Meds That Should Not Be Crushed

PL Detail-Document #300817
−This PL Detail-Document gives subscribers

additional insight related to the Recommendations published in−
PHARMACIST’S LETTER / PRESCRIBER’S LETTER
August 2014
Meds That Should Not Be Crushed

There is a wide range of circumstances that make administration of solid oral medications either impractical or impossible. For example, some
patients might need their meds to be given through a feeding tube. Others might have difficulty swallowing due to the effects of age, stroke,
chemotherapy, impaired gag reflex, etc. Crushing solid oral meds is a way to improve ease of their administration. However, there are many solid
oral medications that should not be crushed. Medications with some type of modified-release mechanism (i.e., extended-release, delayed-release) are
a classic case. Extended-release medications generally should not be crushed since crushing can destroy the release mechanism and allow for
administration of a large dose all at once. Crushing delayed-release meds (formulated with acid-resistant or enteric coating) can alter the mechanism
designed to either protect the drug (from gastric acids) or prevent irritation of the gastric mucosa. In addition, crushing sublingual or buccal tablets,
which are meant to be dissolved in the mouth, can increase or reduce their effectiveness. Crushing bitter-tasting meds can be unpleasant for the
patient. Additionally, crushing meds that are irritating or teratogenic can be harmful for the individual who is crushing the meds. The following
chart lists solid oral medications that should not be crushed.
Please note that this table provides a list of many common medications that should not be crushed, yet there are many more that are not listed.
Brand names listed on the chart are representative and may not be all-inclusive. The most current product labeling for both U.S. and Canadian
products was used to confirm information for the table, in addition to listed references.
Modified-release: Indicates an extended-release or delayed-release formulation as described above.10
Medications That Should Not Be Crushed1-7
Generic Name Brand Name Dosage Form Comments
Acamprosate Campral Tablet • Modified-release
Acetaminophen Tylenol Arthritis Pain Tablet • Modified-release
Extended-Release (U.S.)
Acetazolamide Diamox Sequels (U.S.) Capsule • Modified-release
• Can be opened for administration of intact granules8
Albuterol VoSpire ER (U.S.) Tablet • Modified-release
Alendronate Fosamax Tablet • Irritant (oropharyngeal)
Alfuzosin Uroxatral (U.S.), Tablet • Modified-release
Xatral (Canada)
Alprazolam Xanax XR (U.S.) Tablet • Modified-release
Ambrisentan Letairis (U.S.), Tablets • Teratogenic
Volibris (Canada)
Amoxicillin Moxatag (U.S.) Tablet • Modified-release
More. . .
Copyright © 2014 by Therapeutic Research Center
3120 W. March Lane, Stockton, CA 95219 ~ Phone: 209-472-2240 ~ Fax: 209-472-2249
www.PharmacistsLetter.com ~ www.PrescribersLetter.com ~ www.PharmacyTechniciansLetter.com
(PL Detail-Document #300817: Page 2 of 13)

Amoxicillin/Clavulanate Augmentin XR (U.S.) Tablet • Modified-release
• Tablet is scored and can be split
Aspirin Ecotrin Tablet • Modified-release
• Irritant (gastric)
Aspirin/Dipyridamole Aggrenox Capsule • Modified-release
• Can be opened for administration of intact granules
Atomoxetine Strattera Capsule • Irritant (ocular)
Belladonna Alkaloids Donnatal Extentabs (U.S.) Tablet • Modified-release
Benzonatate Tessalon Perles (U.S.) Capsule • Local anesthetic effect could increase the risk of choking
Bisacodyl Dulcolax Tablet • Modified-release
Bosentan Tracleer Tablet • Teratogenic
Bosutinib Bosulif Tablet • Teratogenic
Budesonide Entocort EC (U.S.), Capsule • Modified-release
Entocort (Canada) • Can be opened for administration of intact granules
Budesonide Uceris (U.S.) Tablet • Modified-release
Bupropion Aplenzin (U.S.); Tablet • Modified-release
Budeprion SR (U.S.);
Wellbutrin SR, XL;
Zyban
Cabozantinib Cometriq (U.S.) Capsule • Teratogenic
Carbamazepine Carbatrol (U.S.), Capsule • Modified-release
Equetro (U.S.) • Can be opened for administration of intact granules
Carbamazepine Tegretol XR (U.S.), Tablet • Modified-release
Tegretol CR (Canada)
Carvedilol Coreg CR (U.S.) Capsule • Modified-release
Cefuroxime Ceftin Tablet • Bad taste
Chlorpheniramine Chlor-Trimeton Allergy Tablet • Modified-release
Maleate 12 Hour (U.S.)
Ciprofloxacin Cipro Tablet • Bad taste
More. . .

