Ingestion of oral tablets is one of the treatment methods that is most frequent and easy to implement. However, problems arise when a patient is unable to swallow solid food, which will also affect the intake of oral medicine. In this situation, patients, caregivers or medical practitioners such as pharmacists and nurses have to look for other alternatives to ensure that the administration of medicines can be done properly. One of these alternatives is to crush the medicines.

There are a few situations in which medicines need to be crushed. Among them is to facilitate the administration of medicine through feeding tube for patients who have difficulty swallowing (dysphagia). In addition, the patient may have to crush the medicine and mix it with food or drinks in order to mask the taste of less palatable medicines. Moreover, some tablets are needed in specific doses for children, but not available in liquid form. Therefore, the medicine should be crushed, dissolved and measured accordingly to the desired dose. However, the question that need to be addressed is, “do all medicines such as capsules, tablets, pills and tablets can be crushed?”

Factors need to be considered before crushing solid oral medicines

When there is a need to crush solid oral medicines, it is very important to know information about the types and formulations of a medicine. Generally, solid oral medicines that cannot be crushed fall into several types:

1. Enteric-coated medicines

   The purpose of an enteric coating of medicines is to protect the medicine from stomach acidity as well as to protect the stomach from the effects of the medicine. Enteric-coated medicines are designed to withstand high acidity in the stomach and thus prevent the medicine from disintegrated before it reaches the target location of the intestines. In addition, it is also designed with the aim of turning the stomach acid into disintegrating agents to the medicine coating and thus ensuring it can be dissolved and acted on the intestine.

   Therefore, crushing enteric-coated medicines is not recommended because it can cause disintegration to occur too early, broken down by stomach acid and in turn, irritates the stomach lining.

2. Modified release medicines

   Modified release medicines is designed to ensure that the medicines consumed is released slowly in the stomach within 12 to 24 hours. This is to ensure that the concentration of the medicines in the blood remain consistent throughout the required duration. This type of medicines reduces the frequency of administration of the medicine and thus, minimizing the side effects of these medicines to patients. Often these types of medicines will have abbreviation LA, ER, XR, CR, SR written in the name of the medicine.

   Thus, this type of medicine cannot be crushed prior to ingestion as it would produce a high concentration of medicine in the body in a short period of time and may cause toxic effects due to overdose. In addition, it will also cause low concentration of the medicine in the blood before the next dose is taken, which can hinder the desired therapeutic effect.

3. Medicines taken sublingually (placed under the tongue)

   Medicines taken sublingually (drug placed under the tongue) to ensure the active ingredient is absorbed directly into the blood vessels under the tongue, thus increasing the concentration of the medicine in the body very quickly. This will also prevent the medicine from being digested in the liver that would reduce the medicine concentration in the blood.

   Therefore, it is not advisable to crush the sublingual medicines to ensure that the absorption and action of these medicines are not affected.

4. Capsule

   Medicines that are formulated in capsules form are not recommended to be opened prior consumed because there is a possibility that some powder is left in the capsule and is not fully swallowed which in turn will affect the targeted treatment effect. Besides, if the medicine inside the capsule is in the form of modified-released granules, it is not advisable to crush.

   Medicine in the form of tablets without a coating, a thin polymer coated tablets or sugar can generally be crushed. However, further consideration is required for medicines that are coated with sugar, as its function is to mask the bitter taste of the drug. In addition, crushing pills, tablets or open capsules can also expose individuals to the risk of toxicity. When the drug is crushed, fine powder produced can enter the body through the mouth or nose. Therefore, crushing of cancer medicines, some antibiotics and hormones are prohibited.

Crushing of medicines, moreover, may lead to patients receiving less than enough doses because there might be small amounts of drug stick to the instrument used to crush the medicines, might be spilled or might be blown by the wind. Since some medicines are highly effective with very little doses, shortage in dose even in small amounts may lead to treatment failure. There are also medicines that will be ruined if the tablet is crushed or removed from the capsules due to exposure to air or light, which may also affect the efficacy of the medicine.

Advice to consumers

Patients, caregiver or healthcare provider must realize that the act of crushing oral solid medicines is not recommended. Medicines prescribed must be taken as a whole and not to be crushed or, in case of capsule, be to opened. Besides, pharmacists would also be able to provide counseling regarding the suitability and the right method to crush, it is allowed.

In a situation where patient may have difficulties to swallow the medicine, patients or care giver are advised to read the information leaflet on the stability and other related information.

Patient laso can discuss with pharmacist on other alternative available such as liquid preparation, patches, dispersible or pessary.