Which tablets should never be crushed?
Not all medications are suitable for crushing. Drugs that should not be crushed are those that are:
- Designed to be controlled release
- Coated for protection or taste
- Dissolvable
- Liquid-filled gel capsules
- Hazardous or irritants
- Intended for a small therapeutic window
They usually have special letters in their name, such as:
- CC
- CD
- ER
- XR
- LA
- XL
- EC
- ODT
- SL
Controlled release
These are designed to release medicine over an extended period to allow less frequent administration. Crushing may mean a fatal dose is released. Formulations include:
| Prefix or Suffix | Examples | Reasons for use |
|---|---|---|
|
12-hour or 24-hour CC — Coat core CD — Controlled delivery CR — Controlled release CRT — Controlled-release tablet DR — Delayed release DA — Delayed absorption ER, XR — Extended release LA — Long acting SA — Sustained action Slo- or SR — Slow release TD — Time delay TR — Time release PA — Prolonged action SSR — Sustained release XL, XT — Extended release |
Mucinex-D 12 hour (guaifenesin and pseudoephedrine hydrochloride) Adalat CC (nifedipine) Adderall XR (amphetamine and dextroamphetamine) Detrol LA (tolterodine) Isosorbide SR (isosorbide mononitrate) Cardura XL (doxazosin) Procardia XL (nifedipine) Cartia XT (diltiazem) |
Longer duration of action Smoother level of drug release over time Special release technology to provide fast release followed by extended release all in one drug Multiple-layered tablets that release as each layer is dissolved Special matrices that allow the slower release of a drug |
Enteric coated
These have a special coating to:
- Protect your stomach from the drug
- Protect the drug from stomach acid
- Target the release of the drug in the intestines
Crushing may lead to the medicine being released too early, being destroyed by stomach acid or irritating your stomach wall.
| Prefix or Suffix | Examples | Reasons for use |
|---|---|---|
|
EC, EN — Enteric coated |
Diclofenac EC (diclofenac) Ecotrin (aspirin) Ery-Tab (erythromycin) |
The drugs are most soluble in the intestines and need to pass through the stomach intact Protection from drugs that irritate the stomach |
Taste-modified
These medications are sugar-coated to improve their taste. If crushed, the unpleasant taste would surface, which could discourage patients from taking the medication.
| Prefix or Suffix | Examples | Reasons for use |
|---|---|---|
|
SPT — Strong, persistent taste TS — Taste |
Ceftin (cefuroxime) Motrin (ibuprofen) Topamax Sprinkle (topiramate) Vesicare (solifenacin) |
Unacceptable taste |
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Dissolvable
These are designed to dissolve on the tongue or under the tongue. Crushing or chewing these may cause a loss of dosage.
| Prefix or Suffix | Examples | Reasons for use |
|---|---|---|
|
ODT — Orally disintegrating tablets |
Lamictal ODT solute (lamotrigine) Zofran ODT (ondansetron) Maxalt-MLT (rizatriptan) Zomig-ZMT (zolmitriptan) |
Difficulty swallowing in children or in stroke, tumor, multiple sclerosis or Parkinson’s disease patients Nausea Prevent patients from hiding medication in the mouth (“cheeking”) to spit out later |
|
SL — Sublingual |
Nitrostat (nitroglycerin) Zubsolv (buprenorphine and naloxone) |
Faster absorption (than swallowed tablet or capsule) |
Liquid content
Soft gelatin capsules (with liquid filling) should not be chewed or split. Removal of the liquid inside may lead to incorrect dosage.
| Prefix or Suffix | Examples | Reasons for use |
|---|---|---|
|
LC — Liquid within capsule LF — Liquid filled |
Drisdol (ergocalciferol) Dulcolax (bisacodyl) |
Designed specifically to ensure proper dosage and absorption |
Hazardous
These have cancer-causing or baby-harming potential when tampered with. They are hormonal or chemotherapeutic drugs.
| Prefix or Suffix | Examples | Warnings |
|---|---|---|
|
None |
Skin contact may cause tumor production Women who are pregnant or may become pregnant should not handle |
Irritant
These can irritate the gut lining or skin if tampered with.
| Prefix or Suffix | Examples | Warnings |
|---|---|---|
|
IR — Irritant |
Actonel (risedronate) Zolinza (vorinostat) |
Chewed, crushed or sucked tablets may cause gut ulcers or skin irritation |
|
MMI — Mucous membrane irritant |
Afinitor (everolimus) Fosamax (alendronate) Valcyte (valganciclovir) |
Small therapeutic windows
Drugs like warfarin or levothyroxine have small therapeutic windows. If split into uneven parts and taken, the dose may be too high or too low.
Exceptions
Some slow-release tablets are scored and can be divided or halved, but not crushed. Examples include Toprol XL (metoprolol succinate) and Sinemet CR (carbidopa and levodopa). Certain long-acting capsules can also be opened and their contents sprinkled without chewing or crushing. Examples include Kadian (morphine) and Xtampza ER (oxycodone).
References
- Institute for Safe Medication Practices (ISMP). Oral Dosage Forms That Should Not Be Crushed. February 21, 2020. Available at: https://www.ismp.org/recommendations/do-not-crush.
- Gracia-Vásquez SL, González-Barranco P, Camacho-Mora IA, et al. Medications that should not be crushed. Medicina Universitaria. 2017. Volume 19, Issue 75, Pages 50-63. https://doi.org/10.1016/j.rmu.2017.03.001.
- Cornish P. "Avoid the crush:" hazards of medication administration in patients with dysphagia or a feeding tube. CMAJ. 2005;172(7):871-872. https://doi.org/10.1503/cmaj.050176.
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