Ciprofloxacin Cipro XR (U.S.), Tablet • Modified-release
Cipro XL (Canada)
Clarithromycin Biaxin XL Tablet • Modified-release
Clonidine Kapvay (U.S.) Tablet • Modified-release
Colestipol Colestid Tablet • Modified-release
Cyclobenzaprine Amrix (U.S.) Capsule • Modified-release
Cyclophosphamide Generics Capsule, Tablet • Teratogenic
Dabigatran Pradaxa Capsule • Intact product must be taken to avoid increased exposure
Dalfampridine Ampyra (U.S.) Tablet • Modified-release
Darifenacin Enablex Tablet • Modified-release
Dasatinib Sprycel Tablet • Teratogenic
Deferasirox Exjade Tablet • Tablet is for oral suspension
Desvenlafaxine Pristiq Tablet • Modified-release
Dexlansoprazole Dexilant Capsule • Modified-release
Dextroamphetamine Dexedrine Capsule • Modified-release
Dexmethylphenidate Focalin XR (U.S.) Capsule • Modified-release
Dextroamphetamine/ Adderall XR Capsule • Modified-release
Amphetamine • Can be opened for administration of intact granules
Diclofenac Voltaren XR (U.S.), Tablet • Modified-release
Voltaren SR (Canada)
Diclofenac/Misoprostol Arthrotec Tablet • Modified-release
• Teratogenic
Didanosine Videx EC Capsule • Modified-release
Diflunisal Generics Tablet • Irritant (gastric)
Diltiazem Cardizem CD, Capsule • Modified-release
Cartia XT (U.S.), • Can be opened for administration of intact granules (Taztia XT
Dilacor XR (U.S.), and Tiazac)
Diltia XT (U.S.),
Continued… Dilt CD, XR (U.S.),
More. . .

Diltiazem, continued Taztia XT (U.S.),
Tiazac
Diltiazem Cardizem LA (U.S.), Tablet • Modified-release
Tiazac XC (Canada)
Dimethyl Fumarate Tecfidera Capsule • Modified-release
Disopyramide Norpace CR (U.S.) Capsule • Modified-release
Divalproex Depakote Sprinkle (U.S.) Capsule • Modified-release

Divalproex Depakote (U.S.), Tablet • Modified-release
Depakote ER (U.S.),
Epival ECT (Canada)
Docusate Sodium Colace Capsule • Bad taste
Donepezil Aricept Tablet • Intact product must be taken to avoid increased rate of
(23 mg strength only) absorption
Doxazosin Cardura XL (U.S.) Tablet • Modified-release
Doxycycline Doryx (U.S.), Capsule, Tablet • Modified-release
Oracea (U.S.),
Apprilon (Canada)
Duloxetine Cymbalta Capsule • Modified-release
Dutasteride Avodart, Capsule • Teratogenic
Jalyn
Enzalutamide Xtandi Capsule • Teratogenic
Ergotamine Ergomar (U.S.) Tablet • For sublingual administration
Erythromycin Erythromycin Capsule • Modified-release
delayed-release • Can be opened for administration of intact granules
Erythromycin E.E.S. Tablet • Modified-release
Erythromycin Ery-Tab (U.S.), Tablet • Modified-release
PCE
Esomeprazole Nexium Capsule (U.S.), • Modified-release
Tablet (Canada) • Capsule can be opened for administration of intact granules
More. . .

Eszopiclone Lunesta (U.S.) Tablet • Bad taste
Etravirine Intelence Tablet • Tablet may be dispersed in water
Everolimus Afinitor Tablet • Irritant (mucous membrane)
• Teratogenic
Felodipine Plendil Tablet • Modified-release
Fentanyl Actiq (U.S.) Lozenge • Lozenge should be sucked, not chewed
Fentanyl Fentora Tablet • Buccal dosage form
Ferrous Gluconate Fergon (U.S.) Tablet • Modified-release
Ferrous Sulfate Feosol (U.S.), Tablet • Modified-release
Feratab (U.S.) • Irritant (gastric)
Fesoterodine Toviaz Tablet • Modified-release
Fexofenadine/ Allegra-D Tablet • Modified-release
Pseudoephedrine
Finasteride Propecia, Tablet • Teratogenic
Proscar
Fluoxetine Prozac Weekly (U.S.) Capsule • Modified-release
Fluvastatin Lescol, Capsule, Tablet • Modified-release (Lescol XL)
Lescol XL
Fluvoxamine Luvox CR (U.S.) Capsule • Modified-release
Gabapentin Gralise (U.S.), Tablet • Modified-release
Horizant (U.S.)
Galantamine Razadyne ER (U.S.), Capsule • Modified-release
Reminyl ER (Canada)
Ganciclovir generic Capsule • Irritant (cytotoxic)
• Teratogenic
Glipizide Glucotrol XL (U.S.) Tablet • Modified-release
Guaifenesin Mucinex (U.S.) Tablet • Modified-release
Guaifenesin/ Mucinex DM (U.S.) Tablet • Modified-release
Dextromethorphan
More. . .

