There are good reasons why certain medications cannot be crushed. Sometimes the coating of the tablet is to help prevent side effects (e.g. enteric coating of aspirin to prevent gastric ulcer), other times it is to maintain its efficacy (e.g. enteric coating of proton pump inhibitor to bypass the acidic stomach, so it can be absorbed in the duodenum). And in some cases, it has nothing to do with efficacy or side effects but to protect the person from hazardous exposure (e.g. cytotoxic medications).
Hence it is important to understand the reason for not crushing the medications so that alternative options can be explored.
Here are 5 examples of medications that we should not crush and why:
- Dabigatran: Dabigatran is a direct oral anticoagulant commonly prescribed for the prevention of stroke in individuals with atrial fibrillation. If the content of the capsule is crushed, there is a possibility of increased absorption and excessive anti-coagulation that may lead to unwanted bleedings. Hence, the medication should not be crushed. An alternative is to switch to rivaroxaban where the tablet can be crushed for easier administration
- Proton Pump Inhibitor: Another common class of medications is proton pump Inhibitor. These include pantoprazole magnesium (Tecta), omeprazole (Losec), lansoprazole (Prevacid), rabeprazole (Pariet). They all work to reduce the production of stomach acid and thereby helping to relieve reflux symptoms (heartburn). If the enteric coating of the tablet is crushed, the medication will be quickly degraded in the stomach before reaching the duedenum for absorption, rendering the drug ineffective. There are few options if the tablet or capsule cannot be swallowed whole:
- Switch to a capsule formulation of omeprazole or lansoprazole where the content can be mixed with soft food for administration
- Switch to Pravacid Fastab which is a fast dissolving tablet of lansoprazole. This option is however not covered by Ontario Drug Benefit
- Ask pharmacy to formulate an oral suspension for administration. There are different formulas to compound a suspension containing a proton pump inhibitor. Many of these formulas require a high content of sodium bicarbonate to buffer the suspension as “basic” as possible to avoid the acidic degradation in the stomach.
- Long acting opioids: MS Contin or Hydromorph Contin are long acting and sustained release formulation of opioids to help treat individuals with chronic pain. They are designed to slowly release the medication to help with pain relief. If the integrity of the capsule or tablet is destroyed, the medication may be rapidly absorbed, leading to possible opioid overdose and side effects (e.g. oversedation) and does not last the intended duration, leading to inadequate pain control. If the tablet cannot be swallowed whole, it may be necessary to use immediate release formulation to be given more frequently.
- Cytotoxic medications: Many cytotoxic medications can be given orally as tablets. However, they can be harmful to healthy cells and as such, individuals handling them should take precaution to minimize unnecessary exposure. It is recommended to use the “no touch” technique or whatever approved protocol in place for the institution. But the basic protection is to minimize touching the tablet (e.g. wear gloves) and to avoid crushing it in any way, as destroying the integrity of the tablet may cause unintentional inhalation of the medication. The most common examples include methotrexate and hydroxyurea.
- Teratogenic medications: Many individuals don’t realize that medication such as finasteride should not be crushed. Although it is not considered as cytotoxic medication, it has terotogenic properties which means it can lead to harmful effects to the fetus or embryo. Women of childbearing age should avoid direct contact of the content by avoiding crushing the medication.
A number of organizations has developed various lists of medications that should not be crushed. Here’s one from ISMP. So before you crush another tablet, check first to see if it can be crushed and understand the reasoning behind this instruction.
Doing so will help identify alternative options but more importantly, to protect yourself, to ensure the drug works and to prevent its side effects.