the powder is designed to
thicken in water. This may
cause tube blocking so is very
important. Hard to crush and
bitter taste.
Try other hypnotic e.g.
Temazepam / Nitrazepam
Do not crush Zimovane as
bioavailability may be altered.
ZOLPIDEM
ZONISAMIDE
Yes
Yes
Open capsule and suspend
contents in water. Has been
added to food and apple juice
ZUCLOPENTHIXOL
Yes
May block tube as not very
soluble
REFERENCES
NEWT guidelines
Enteral feeding book
Previous Dysphagia guidelines
Cornwall dysphagia guidelines
Waltham Forest guidelines
NELM Q and A which injections can be used orally
Manufacturers