Guaifenesin/ Mucinex D (U.S.) Tablet • Modified-release
Pseudoephedrine
Guanfacine Intuniv (U.S.), Tablet • Modified-release
Intuniv XR (Canada)
Hydromorphone Exalgo (U.S.), Tablet • Modified-release
Jurnista (Canada)
Hydroxyurea Droxia (U.S.), Capsule • Irritant (cytotoxic)
Hydrea
Hyoscyamine Levbid (U.S.) Tablet • Modified-release
Ibandronate Boniva (U.S.) Tablet • Irritant (oropharyngeal)
Ibuprofen Advil, Tablet • Bad taste
Motrin
Imatinib Gleevec Tablet • Bad taste
Indinavir Crixivan Capsule • Bad taste
Indomethacin Indocin SR (U.S.) Capsule • Modified-release
Isosorbide Dinitrate Dilatrate-SR (U.S.) Capsule • Modified-release
Isosorbide Dinitrate Isordil Sublingual (U.S.) Tablet • Sublingual dosage form
Isosorbide Mononitrate Imdur Tablet • Modified-release
Isotretinoin Absorica (U.S.), Capsule • Irritant (esophageal)
Accutane (Canada), • Teratogenic
Amnesteem (U.S.),
Clarus (Canada),
Epuris (Canada),
Sotret (U.S.)
Isradipine DynaCirc CR (U.S.) Tablet • Modified-release
Lamotrigine Lamictal XR (U.S.) Tablet • Modified-release
More. . .

Lansoprazole Prevacid Capsule • Modified-release
Lansoprazole Prevacid SoluTab (U.S.), Tablet • Should be dissolved in the mouth, not chewed
Prevacid FasTab (Canada)
Leflunomide Arava Tablet • Teratogenic
Lenalidomide Revlimid Capsule • Teratogenic
Levetiracetam Keppra Tablet • Bad taste
Levetiracetam Keppra XR (U.S.) Tablet • Modified-release
Levodopa/Carbidopa Sinemet CR Tablet • Modified-release

Lithium Carbonate Lithobid (U.S.), Tablet • Modified-release
Lithmax (Canada)
Lopinavir/Ritonavir Kaletra Tablet • Reduced bioavailability with crushing11
Loratadine/ Claritin-D (U.S.), Tablet • Modified-release
Pseudoephedrine Claritin Allergy and Sinus
(Canada)
Lovastatin Altoprev (U.S.) Tablet • Modified-release
Lovastatin/Niacin Advicor (U.S.) Tablet • Modified-release
Lubiprostone Amitiza (U.S.) Capsule • Stability is compromised12
Macitentan Opsumit Tablet • Teratogenic
Memantine Namenda XR Capsule • Modified-release
Mesalamine Delzicol (U.S.), Capsule (U.S.), • Modified-release
Pentasa Tablet (Canada) • Capsules can be opened for administration of intact granules
(Pentasa [U.S.])
Mesalamine Apriso (U.S.), Tablet • Modified-release
Asacol,
Lialda (U.S.)
Metformin Fortamet (U.S.), Tablet • Modified-release
Glucophage XR (U.S.),
Glumetza
More. . .

Methylphenidate Metadate CD (U.S.), Capsule • Modified-release
Ritalin LA (U.S.), • Can be opened for administration of intact granules
Biphentin (Canada)
Methylphenidate Concerta, Tablet • Modified-release
Metadate ER (U.S.),
Methylin ER (U.S.),
Ritalin SR
Metoprolol Succinate Toprol-XL (U.S.) Tablet • Modified-release
Metoprolol Tartrate Lopresor SR (Canada) Tablet • Modified-release
Metronidazole Flagyl ER (U.S.) Tablet • Modified-release
Minocycline Solodyn (U.S.) Tablet • Modified-release
Miragegron Myrbetriq Tablet • Modified-release
Morphine Sulfate Avinza (U.S.), Capsule • Modified-release
Kadian • Can be opened for administration of intact granules
Morphine Sulfate MS Contin, Tablet • Modified-release
Oramorph SR (U.S.)
Morphine/Naltrexone Embeda (U.S.) Capsule • Modified-release
Mycophenolate CellCept Capsule, Tablet • Teratogenic
Mycophenolic Acid Myfortic Tablet • Modified-release
• Teratogenic
Naproxen EC Naprosyn (U.S.), Tablet • Modified-release
Naprelan
Nevirapine Viramune XR Tablet • Modified-release
Niacin Niaspan, Tablet • Modified-release
Niaspan FCT (Canada)
Niacin/Simvastatin Simcor (U.S.) Tablet • Modified-release
Nicardipine Cardene SR (U.S.) Capsule • Modified-release
Nicotine Nicorette (U.S.) Lozenge • Should be dissolved in the mouth, not chewed
Nifedipine Adalat CC (U.S.), Tablet • Modified-release
Procardia XL (U.S.),
Adalat XL (Canada)
More. . .

