■ medications
ucation
division news
what happens when
medications are crushed:
some examples
Table Three: What happens when medications are crushed—some examples (Adapted and sourced from 7–11)
Generic name (some brand names)
Analgesics
Morphine sulphate (MS Contin)
Oxycodone (OxyContin)
Paracetamol (Duatrol SR, Panadol Extend, Panadol Osteo)
Tramadol (Tramahexal SR, Tramal SR, Zydol SR )
Antibiotics
Cefaclor (Ceclor CD, Keflor CD)
Amoxycillin and clavulanic acid (Augmentin Duo, Clamoxyl Duo)
Doxycycline (Doryx, Doxsig, Doxy-50, Doxy-100, Doxyhexal,
Doxylin, Vibramycin, Vibra-Tabs 50)
Erythromycin (EES, Eryc)
Nitrofurantoin (Macrodantin)
Antidepressants
Venlafaxine (Efexor XR)
Antiepileptics
Carbamazepine (Tegretol CR)
Antihistamines
Dexchlorpheniramine (Polaramine Repetabs),
Dexchlorpheniramine/pseudoephedrine (Demazin Day/Night relief,
sustained-release tablets, etc)
Fexofenadine/pseudopehdrine (Telfast Decongestant)
Loratadine/pseudoephedrine (Clarinase 24 hour relief, repetabs)
Pheniramine (Avil Retard)
Antineoplastic and Immunomodulating agents
Altretamine (Hexalen), azathioprine (Imuran), busulphan
(Myleran), capecitabine (Xeloda), chlorambucil (Leukeran)
cyclophosphamide (Cycloblastin), cyclosporin (Neoral),
levamisole (Ergamisol), etoposide (Vepesid), hydroxyurea (Hydrea),
idarubicin (Zavedos), melphalan (Alkeran), mercaptopurine
(Purinethol), methotrexate (Ledertrexate, Methoblastin),
temozolomide (Temodal) and others
Anti-Parkinson’s disease
Levodopa controlled release (Sinemet CR, Madopar HBS)
Cardiovascular medications
Candesartan /hydrochlorothiazide (Atacand Plus)
Isosorbide mononitrate (Imdur, Duride, Imtrate, Monodur)
Indapamide 1.5mg (Dapa-Tabs, Natrilix SR)
Felodipine (Felodur SR, Plendil ER)
Nifedipine (Adalat, Adalat Oros, Adefin, Adefin XR, Nifecard,
Nifehexal, Nyefax)
Nimodipine (Nimotop)
Verapamil (Anpec SR, Cordilox SR, Isoptin SR, Veracaps SR)
Quinidine (Kinidin Durules)
Aspirin enteric coated (Astrix 100 capsules, Cartia)
Glyceryl trinitrate sub lingual (Anginine)
Dipyridamole SR (Asasantin SR, Persantin SR)
Page 18 DIVISION NEWS Volume 16 No 2 April – may 2006
medications ■
division news
a crushing problem
Dr jenny gowan crunches the facts
on swallowing medications
Swallowing poses a challenge for medication
administration. When patients cannot swallow
tablets whole, they or their carers often crush
Category Generic name (some brand names) Category them.
In Aged Care Homes, particularly in high
Electrolyte care facilities, crushing is common. There are
1 Sustained release potassium chloride (Duro-K, Slow-K, Span-K) 3 protocols in place, but it still causes concern.
1 Legally, crushing or opening medication
1 results in unlicensed administration: liability
Endocrinology
1 lies solely with the nurse if the action
Alendronate (Fosamax), 3
was unauthorised and is shared with the
Risedronate (Actonel)
1 prescriber and pharmacist offering advice if it
1, 2
Gastrointestinal has been authorised.
Docusate (Coloxyl), Docusate & senna Coloxyl & senna) 6 Doctors and pharmacists are often unaware
3
[frequently crushed if acceptable to patient]
of this increasingly common practice.
