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To Crush or Not to Crush

From: The Hospitalist, April 2009

Do your homework before breaking down medications

by By Michele B. Kaufman, PharmD, BSc, RPh

There are multiple reasons for crushing tablets or capsule contents before administering medications, but there are numerous medications that should not be crushed. These medications should not be chewed, either, usually due to their specific formulations and their pharmacokinetic properties.1 Most of the no-crush medications are sustained-release, oral-dosage formulas. The majority of extended-release products should not be crushed or chewed, although there are some newer slow-release tablet formulations available that are scored and can be divided or halved (e.g., Toprol XL).

A common reason for crushing a tablet or capsule is for use by a hospitalized patient with an enteral feeding tube. A recent review in the American Journal of Health-System Pharmacy provides more details about administering medications in patients with enteral feeding tubes.2 Oral solutions can be used when commercially available and medically appropriate. If an oral solution or suspension is not available, the hospital pharmacy should be consulted to determine if a liquid formulation of the product can be extemporaneously prepared. In some cases, after careful consideration of compatibility, stability, and drug absorption changes, an injectable formulation of a product may be used. You should always consult your hospital pharmacist for information on this modality of drug administration.

Some patients have difficulty swallowing tablets or capsules; some dislike the taste. In these cases, crushing of medication for powdered delivery (to be mixed with food or beverages) should be considered. But beware of certain caveats, as not all medications are suitable for crushing. Generally, meds that should not be crushed fall into one of these categories:

  • Sustained-release tablets, which can be composed of multiple layers for different drug release times, as can beads within capsules. Some of the more common prefixes or suffixes for sustained-release, controlled-release, or controlled-delivery products include: 12-hour, 24-hour, CC, CD, CR, ER, LA, Retard, SA, Slo-, SR, XL, XR, or XT.
  • Enteric-coated tablets, which are formulated because certain drugs can be irritating to the stomach or are degraded by stomach acid. By enteric-coating tablets or capsule beads, the drug’s release can be delayed until it reaches the small intestine. Prefixes include EN- and EC-.

Other medications have objectionable tastes and are sugar-coated to improve tolerability. If this type of medication is crushed, the patient would be subject to its unpleasant taste, which could significantly impair medication adherence. Additionally, both sublingual and effervescent medications should not be crushed because it will decrease the medication’s effectiveness.

Hospital Pharmacy publishes a wall chart that includes many of these types of formulations, along with their do’s and don’ts. If there is ever any doubt about the best way to administer a particular product or whether it can be halved or crushed, ask your pharmacist.3 TH

Michele B. Kaufman, PharmD, BSc, RPh, is a freelance medical writer based in New York City.

Market watch

New Generics

  • Stavudine capsules (generic Zerit)4

New Drugs, Indications & Dosage Forms

Cinryze, a C1 esterase inhibitor (human), is FDA-approved as a new orphan drug for routine prophylaxis against angioedema in patients with hereditary angioedema (HAE).5 The drug is administered intravenously (IV) and can be administered every three to four days for routine HAE attack prevention, which can spontaneously occur during stress, surgery, or infection, and lead to rapid swelling of the hands, feet, limbs, face, intestinal tract, or airway.6

Granisetron 3.1mg/24-hour transdermal patch (Sancuso) is FDA-approved for preventing nausea and vomiting in adults receiving moderate or high-chemotherapy regimens for up to five consecutive days.7 To dose the patch, apply it to a clean, dry area of intact healthy skin on the upper outer arm 24 to 48 hours before chemotherapy, and remove it at least 24 hours after chemotherapy has been completed. A patch may be worn for up to seven days. They should not be cut.

Hydrocodone bitartrate 10-mg/chlorpheniramine 8-mg (Tussicaps) is FDA-approved as a Schedule III controlled substance as an antitussive/antihistamine combination.8 Adult dosage is one capsule every 12 hours.

Lacosamide (Vimpat) is FDA-approved for add-on therapy in patients ≥17 years with uncontrolled, partial-onset seizures.11 The starting dose is 50 mg twice daily and may be increased to a daily dose of 200-400 mg as two divided doses. The most common adverse reactions in clinical trials were diplopia, headache, dizziness, and nausea. Both the oral tablets and the IV infusion are bioequivalent.