Nilotinib Tasigna Capsule • Modified-release
Nisoldipine Sular (U.S.) Tablet • Modified-release
Nitroglycerin Nitrostat Tablet • Sublingual dosage form
Omeprazole Prilosec (U.S.), Capsule, Tablet • Modified-release
Prilosec OTC (U.S.), • Capsule can be opened for administration of intact granules
Losec (Canada) (Prilosec)
Orphenadrine Norflex ER (U.S.) Tablet • Modified-release
Oxybutynin Ditropan XL Tablet • Modified-release
Oxycodone OxyContin (U.S.), Tablet • Modified-release
OxyNeo (Canada)
Oxymorphone Opana ER (U.S.) Tablet • Modified-release
Paliperidone Invega Tablet • Modified-release
Pancreatic Enzymes Creon, Capsule • Modified-release

Pancreaze (U.S.), • Irritant (oral mucosal)
Pertzye (U.S.), • Can be opened for administration of intact granules
Ultresa (U.S.),
Zenpep (U.S.)
Pantoprazole Protonix (U.S.), Tablet • Modified-release
Pantoloc (Canada)
Paroxetine Paxil CR Tablet • Modified-release
Pentoxifylline Trental (U.S.) Tablet • Modified-release
Phenylephrine/ Zotex PE (U.S.) Tablet • Modified-release
Brompheniramine
Piroxicam Feldene (U.S.) Capsule • Irritant (oropharyngeal)
Pomalidomide Pomalyst Capsule • Teratogenic
Potassium Chloride Micro-K (U.S.) Capsule • Modified-release
Potassium Chloride Klor-Con (U.S.) Tablet • Modified-release
Praziquantel Biltricide Tablet • Bad taste
More. . .

Promethazine Phenergan (U.S.), Tablet • Bad taste
Histantil (Canada)
Propafenone Rythmol SR (U.S.) Capsule • Modified-release
Propranolol Inderal LA, Capsule • Modified-release
InnoPran XL (U.S.)
Pseudoephedrine Sudafed 12 Hour, 24 Hour Tablet • Modified-release
(U.S.)
Pseudoephedrine/ Lodrane 24D (U.S.), Capsule, Tablet • Modified-release
Brompheniramine Lodrane 12D (U.S.),
LoHist 12D (U.S.)
Pseudoephedrine/ Zyrtec D (U.S.), Tablets • Modified-release
Cetirizine Reactine Allergy and Sinus
(Canada)
Pseudoephedrine/ Clarinex D (U.S.) Tablets • Modified-release
Desloratadine
Pseudoephedrine/ Allegra D Tablet • Modified-release
Fexofenadine
Pyridostigmine Mestinon Timespan (U.S.), Tablet • Modified-release
Mestinon SR (Canada)
Quetiapine Seroquel XR Tablet • Modified-release
Rabeprazole Aciphex (U.S.), Tablet • Modified-release
Pariet (Canada)
Raloxifene Evista Tablet • Bad taste
Ranolazine Ranexa (U.S.) Tablet • Modified-release
Regorafenib Stivarga Tablet • Teratogenic
Ribavirin Copegus (U.S.), Capsule, Tablet • Teratogenic
Rebetol (U.S.)
Risedronate Actonel Tablet • Irritant (oropharyngeal)
Risedronate Atelvia (U.S.), Tablet • Modified-release
Actonel DR (Canada) • Irritant (oropharyngeal)
Risperidone Risperdal M Tablet • Must be allowed to dissolve on the tongue
Ropinirole Requip XL (U.S.) Tablet • Modified-release
More. . .

Simeprevir Olysio (U.S.), Capsule • Per manufacturer (no data)13
Galexos (Canada)
Solifenacin Vesicare Tablet • Modified-release
Sulfasalazine Azulfidine EN-Tabs (U.S.), Tablet • Modified-release
Salazopyrin EN (Canada)
Sunitinib Sutent Capsule • Teratogenic
Tamsulosin Flomax (U.S.), Capsule, Tablet • Modified-release
Flomax CR (Canada)
Tapentadol Nucynta ER Tablet • Modified-release
Telithromycin Ketek (U.S.) Tablet • Modified-release
Temozolomide Temodar (U.S.), Capsule • Irritant (cytotoxic)
Temodal (Canada)
Thalidomide Thalomid Capsule • Teratogenic
Theophylline Theo-24 (U.S.) Capsule • Modified-release
Theophylline Theochron (U.S.), Tablet • Modified-release
Uniphyl
Tipranavir Aptivus Capsule • Bad taste
Tolterodine Detrol LA Capsule • Modified-release
Topiramate Topamax Capsule, Tablet • Bad taste
• Teratogenic
• Capsules can be opened for administration of intact granules
Topiramate Qsymia (U.S.), Capsule • Modified-release
Qudexy XR (U.S.), • Teratogenic
Trokendi XR (U.S.) • Can be opened for administration of intact granules (Qudexy
XR)
Tramadol Ryzolt (U.S.), Tablet • Modified-release
Ultram ER (U.S.),
Zytram XL (Canada)
Trazodone Generics Tablet • Bad taste

More. . .