Olsalazine (Dipentum), mesalazine (Mesasal, Salofalk),
1
sulfasalazine (Salazopyrin) 4 Altering the solid dosage forms by crushing
3
Omeprazole (Losec, Acimax), lansoprazole (Zoton), pantoprazole 2 tablets or opening capsules may result in
(Somac) [Some brands may be dispersed in water prior to reduced effectiveness, a greater risk of Dr Jenny Gowan at the Division, training
1 administration] toxicity, or in an unacceptable taste or texture. pharmacists in medication review procedures
Iron products
In Aged Care Homes a list of medications
which must not be crushed or chewed is • For cytotoxic medication, there should be a
1 Iron-containing products (Ferrogradumet, Fergon, FGF, Fefol) 3
usually provided by the pharmacist. The table dedicated set of equipment for each resident.
Non-steroidal anti-inflammatory agents (NSAIDs) opposite gives some examples Equipment (such as a mortar and pestle) should
1 Ketoprofen Sustained release (Orudis SR, Oruvail SR) 1 be cleaned with a damp cloth, followed by a dry
Controlled-release medications
Naproxen Sustained release (Naprosyn SR, Proxen SR) 3 cloth, after use for each resident. Plastic screw-
1 Diclofenac enteric coated (diclofenac and misoprostol—Arthrotec, 3 Many medications are formulated to release
drug in a controlled manner over a defined type crushers should be avoided.
1 Clonac, Diclohexal, Dinac, Fenac, Voltaren)
1 Other NSAIDs may cause an irritant effect 3 dosing period, usually 12 or 24 hours. Finally . . .
1 Crushing these medications may result in If you are giving tablets and capsules together,
Pancreatic supplements
Pancrease, Cotazym, Creon 4 an unintended large bolus dose. Medications crush the tablets first, then open the capsule and
labelled as “controlled release” (CR), add its powder or pellets, to prevent crushing
6 Psychoactive medications “sustained release” (SR), “modified release” sustained release or enteric-coated pellets.
Chlorpromazine (Largactil) 5
5 (MR) “controlled delivery” (CD), “enteric Make sure the crushed tablets or capsule
Respiratory coated” (EC) are slow-release formulations. contents are taken as soon as possible, to reduce
Theophylline controlled release (Nuelin SR, Theodur) 1 They cannot be crushed, although some can degradation and minimise any risk.
be halved. Capsules containing medication in Mixing with a small amount of acceptable food
Miscellaneous
Isotretinoin (Roaccutane) 3,5
small pellets, with the release properties are such as jam or fruit puree can mask an unpleasant
Methylphenidate (Concerta) 1 built into each pellet, can be opened but not taste and increase compliance.
Phenytoin (Dilantin) 1 crushed. As crushing carcinogenic or teratogenic
1
Pseudoephedrine SR (Sudafed 12 hour relief) 6 Some swallowing solutions products may be a hazard to the carer because of
Quinine sulphate (Quinate, Quinoctal, Quinsul) 6 It is important to ask all patients whether aerolisation of particles, consider using antibiotic
1 Quinine bisulphate (Biquinate, Myoquin, Quinbisul) 6 they are having swallowing difficulties. mixtures.
1
1
Legend 1. Altered absorption characteristics Using another brand, or changing from Email jenny.gowan@ndgp.org.au for a copy of her
1
2. Medication instability a tablet to a capsule, liquid or dispersible paper on this topic, including references.
2
3. Local irritant effect formulation, may help. Speech therapists
4. Failure to reach site of action
5. Occupation health and safety
can also provide valuable assistance with Medication reviews (HMRs and RRMRs) can alert
swallowing techniques.
2
1
6. Unacceptable/undisguisable taste GPs and pharmacists to many problems. The
Equipment for crushing tablets should:
1 Note: List of brands and medications is not exhaustive. • Permit complete recovery of powdered
review can also help solve the problem by looking
1 Some tablets may be cut in half but not crushed. material at medication alternatives.
1 Check with product information before recommending crushing,
1 cutting or dispersing. • Be washed and dried after use for each For all information on medication reviews,
person
call the Division’s Dr Jenny Gowan, 8480 4611.
DIVISION NEWS Volume 16 No 2 April – may 2006 Page 19
THE AUSTRALIAN JOURNAL OF PHARMACY VOL.87 FEBRUARY 2006 � 61