Published: 6 September 2018

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Considered Crushing for Troublesome Throats

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Prescriber Update 39(3): 35–36
September 2018

Background

Oral medicines are commonly altered for administration in patients who have swallowing difficulties or for administration down feeding tubes. Alteration methods include crushing or opening capsules. Some medicines can be altered for easier administration (eg, allopurinol tablets). However, such alteration is not appropriate for many medicines because the finished product is formulated to be swallowed as a whole tablet or capsule¹.

Some medicine names are accompanied by abbreviations that indicate they should be administered whole (Table 1). When prescribing, dispensing or administering these medicines, care should be taken to ensure the patient is able to swallow them¹.

What can happen?

Adverse effects associated with the altering of tablets include local irritation, cytotoxic exposure, increased bioavailability or loss of effect. Dose dumping occurs when a modified release formulation (or similar) is not administered as a whole tablet/capsule. The patient receives the full dose at once, rather than over a period of time as intended.

Table 2 lists some commonly prescribed medicines and associated adverse effects that may occur if the medicine is not administered as a whole tablet/capsule. These types of adverse effects can result in hospital admissions².

A larger list is available at www.saferx.co.nz/Crushing-table-RAC.pdf.

Example of a serious adverse event

The Centre for Adverse Reactions Monitoring (CARM) recently received a report of a patient who developed an oesophageal ulcer next to their carotid artery. The patient had been attempting to take alendronate (as Fosamax Plus), despite their dysphagia (CARM ID: 129320). Attempted dilation of the oesophagus resulted in rupture, and the patient required Total Parenteral Nutrition (TPN) for many weeks. The original ulcer likely occurred due to improper passage of the alendronate tablet through the oesophagus. Alendronate is known to cause chemical burns if it is in contact with the oesophageal mucosa for too long (see Table 2).

Please report all adverse events that are suspected to be due to the incorrect administration of a medicine to CARM (https://nzphvc.otago.ac.nz/report/).

Table 1: Types of formulations that cannot be altered at the point of oral administration, with associated abbreviations and examples (this is not an exhaustive list)

Abbreviation	Type of formulation	Examples
CR	Controlled release	Metoprolol CR, Sinemet CR, Oxycodone CR (Oxycontin)
SR	Sustained release	Morphine SR (m-Eslon), Isosorbide mononitrate SR (Duride)
MR	Modified release	Ferrograd MR
CD	Controlled delivery	Diltiazem CD
EC	Enteric coated	Aspirin EC, Mesalazine EC (Asacol, Asamax, Pentasa)
HBS	Hydrodynamically balanced system	Madopar HBS
LA	Long acting	LA-Morph
ER	Extended release	Felodipine ER (Plendil)
FC	Film coated	Methotrexate, Sertraline

Source: SaferRx. 2018. Crushing guide for oral medication in Residential Aged Care. URL: www.saferx.co.nz/RAC_crushing_intro.pdf (accessed 12 July 2018).

Table 2: Commonly prescribed medicines and the adverse effects that may occur if not administered correctly

Medicine	Adverse effect
Metoprolol CR, Felodipine ER, Isosorbide mononitrate SR	Hypotension, falls, and loss of efficacy later in the day
Dabigatran (Pradaxa)	Opening the capsules increase bioavailability by 75%, increasing the risk of gastritis and bleeding
Levodopa + carbidopa/benserazide (Sinemet CR, Madopar HBS)	Dyskinesia, hallucinations, other motor complications
Oxycodone (Oxycontin, Oxycodone CR), Morphine (m-Eslon SR, LA-Morph)	Dose dumping causing respiratory depression, loss of consciousness and death
Alendronate (Fosamax), Risedronate	Local irritation and ulceration may occur if the tablet doesn’t pass through the oesophagus quickly
Methotrexate, Azathioprine	Risk of exposure to cytotoxic medicine by person other than the patient
Mesalazine LA, Pantoprazole EC tablet	Loss of efficacy

Source: SaferRx. 2018. Guide for crushing oral medication for residents with swallowing difficulties in Residential Aged Care July 2018. URL: www.saferx.co.nz/Crushing-table-RAC.pdf (accessed 12 July 2018).

If a patient has swallowing difficulties but needs an oral medicine, discuss alternatives with a pharmacist, for example, changing to a different medicine in the same class where the formulation can be altered, or the use of patches or sublingual formulations.

References

1. SaferRx. 2018. Crushing guide for oral medication in Residential Aged Care. URL: www.saferx.co.nz/RAC_crushing_intro.pdf (accessed 12 July 2018).
2. SaferRx. 2018. Guide for crushing oral medication for residents with swallowing difficulties in Residential Aged Care July 2018. URL: www.saferx.co.nz/Crushing-table-RAC.pdf (accessed 12 July 2018).