Trazodone Oleptro Tablet • Modified-release
Trospium Sanctura XR9 Capsule • Modified-release
Valganciclovir Valcyte Tablet • Teratogenic
Valproic Acid Depakene Capsule • Irritant (oropharyngeal)
Valproic Acid Stavzor (U.S.) Capsule • Modified-release
• Irritant (oropharyngeal)
Vandetanib Caprelsa Tablet • Teratogenic
Venlafaxine Effexor XR Capsule • Modified-release
Verapamil Verelan, Capsule • Modified-release
Verelan PM (U.S.) • Can be opened for administration of intact granules
Verapamil Calan SR (U.S.), Tablet • Modified-release

Covera-HS (U.S.), • Tablet is scored and can be split (Calan SR, Isoptin SR)
Isoptin SR
Vismodegib Erivedge Capsule • Teratogenic
Vorinostat Zolinza Capsule • Irritant (skin and mucous membrane)
Zileuton Zyflo CR (U.S.) Tablet • Modified-release
Zolpidem Ambien CR (U.S.) Tablet • Modified-release
Zolpidem Intermezzo (U.S.) Tablet • Sublingual dosage form
Users of this PL Detail-Document are cautioned to use their own professional judgment and consult any other necessary or appropriate sources prior to making
clinical judgments based on the content of this document. Our editors have researched the information with input from experts, government agencies, and national
organizations. Information and internet links in this article were current as of the date of publication.
More. . .
Project Leader in preparation of this PL Detail- http://www.clinicalpharmacology.com. (Accessed

Document: Stacy A. Hester, R.Ph., BCPS, July 7, 2014).
6. Lexicomp Online. Hudson, OH: Lexi-Comp, Inc.
Assistant Editor http://online.lexi.com. (Accessed July 7, 2014).
7. PL Detail-Document, Drugs with Handling Concerns
References Due to Reproductive Risk. Pharmacist’s
1. McPherson ML. Don’t crush that tablet! Am Pharm Letter/Prescriber’s Letter. May 2012.
1994;NS34:57-8. 8. Personal communication. Barr Labs. Medical
2. Miller D, Miller H. To crush or not to crush? What to information. November 13, 2008.
consider before giving medications to a patient with a 9. Personal communication. Indevus. Medical
tube or who has trouble swallowing. Nursing information. November 12, 2008.
2000;30:50-2. 10. USP. Nomenclature guidelines. November 5, 2012.
3. Beckwith MC, Feddema SS, Barton RG, Graves C. http://www.usp.org/sites/default/files/usp_pdf/EN/US
A guide to drug therapy in patients with enteral PNF/2012-11-07_nom_guidelines.pdf. (Accessed
feeding tubes: dosage form selection and July 17, 2014).
administration methods. Hosp Pharm 2004;39:225- 11. Best BM, Capparelli EV, Diep H, et al.
37. Pharmacokinetics of lopinavir/ritonavir crushed
4. Mitchell JF. Oral dosage forms that should not be versus whole tablets in children. J Acquir Immune
crushed. January 2014. Defic Syndr 2011;58:385-91.
http://www.ismp.org/Tools/DoNotCrush.pdf. 12. Personal communication (verbal and written).
(Accessed July 7, 2014). Takeda. Deerfield, IL 60015. July 21, 2014.
5. Clinical Pharmacology [database online]. Tampa, 13. Personal communication (verbal). Janssen.
FL: Gold Standard, Inc.; 2014. Titusville, NJ 08560. July 21, 2014.
Cite this document as follows: PL Detail-Document, Meds That Should Not Be Crushed. Pharmacist’s
Letter/Prescriber’s Letter. August 2014.
Evidence and Recommendations You Can Trust…