Mesalamine extended-release 0.375-gm capsules (Apriso) is FDA-approved for once-daily dosing for the maintenance of remission of ulcerative colitis.9 Mesalamine is a local-acting aminosalicylate. The recommended dose is four capsules (1.5 g/day) in the morning with or without food. Because release of the active drug is pH-dependent, it should not be administered with antacids.

Ranolazine (Ranexa) is FDA-approved as an initial treatment for chronic angina.10 It can be used as monotherapy, in combination with beta blockers, or with other drugs.

Quetiapine extended-release tablets (Seroquel XR) are FDA-approved to treat depressive episodes in bipolar disorder, manic and mixed episodes in bipolar I disorder, and the maintenance treatment of bipolar I disorder as adjunct therapy to lithium or divalproex.11 It already is approved to treat schizophrenia. It is available in two new dosage strengths, 50- and 150-mg tablets.12 This is in addition to the previously available strengths of 200-, 300- and 400-mg tablets.

New Warnings

There have been more than 1,000 serious adverse events—including 50 deaths—associated with the use of varenicline (Chantix) since its approval in 2006.13 The FDA’s MedWatch program, which underestimates and does not determine causality, noted at least 3,325 serious injuries.14 The FDA has warned of suicidal ideation in patients taking varenicline, along with the possibility of severe mood and behavior changes, as well as worsening or recurring psychiatric illness with this agent.

References

1. Mitchell J. Oral dosage forms that should not be crushed or chewed: facts and comparisons 4.0. Hospital Pharmacy Web site. Available at: online.factsandcomparisons.com/Viewer.aspx?book=atoz&monoID=fandc-atoz1040. Accessed March 5, 2009.

2. Williams NT. Medication administration through enteral feeding tubes. Am J Health Syst Pharm. 2008;65(24):2347-2357.

3. Mitchell JF. Oral dosage forms that should not be crushed: wall ch­art. Wolters Kluwer Health Web site. Available at: www.factsandcomparisons.com/Products/product.aspx?id=1111. Accessed Jan. 26, 2009.

4. Mylan's Matrix receives final FDA approval for the generic version of the antiretroviral Zerit capsules. Wolters Kluwer Health Web site. Available at: http://mylan.mediaroom.com/index.php?s=43&item=399. Accessed Jan. 23, 2009.

5. Product approval information. U.S. Food and Drug Administration Web site. Available at: www.fda.gov/Cber/products/Cinryze.htm. Accessed Jan. 14, 2009.

6. FDA licenses for marketing new therapy for rare genetic disease. U.S. Food and Drug Administration Web site. Available at: www.fda.gov/bbs/topics/NEWS/2008/NEW01903.html. Accessed Jan. 14, 2009.

7. Sancuso patch approved for nausea and vomiting. Monthly Prescribing Reference Web site. Available at: www.empr.com/Sancusopatchapprovedfornauseaandvomiting/article/122384/. Accessed Jan. 14, 2009.

8. TussiCaps now available for cough suppression. Monthly Prescribing Reference Web site. Available at: www.empr.com/TussiCapsnowavailableforcoughsuppression/article/122377/. Accessed Jan. 14, 2009.

9. UCB’s Vimpat approved by U.S. FDA as adjunctive therapy for partial onset seizures in adults. Medical News Today Web site. Available at: www.medicalnewstoday.com/articles/127354.php. Accessed Jan. 14, 2009.

10. Apriso granted FDA marketing approval for maintenance of remission of ulcerative colitis. Medical News Today Web site. Available at: http://www.medicalnewstoday.com/articles/127839.php. Accessed Jan. 14, 2009.

11. http://biz.yahoo.com/ap/081106/cv_therapeutics _ranexa.html?.v=1. Accessed February 2, 2009.

12. FDA approves Seroquel for bipolar maintenance. Monthly Prescribing Reference Web site. Available at: www.prescribingreference.com/news/showNews/which/SeroquelXRForBipolar10101. Accessed Jan. 14, 2009.

13. Seroquel XR Web site. Available at: www.pharmacistelink.com/news/2009/01/14_seroquel.pdf. Accessed Jan. 23, 2009.

14. Peck P. Smoking cessation drug linked to 1,001 new serious adverse events. Medpage Today Web site. Available at: www.medpagetoday.com/PrimaryCare/Smoking/11428. Accessed Jan. 14, 2009.

15. Public health advisory: important information on Chantix (varenicline). U.S. Food and Drug Administration Web site. Available at: www.fda.gov/CDER/Drug/advisory/varenicline.htm. Accessed Jan. 14, 2009.


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