Can a medication be crushed?

Can This Medication Be Crushed?

Crushing medications should only be done as a last resort after exploring alternative formulations, and requires pharmacist consultation to determine safety for each specific drug. 1

General Principles for Medication Crushing

When Crushing May Be Considered

• Crushing is appropriate only for patients with swallowing difficulties (dysphagia) or those requiring enteral tube administration who cannot access alternative formulations 1, 2
• Always consult a pharmacist before crushing any medication to assess whether the specific drug can be safely crushed 1
• Crushing should be considered off-label use and carries additional clinical and legal responsibility 1, 3

Medications That Should NEVER Be Crushed

• Extended-release or sustained-release formulations - crushing destroys the controlled-release mechanism, causing potentially fatal overdose 4
• Enteric-coated or gastro-resistant tablets - crushing eliminates protective coating, leading to drug degradation and underdosing 4
• Bictegravir/tenofovir alafenamide/emtricitabine - specifically contraindicated for crushing 5
• Delayed-release medications in patients with short bowel syndrome 1
• Medications that are chemically unstable when exposed to light, moisture, or food 4

Specific Medications That CAN Be Crushed

Methotrexate

• Methotrexate tablets (2.5 mg scored) can be split and crushed for pediatric psoriasis patients 5
• This is particularly useful for younger children who may find subcutaneous administration traumatic 5

Metronidazole

• Metronidazole tablets can be crushed and suspended in water for immediate administration 6
• For nasogastric/gastric tube administration, crush tablets, suspend in water, and administer through gastric tubes (not jejunal tubes) 6
• Flush tube with at least 30 mL of water before and after administration to prevent obstruction 6

Acitretin

• Can be crushed for pediatric psoriasis patients when necessary 5

Safe Crushing Technique

Proper Methodology

• Use a mortar and pestle or appropriate crushing device 7
• Suspend crushed powder in plain water at room temperature 7
• Administer within 2 hours of crushing 7
• Ensure accurate dosing by using appropriate measuring tools 1

For Enteral Tube Administration

• Use syringes and connectors meeting recognized standards to avoid misconnection errors 1
• Flush tube before and after medication administration to prevent blockage 1, 6
• Administer through gastric tubes rather than jejunal tubes when possible for optimal absorption 6

Critical Safety Considerations

Risks of Crushing

• Significant loss of active ingredient: Studies show crushing can result in 6-9% loss of powder and active pharmaceutical ingredient in home settings 8
• Altered pharmacokinetics and pharmacodynamics may compromise treatment efficacy 2, 4
• Healthcare worker exposure to hazardous drug particles (potentially carcinogenic, teratogenic, or allergenic) 4
• Risk of fatal overdose with sustained-release products or underdosing with enteric-coated formulations 4

Alternative Strategies to Explore First

• Liquid formulations should be prioritized when available 1
• Topical applications may be appropriate alternatives 1
• Oral suspensions (may require compounding) 6
• Different dosage forms of the same medication 7

Special Populations

• For chemotherapy patients with severe mucositis, switch to regimens available in liquid formulation or that can be safely crushed 5
• Avoid crushing in patients requiring precise drug delivery or those with absorption issues 1

Clinical Decision-Making Algorithm

1. Assess patient's swallowing ability and determine if crushing is truly necessary 1, 2
2. Consult pharmacist immediately to verify crushability of the specific medication 1
3. Check for alternative formulations (liquids, suspensions, topical) before proceeding 1, 6
4. Verify the medication is NOT: extended-release, enteric-coated, or specifically contraindicated for crushing 5, 4
5. If crushing is approved: Use proper technique, administer immediately, and document the intervention 1, 7
6. Monitor patient closely for altered therapeutic effects or adverse events 2

Documentation Requirements

• All interventions involving medication modification should be documented in the patient record 5
• Note the reason for crushing, pharmacist consultation, and patient response 5