3120 West March Lane, Stockton, CA 95219 ~ TEL (209) 472-2240 ~ FAX (209) 472-2249
Copyright  2014 by Therapeutic Research Center
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(Page 1 of 5)
Technician Tutorial:
Which Tablets and Capsules Can Be Crushed, Opened, or Split?
Pharmacists and pharmacy staff in community and hospital settings are often asked to prepare or dispense
medications in a different strength or form than originally supplied by the manufacturer. In some cases,
alternative dosage forms can help save money for the patient. For example, a prescription may be written
for a patient to take one-half of a 10 mg tablet nightly instead of one whole 5 mg tablet. This reduces the
total quantity of pills the patient pays for each month, and possibly the total cost of the prescription.
Drugs may also need to be altered for children or other patients to increase palatability or compliance, as
with a tablet that is crushed and sprinkled over applesauce to administer a dose. In other cases, patients
may not be able to ingest anything, including medications, by mouth for a variety of medical reasons.
Patients unable to ingest food or liquids by mouth often receive nutrition through an “enteral feeding
tube” inserted into the mouth, nose, or an opening surgically made in the skin. These patients might also
require their medications to be administered through the feeding tube. Whatever the reason, these
scenarios can create dilemmas in the pharmacy. Pharmacists and technicians need to know which tablets
can be crushed or split, and which capsules can be opened. Making the right decision will help ensure
that patients get the correct dose and do not experience loss of drug effectiveness or drug toxicity.
Pharmacy technicians play an important role in assisting the pharmacist in these decisions and preparing
prescriptions for medications that need to be delivered in alternate dosage forms.
Mr. Brown, a 65-year-old male patient, brings in the following prescription:
The prescription is written for Advicor 1000/40, one-half tablet, taken daily at bedtime.
When Mr. Brown hands you the prescription, he mentions that his prescriber reduced his dose of
Advicor to 500/20 each day. However, he still has some of the 1000/40 tablets left. He asked his
prescriber to continue writing 1000/40 because he thinks he might save money by splitting the
tablets.
As you are preparing Mr. Brown’s prescription, you are unsure how you should enter the
directions into the pharmacy computer. You also wonder whether you are supposed to go ahead
and split all of the tablets for Mr. Brown or if you leave them for Mr. Brown to split at home.
What should you consider when entering a prescription into the pharmacy computer when
tablets will be split?
Although splitting tablets may provide a benefit to the patient, the practice may be new to some patients
and confusing to those who are not accustomed to it. Always spell out the directions rather than using
numbers on the pharmacy label to help avoid patient error. For example, entering this sig as “Take one-

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(Page 2 of 5)
half tablet at bedtime” is preferred over “Take ½ tablet at bedtime.” Patients who are unable to read the
smaller fraction numbers may misinterpret the “1/2” as “1,” “2,” “12,” or “1 to 2.”
Always double-check your days’ supply in the computer to ensure that it is correct. Pharmacy computer
systems may default to the number of tablets as the days’ supply, so you may need to manually enter the
correct days’ supply for insurance purposes.
What are some reasons a tablet CANNOT be split or crushed, or that a capsule CANNOT be
opened?
Splitting a tablet or opening a capsule is not always okay, even if the prescription is written with
directions to do so. The following are reasons that tablets or capsules must be administered intact:
 Splitting, crushing, or opening the capsule would destroy a modified-release mechanism. If a
modified-release mechanism (e.g., delayed-release, extended-release, controlled-release) is
destroyed, a large portion of the dose can be “dumped” or released into the body all at once or
into a part of the GI tract where it might not be absorbed. This could increase or reduce the
effects of the drug. An example is extended-release oxycodone (OxyContin-U.S., OxyNeo-
Canada). Crushing these tabs prior to administration could cause overdose, with very serious
side effects such as sedation and slow breathing.
 Some medications taste very bad. An example of this is cefuroxime tablets. They have an
undesirable metallic taste.
 Some medications might be irritating. Destroying a mechanism to protect against exposure to
an irritating drug, such as an enteric coating, can result in irritation or injury. Or contact with a
drug could be cytotoxic or irritating to the skin or mucous membranes of the person handling
the dosage form.
 Some medications might be harmful to the person administering them if they are not
administered intact. An example of this is dutasteride (Avodart, etc). Dutasteride can be
absorbed through the skin and can cause birth defects in male babies. Dutasteride caps or tabs
shouldn’t be crushed, and they should not even be handled by women of childbearing potential.
How do you know if it is okay to split or crush a tablet, or to open a capsule?

Most of the time, single-ingredient tablets that aren’t coated and aren’t modified-release can be split or
crushed. If a tablet is scored, such as Toprol XL-U.S., then you know it can be split.
Some capsules can be opened, and the contents administered with a beverage or mixed with food. Some
examples of meds where this is true are Aggrenox and Tiazac. The specific beverage or food that the
capsule contents can be mixed with might be specified in the package insert. Applesauce is a common
recommendation.
It’s not always possible to figure this out by simply looking at the tablets or capsules. Plus, you can’t
always depend on the suffix to indicate a controlled-release product. Go to our PL Technician Tutorial,
What Drug Names Really Mean, for more information on drug name suffixes. We have a helpful list,
Meds That Should Not be Crushed, with many tablets and capsules that must be administered intact. You
can also check the package insert.
With these principles in mind, you do some more research on Mr. Brown’s Advicor. There’s
nothing in the brand name of the drug (XL, CR, etc) to indicate that it’s a controlled-release
tablet. However, you know Advicor is not scored, so you are still unsure whether it’s okay to
split. You check the Meds That Should Not be Crushed list and, sure enough, Advicor is on the
list. It’s a controlled-release product.

