To crush, or not to crush, that is the question we often face when trying to administer medications to our patients that are no longer able to swallow tablets and capsules whole. But how do we know what medications can be administered safely when crushed and what medications cannot?
We have all been there - the inevitable time when one of our hospice patients can no longer swallow whole capsules and tablets. The seemingly simple answer would be to crush the medication and add the crushed medication to a liquid or soft food, but herein lies the question - How do we know which medications can be safely crushed?
The answer is not as straightforward as we would like, but, as a rule of thumb, there are certain categories of medications that cannot be safely crushed.
The first clue is often found in the name.
Extended Release Medications – Medications that are extended release means just what the name implies, the drug is released slowly over a given period of time. These types of medications should not be crushed as it allows the drug to be released at a faster rate and can, in fact, destroy the actual medication leading to decreased efficacy. Many of these types of medications indicate whether a drug is extended release in the name. Examples are:
- CD - Controlled dose
- CR - Controlled release
- CRT - Controlled release tab
- LA - Long acting
- SA - Sustained action
- SR - Sustained release
- TR - Timed release
- TD - Time delay
- XL - Extended release
- XR - Extended release
Can it hurt?
Other medications are designed to protect the mucus membranes in our stomach or intestines. The most common form is Enteric Coated Medications. Aspirin EC (i.e. Ecotrin) is a prime example of an enteric coated medication. Enteric coating allows the medication to be released in the small intestine instead of the stomach, thus reducing irritation to the lining of the stomach. Therefore, enteric coated medications should NOT be crushed.
Watch out for capsules and coated tablets.
Some medications contain chemicals which are FOUL tasting! And, I do mean FOUL. For these types of medications, the manufacturer often coats the tablet or places in a gel capsule to conceal the taste. When the tablet/gel capsule is crushed, the patient is left tasting the unpalatable medication which may prove to be difficult to convince even the most pleasant patient to consume.
What about dissolvable tablets?
Effervescent medications are tablets that are dropped into a liquid and dissolve quickly. An example of an effervescent tablet the common population knows is Alka-Seltzer’s commercial “Plop, plop, fizz, fizz…” Once effervescent tablets are crushed, it loses the ability to dissolve correctly.
The final category of medications not to crush is the potentially hazardous substances. Some medications have contraindications and can be carcinogenic or genotoxic. Refer to MSDS institution guidelines.
There is hope - your pharmacist!
Your pharmacist has a wealth of information available to help determine if a medication may be crushed or not. Fortunately for us, many medications have solutions/suspensions or suppositories available if the medication is unable to be crushed. Compounding medications have become more common in pharmacies to provide alternative delivery systems of medications. If you ever have a question as to whether a medication can be crushed or not, just ask your pharmacist!
A short list of common medications we SHOULD NOT crush:
Aggrenox Aspirin/dipyridamole Extended release
Ambien CR Zolpidem CR Slow Release
Amitiza Lubiprostone Manufacturer recommends
Aricept 23mg Donepezil Film coated
Ecotrin Aspirin EC Delayed release, enteric coated
Dulcolax Bisacodyl Enteric coated
Colace Docusate sodium Foul taste
Cymbalta Duloxetine Enteric coated
Depakene Valproic acid Slow release, mucus membrane, hazardous
Depakote Divalproex Delay release, hazardous
Dilantin Phenytoin Extended release, manufacturer recommends
Flomax Tamsulosin Slow release
Geodon Ziprasidone Hazardous substance
Imdur Isosorbide mononitrate Extended release
K-Dur, Klor-Con, K-Tab Potassium chloride Slow, extended release
Keppra Levetiracetam Foul taste
MS Contin Morphine Sulfate ER Slow, extended release
Mucinex Guaifensin Slow release
Mucinex DM Guaifensin/dexmethorphan Slow release
Nexium Esomeprazole Delayed release
OxyContin Oxycodone ER Slow, extended release
Pradaxa Dabigatran Bioavailability decreases by 75%
Prevacid Lanoprazole Delayed release
Prilosec Omeprazole Delayed release
Protonix Pantoprazole Slow release
Tessalon Perles Benzonatate May cause choking if opened or chewed and swallowed
Sumycin Tetracycline Hazardous substance
Topamax Topiramate Foul taste
Xanax ER Alprazolam ER Slow release
**This list is not exhaustive. You may find a complete list by visiting: https://www.ismp.org/recommendations/do-not-crush
- Digi Graham, D.Ph
Director of Clinical Services at PDCRx