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VOLUME 18    NO.4                                                      APRIL 2003

PHARMACY, THERAPEUTICS AND NUTRITION COMMITTEE ACTION FOR JANUARY-MARCH 2003

ORAL DOSAGE FORMS THAT SHOULD NOT BE CRUSHED

            There are numerous oral medications that should not be crushed because of their special pharmaceutical formulation or characteristics.  Crushing or chewing such agents may substantially alter their pharmacokinetics.  Additional reasons for not chewing or crushing these drugs include poor taste, irritant properties or carcinogenic potential.  Examples of special formulations include sublingual or buccal, enteric coated, and extended release tablets or capsules.  Some medications are inherently corrosive to the oral mucosa and/or upper gastrointestinal tract, markedly bitter to the taste, or capable of staining oral mucosa or teeth.  Finally, several medications are potentially carcinogenic and require limited handling by medical personnel.  Crushing or breaking of agents that have carcinogenic/teratogenic potential may not alter the dosage form or delivery mechanism, but may cause aerosolization of particles - thus exposing the handlers of these products to health risks.

            For patients who cannot swallow whole tablets or capsules, or for patients on enteral nutrition, the most logical approach is to use liquid solution or suspension forms of the same medications.  In some cases, there must be a dosage adjustment when the liquid is substituted.  This is especially true if the tablet or capsule is an extended-release medication.  If a liquid or suspension is not commercially available, the pharmacist should be consulted to determine if the drug may be crushed (tablet) or opened (capsule) for oral or tube administration.

            Occasionally, it is possible to substitute the injectable form of the medication by placing the appropriate amount of injection in some suitable fluid, such as juice.  This should be done, however, only after consultation with a pharmacist to insure that there are no problems regarding compatibility or changes in absorption of the drug.

            Another alternative is to use a chemically different but clinically similar medication that is available in a liquid form.

            Some medications that cannot be crushed may be administered in other ways, such as administering the contents of a capsule in soft food.

SUMMARY OF DRUG FORMULATIONS THAT PRECLUDE CRUSHING

Type	Reason(s) for the Formulation
Enteric-coated	Designed to pass through the stomach intact with drug being released in the intestines to: 1) prevent destruction of drug by stomach acids 2) prevent stomach irritation 3) delay onset of action

Drug Product	Dosage Form	Dosage Reasons/Comments
Depakote	Capsule	Enteric-coated

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