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(Page 3 of 5)
You alert the pharmacist and she notifies the patient about the need for a change to Advicor
500/20. She explains to Mr. Brown that the reason his prescription must be changed is that
Advicor tablets should not be split.
For tablets that are okay to split, should this be done in the pharmacy for the entire
prescription at the point of dispensing, or should the patient split tablets individually at home
as they are dosed?
It depends. Ideally, tablets should not be split in advance in the pharmacy since long-term storage of a
split tablet may theoretically affect tablet and drug stability. Also, tablet splitting is an inexact science,
so not each tablet will be split into an exact half dose. Splitting all tablets at once could result in dose
variations if patients take all the “large halves” first or if tablet pieces disintegrate into smaller parts.
Instead, most experts prefer that patients split tablets at home as they are scheduled to take them. This
ensures that the inside of a tablet is not exposed to the elements for longer than necessary to optimize
stability. It also helps minimize dose fluctuations since an unevenly split tablet will be taken in two
successive doses.
However, not all patients are able to split tablets effectively. Elderly patients with limited eyesight or
dexterity may struggle with splitting tablets. In these cases, the pharmacist can steer the patient towards
an over-the-counter tablet splitting device to help them, or choose to split all of a patient’s tablets at once
in the pharmacy at the point of dispensing. Any patient who will need to split tablets at home should
purchase a tablet splitter. This is a helpful tool to use even with scored tablets to ensure an even cut and
less variation in split tablet sizes.
What are some alternatives for patients who can’t take capsules or tablets?
Liquid medications and specifically designated sprinkle-type dosage forms are usually preferred for
patients who can’t take tablets or capsules. In addition, dosage forms such as sublingual or buccal tablets
that dissolve in the mouth and don’t need to be swallowed might be options. Using transdermal patches
can also help avoid the problem of having to split or crush tablets or open capsules.
You are working in the pharmacy again the following Saturday when you receive a phone call
from a nurse at a nearby long-term care facility. Your pharmacy has a contract to supply the
facility with emergency medications at nights and on the weekend when their usual pharmacy is
closed. The nurse says that their patient Emma Johns had an “NG tube” inserted this afternoon.
She’d like to talk to the pharmacist about Mrs. Johns’ medication list and how her medications
should be given tonight with the tube in place.
The pharmacist talks to the nurse and hangs up the phone with a list of medications in hand. She
asks you to help her do some research to determine whether Mrs. Johns’ meds can be given
through a nasogastric feeding tube or what other alternatives are available.
What is a nasogastric feeding tube? What are some other types of enteral feeding tubes
commonly seen in practice?
A nasogastric (NG) tube is inserted through the nose and terminates (ends) in the stomach. However,
feeding tubes can be inserted through the mouth, through the nose, or through the skin and they can
terminate in different parts of the gastrointestinal tract, including the stomach, duodenum, or jejunum.
You’ll hear lots of different terms referring to different types of tubes.

Phone: 209-472-2240 ~ Fax: 209-472-2249
(Page 4 of 5)
Another type of tube that is inserted through the nose is a Dobhoff tube. It’s a small-bore tube, which is
narrow and can be clogged with medications easily. Only liquids should be given through this type of
tube.
Some larger bore tubes, which are wider and less likely to clog, include orogastric (OG) tubes,
gastrostomy (G) tubes, and jejunostomy (J) tubes. An orogastric tube is inserted through the mouth.
Gastrostomy tubes and jejunostomy tubes are inserted directly through the skin and into the
gastrointestinal tract.
What kinds of medications can be given through feeding tubes?

If a drug is required to be given through a feeding tube, a liquid dosage form is usually preferred.
Sometimes, IV formulations can be used orally and administered through a feeding tube. Examples
include vitamin K and acetylcysteine. For drugs that are not available in a liquid form, pharmacy staff
may be asked to crush a tablet or the contents of a capsule into a fine powder and mix the powder with
water to form a “slurry” that can be administered directly into the feeding tube. Or a nurse or caregiver
may do this prior to administration of the med.
Again, it’s important to be aware of which tablets and capsules can’t be crushed or opened or given
through feeding tubes. These include extended-release or delayed-release, enteric-coated, and
microencapsulated products such as Tegretol XR-U.S., enteric-coated aspirin, Depakote-U.S., and others.
Note that some extended- and delayed-release capsules (e.g., some pancreatic enzymes, Verelan-U.S.,
others) can be opened, and the pellets or granules can be administered down a feeding tube. The pellets
or granules must be kept intact and not crushed so that they retain their modified-release quality.
Depending on where a feeding tube terminates, some drugs might not be appropriate at all. For example,
sucralfate works by coating, or creating a physical barrier, in the stomach. Administering sucralfate
through a tube that ends in the intestine, which is farther along in the GI tract than the stomach,
completely bypasses sucralfate’s site of action.
Bulk-forming laxatives, like psyllium (Metamucil) should not be given through a feeding tube. They can
form a semisolid mass that will clog a feeding tube, and require removal and replacement of the tube in
about one out of three patients. Cholestyramine (Questran-U.S., Olestyr-Canada) is another drug prone to
clogging feeding tubes.
What kinds of problems can come up when oral meds must be given through feeding tubes
and how can they be avoided?
Administering medications through a feeding tube poses some risk to the patient. A tablet or other solid
dosage form administered improperly through an enteral tube can result in toxicity if too much drug is
absorbed in the GI tract, and loss of effectiveness if too little drug is given or if too little drug is absorbed
in the GI tract.
Some medications can clog feeding tubes. Inadequate flushing is the most common cause of tube
blockage. Generally, 15 to 30 mL of water should be used to flush a feeding tube before and after
administration of a medication to avoid clogging the tube.
Medications should never be mixed together with “tube feeds” (liquid nutrition preparations given by a
feeding tube) because the two might not be compatible. Problems include physical incompatibilities, like
clumping, which can clog a tube, and reduced gastrointestinal absorption of a drug, which can lead to
reduced drug effect. In some cases, tube feeds will need to be completely stopped for a period of time
before a drug is given, and then started a couple of hours after the drug has been administered to prevent

