The right choice for your patient

It can be helpful for tablets to be crushed or capsules opened before administration in some situations. For example:

• patients with swallowing difficulties
• covert oral administration of medicines
• immediately following bariatric surgery
• administration via enteral feeding tubes

Not all tablets can be crushed or capsules opened. It is important to check beforehand.

This page lists sources of information and advises how, alongside pharmaceutical knowledge, they can be used.

In swallowing difficulties, first follow our guide Choosing medicines formulations in swallowing difficulties.

If you need further support, the SPS Medicines Advice service (for NHS primary care health professionals in England) or local medicines management teams may help.

Sources of information

Resources differ in their focus. Taste is only relevant for oral administration. Tube blockage is only relevant for administration via feeding tubes.

SPS resources

Medicines suitable for adults with swallowing difficulties provides lists of medicines suitable for patients with swallowing difficulties, for some therapeutic classes. They note if tablets can be crushed or capsules opened and state if this is within the licence or ‘off-label’.

Each list includes multiple medicines within the same therapeutic group and can be used to consider suitable alternatives.

Using solid oral dosage form antibiotics in children provides information on crushing tablets or opening capsules for some common antibiotics.

Summaries of Product Characteristics

Summaries of Product Characteristics (SmPCs) contain information on licensed uses of the medicine. Section 4.2 covers method of administration.

Sometimes information on administration in swallowing difficulties or via feeding tubes is included in the SmPC. If so, such use is licensed rather than ‘off-label’.

Instructions may differ between brands of the same medicine.

If not explicitly licensed, other information in the SmPC can be used to decide whether tablets may be crushed or capsules opened ‘off-label’.

Medicines for Children

Medicines leaflets advise on giving medicines to children. Some include information on crushing tablets or opening capsules.

NEWT guidelines

Individual drug monographs (subscription required) give information on administration in swallowing difficulties and via feeding tubes. Monographs usually include information on crushing tablets or opening capsules. Some monographs note if medicines have a particular taste.

Drug administration via feeding tubes

Drug administration via enteral feeding tubes monographs (subscription required) give information on crushing or dispersing tablets and opening capsules, listed by brand and generic preparations.

The focus is on administration via feeding tubes, but information can be interpreted for oral administration. Medicines that may block tubes can be considered for oral administration.

Medicine manufacturer

Sometimes manufacturers will provide information on administering their medicines ‘off-label’ to patients with swallowing difficulties.

Some manufacturers have made additional information available online via the HCP Med Info section of the electronic Medicines Compendium (eMC). Few medicines are currently included. To use:

• search for the medicine
• go to the ‘HCP Med Info’ tab if there is one
• click that you are a healthcare professional, then search for ‘crush’ or ‘open’

Manufacturer medical information contact details are in the BNF or eMC. They are not obliged to give information on ’off-label’ use.

Pharmaceutical and clinical considerations

Some factors identify tablets and capsules that cannot be crushed and opened.

The main factors to consider are:

• modified-release properties
• tablet coating
• operator exposure to the medicine

Modified-release properties

Modified-release preparations might have names that include MR, SR, XL or LA. They are usually unsuitable for crushing.

Use the SmPC (particularly sections 3, 4.2, 5.2 and 6.1) to identify medicines with modified-release properties. Look also for words such as ‘pellet’ and ‘granule’.

If you cannot find confirmation that modified-release tablets can be dispersed or capsules opened, switch to an immediate-release formulation.

The dose frequency will likely need to be adjusted. Specific medicine switches for solid dose and liquid formulations may help.

Modified-release tablets

Tablets may be given modified-release (MR) properties by:

• a coating that dissolves slowly or under specific conditions
• distributing the drug through a ‘matrix’ that releases it slowly
• being made of granules or beads, each with MR coating

If you crush a MR tablet, the modified-release properties will be lost. All the drug will be released at once. This could mean the:

• patient receives the drug more quickly, leading to higher blood levels and risk of toxic effects. For example, crushing morphine MR tablets.
• drug is released at the wrong site in the gastrointestinal tract, so it may not work. For example, crushing Octasa (mesalazine) tablets.

Some MR tablets made of granules, beads or pellets may be dispersed in water; the granules, beads or pellets must not be crushed or chewed.

Some matrix MR tablets can be halved but not crushed. For example, Tegretol (carbamazepine) prolonged release tablets.

Modified release capsules

Modified-release capsules are often modified-release granules, beads or pellets within a usual capsule shell. These can often be opened, and the contents taken with soft food. However, the granules, beads or pellets must not be chewed or crushed.

For example, dipyridamole modified-release capsules can be opened and the granules mixed with water, juice or soft food. The granules must not be crushed or chewed.

Tablet coating or capsule shell

Not all tablets are coated. The SmPC will say if a tablet is coated in section 2, 3 or 6.1.

Enteric-coating

Enteric-coated (EC) and gastro-resistant tablets (GR) tablets are not suitable for crushing. The coating is usually intended to prevent stomach acid from destroying the drug. If the coating is damaged, the protection will be lost and the drug may not work.

Film- or sugar-coating

Film-coating and sugar-coating do not change the absorption of the medicine. These tablets can usually be crushed, although this may be difficult.

Film or sugar-coated tablets may taste bitter once crushed.

Capsule shell

Hard capsules are made up of two halves which can be pulled apart. They contain powder or granules and can often (but not always) be tipped out and given with food or drink.

There are exceptions. The SmPC for dabigatran capsules notes bioavailability is significantly increased if given without the capsule shell.

Soft capsules are slightly squashy and the halves are sealed together. They usually contain liquid or paste. They are usually not suitable for opening.

Other considerations

Scored tablets

If the SmPC says a tablet can be split in half, it can usually be crushed or dispersed ‘off-label’ unless it is also modified-release. For scored modified-release tablets, see the modified-release tablets section.

Chewable tablets

Chewable tablets may be crushed.

Specialised medicines

Some tablets and capsules are formulated as amorphous solid dispersions or nanocrystals. Bioavailability is decreased if these the tablets or capsule contents are crushed.

These are mostly used for HIV antiviral medicines, cancer chemotherapy and medicines to prevent transplant rejection. Liaise with the patient’s specialist if crushing is necessary.

Operator exposure

Consider the nature of the medicine and the risk it may pose to the operator from inhalation or topical exposure.

Do not crush cytotoxic or teratogenic medicines unless there is no alternative. Risk may also be increased with antibiotics, immunosuppressants and hormones.

Operators should take precautions to avoid exposure. Advising how to crush or disperse tablets and open capsules has further information.