Drug delivery systems have become increasingly complex. Tablets and capsules may have special coatings for example 'sugar coated', 'film coated' or 'enteric coated ‘ or they may be designed to modify the rate that the drug is released into the body. It is important to understand the mechanism as well as the rationale before deciding whether it is safe or appropriate to crush tablets or open capsules. 1

    The tablets and capsules with the following words/letters in their names should never be crushed, opened, chewed or sucked. 2

    Word/letter  Type of product CR/Chrono  Controlled Release EC/EN  Enteric Coated LA  Long Acting MR/Retard/Slow/Continus  Modified Release SA  Sustained Action SR/Dur/Dural  Sustained Release XL  Extended Release

    The information below details some common examples of tablets and capsules where advice on crushing or opening should be sought prior to manipulation. In these examples, an alternative formulation, such as a liquid medicine , may be a more appropriate option for patients with swallowing difficulties. 1

    Modified release medicines

    Frequently identifiable by two letters such as M/R, LA, SA, CR, XL or SR at the end of the name. Words such as "Retard", "Slow" or “Continus” in the title is sometimes used instead. These medicines are designed to be released over a prolonged period, the mechanism for slowing absorption may be damaged if the medication is manipulated. 2

    Damage of a modified release medication may result in the whole dose being released quicker than intended. This results in the patient experiencing a period where the drug concentration is too high, causing toxicity, followed by a period where the drug concentration is too low to be therapeutically active meaning that the underlying condition is not being effectively treated. 1

    Examples:

    • Verapamil m/r
    • Propranolol m/r
    • Felodipine m/r
    • Diclofenac m/r

    Enteric coated medicines

    Usually identifiable by the two letters EN or EC at the end of the name. 2 These medicines have a special coating on the outside which doesn’t dissolve in stomach acid. This may be to protect the stomach from the drug, protect the drug from the stomach acid or to target the release of the drug past the stomach. 1 Crushing enteric coatings may result in the drug being released too early, being destroyed by stomach acid, or irritating the stomach lining. 3

    Examples:

    • Diclofenac e/c
    • Naproxen e/c
    • Sulfasalazine e/c

    Film or sugar-coated medicines

    Disruption of the film or sugar coating on a drug may result in rapid degradation of the active ingredient and may also cause skin irritation in patients or carers. 2 Crushing these tablets therefore may not seriously affect how the drug is released but may cause the resultant mixture to be unpleasant to taste which is likely to negatively affect adherence. 1

    Examples:

    • Quinine sulphate
    • Ibuprofen

    Hormonal, cytotoxic or steroidal medicines

    Any alteration of a solid-dose oral formulation should be considered under Control of Substances Hazardous to Health (COSHH) regulations since there may be an increased exposure to chemical components. This is of particular importance with hormonal, cytotoxic or steroidal medications. If the tablet is crushed, the drug may go into the air and the dose inadvertently received by the administrating nurse or carer. 2

    Examples:

    • Tamoxifen
    • Methotrexate

    Rosemont Pharmaceuticals support the knowledge of healthcare professionals concerning patients with swallowing difficulties. Please register for an account to view more information about our portfolio of liquid medicines or view our range of educational resources . Alternatively, get in touch with us if you would like to speak to someone regarding our products.

    View References

    1. Medicines Management and Older People- a guide for healthcare professionals. Edited by R Greenwall. August 2016. | 2. Wright D, Chapman N, Foundling-Miah M et al. Consensus guideline on the medication management of adults with swallowing difficulties. In: Foord-Kelcey G, editor. Guidelines – summarising clinical guidelines for primary care. 30th ed. Berkhamsted: Medendium Group Publishing Ltd; October 2006. | 3. The Royal Pharmaceutical Society. Pharmaceutical Issues when Crushing, Opening or Splitting Oral Dosage Forms June 2011. Available at: https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Support/toolkit/pharmaceuticalissuesdosageforms-%282%29.pdf (Accessed 7th April 2020)

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    Source: www.rosemontpharma.com

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