Phone: 209-472-2240 ~ Fax: 209-472-2249
(Page 5 of 5)
mixing of the two. Examples of drugs that require this include phenytoin oral suspension and some
antibiotics.
What kinds of errors can occur when patients can’t take tablets or capsules intact and how
can they be avoided?
As mentioned, the inappropriate splitting or crushing of tablets, or opening of capsules with a controlled-
release mechanism can cause “dose dumping,” which can lead to toxic effects of the drug. Or the drug’s
effectiveness may be reduced.
A serious error that has been documented with oral liquids involves the administration of the liquid
medication intravenously instead of via the feeding tube. This is very dangerous, and can cause death.
For this reason, it’s recommended that oral liquid medications are never dispensed in IV syringes or
syringes that resemble IV syringes. Amber oral syringes should always be used for dispensing oral
medications that must be drawn up into a syringe and that aren’t already unit-dosed. The use of auxiliary
labels, like “for oral use only” or “not for IV injection” should also be considered.
Mrs. Johns is taking five medications: simvastatin 20 mg tablets, hydrochlorothiazide 25 mg

tablets, extended-release oxycodone 20 mg tablets, aspirin 81 mg tablets, and docusate 100 mg
capsules. As you look through the list, you know that the extended-release oxycodone tablets
cannot be given through a feeding tube and that docusate also comes in a liquid form. You tell
this to the pharmacist and she agrees that the other three meds are okay to be crushed and
administered through the feeding tube. The pharmacist makes a phone call to the nurse to let
her know that she will need an alternative to the extended-release oxycodone and that the
docusate can be switched to a liquid formulation.
Project Leader in preparation of this PL Technician Tutorial: Stacy A. Hester, R.Ph., BCPS, Assistant
Editor
Cite this document as follows: PL Technician Tutorial, Which Tablets and Capsules Can Be Crushed, Opened,
or Split? Pharmacist’s Letter/Pharmacy Technician’s Letter. August 2014.

Phone: 209-472-2240 ~ Fax: 209-472-2249

Meds That Should Not Be Crushed

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Meds That Should Not Be Crushed

Medications That Should Not Be Crushed1-7

Medications That Should Not Be Crushed1-7

Medications That Should Not Be Crushed1-7

Divalproex Depakote Sprinkle (U.S.) Capsule • Modified-release

Medications That Should Not Be Crushed1-7

Medications That Should Not Be Crushed1-7

Medications That Should Not Be Crushed1-7

Levodopa/Carbidopa Sinemet CR Tablet • Modified-release

Medications That Should Not Be Crushed1-7

Medications That Should Not Be Crushed1-7

Pancreatic Enzymes Creon, Capsule • Modified-release

Medications That Should Not Be Crushed1-7

Medications That Should Not Be Crushed1-7

Trazodone Generics Tablet • Bad taste

Medications That Should Not Be Crushed1-7

Verapamil Calan SR (U.S.), Tablet • Modified-release

Project Leader in preparation of this PL Detail- http://www.clinicalpharmacology.com. (Accessed

Evidence and Recommendations You Can Trust…

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Mr. Brown, a 65-year-old male patient, brings in the following prescription:

Copyright © 2014 by Therapeutic Research Center

How do you know if it is okay to split or crush a tablet, or to open a capsule?

Copyright © 2014 by Therapeutic Research Center

Copyright © 2014 by Therapeutic Research Center

What kinds of medications can be given through feeding tubes?

Copyright © 2014 by Therapeutic Research Center

Mrs. Johns is taking five medications: simvastatin 20 mg tablets, hydrochlorothiazide 25 mg

Copyright © 2014 by Therapeutic Research Center

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