Rx Update: March 2004
Medications That Should Not Be Crushed
Joan Murhammer, R.Ph., Mary Ross, R.Ph., M.B.A., Kevin Bebout,
R.Ph.
Peer Review Status: Internally Reviewed
If a liquid formulation of a medication is not available, it is
sometimes desirable to crush a medication for a patient who is
experiencing difficulty swallowing tablets/capsules or has a
nasogastric tube placed. However, due to special pharmaceutical
formulations of some medications, crushing the tablet/capsule may be
an unsafe practice. Some reasons why certain medications should not
be crushed before administration include:
- Crushing a sublingual or buccal tablet may cause the drug to
be ineffective.
- When enteric-coated tablets are crushed, the drug is released
too early and may be destroyed by stomach acid or irritate the
stomach lining.
- Extended-release formulations should not be crushed because
they may cause an increased risk of adverse effects or potentially
deliver a toxic dose of the active ingredient. Many
extended-release formulations have abbreviations affixed to their
name (e.g., CR, LA, SR, XL, XR) to identify them as
extended-release.
- Crushing products with carcinogenic/teratogenic potential may
expose handlers to health risks through aerosolization of the
product.
- Fragility, bitter taste, local anesthetic effect, the ability
to stain teeth, and irritation of the mouth or esophageal
mucosa.
A partial list of medications that should not be crushed
includes:
- Enteric-coated:
- Bisacodyl (Dulcolax®), enteric-coated
aspirin (Ecotrin®), lansoprazole
(Prevacid®), omeprazole
(Prilosec®), pancrelipase
(Pancrease®), divalproex sodium
(Depakote®), many erythromycin products
- Extended-release:
- Diltiazem controlled-dissolution (Cardizem
CD®), fexofenadine/pseudoephedrine
(Allegra-D®), mesalamine
(Asacol®, Pentasa®), verapamil
sustained-release (Calan SR®, Isoptin
SR®), oxybutynin extended-release (Ditropan
XL®), propranolol long-acting (Inderal
LA®), tamsulosin (Flomax®),
divalproex sodium extended-release (Depakote
ER®), many theophylline products
- Bitter taste:
- Cefuroxime (Ceftin®), ciprofloxacin
(Cipro®), docusate (Colace®),
ibuprofen (Motrin®)
- Irritant:
- Alendronate (Fosamax®), atomoxetine
(Strattera®), diflunisal
(Dolobid®), isotretinoin
(Accutane®), piroxicam
(Feldene®), risedronate
(Actonel®), valproic acid
(Depakene®)
- Safety:
- Finasteride (Proscar®), mycophenolate
(Cellcept®), other cancer chemotherapy
agents
- Anesthetizes local mucosa:
- Benzonatate (Tessalon Perles®)
- Fragility:
- Mirtazapine (Remeron SolTab®), olanzapine
(Zyprexa Zydis®)
- Ability to stain teeth:
- Amoxicillin/clavulanate (Augmentin®),
linezolid (Zyvox®), iron products
If you need a liquid formulation of a medication or if there
are any questions regarding the acceptability of crushing certain
medications, please contact the Pharmacy serving your area or the
Drug Information Center (6-2600).
-------------------
Adapted from:
Mitchell JE. Oral Dosage Forms That Should Not Be Crushed: 2000
Update. Hospital Pharmacy. 2000; 35:553-7.
Miller H, Miller D. To Crush or Not to Crush. Nursing. 2000; 30:50-2.
Title Page