Crushing tablets and opening capsules
Key pointsSome patients are not able to swallow tablets/capsules, or may have feeding tubes, but:
- Don't crush modified-release or enteric-coated ('EC') tablets as it may stop the medicine working properly or cause more side effects.
- Don't crush cytotoxic (chemotherapy) tablets because the dust might be harmful if breathed in or spilled.
- Some tablets will disperse in water without crushing and some capsules can be opened (see Info sources, below). Yet they may taste unpleasant, and they may not be suitable for putting down a feeding tube.
- Sometimes a different formulation of the same medicine, or a similar medicine, may be more appropriate for your patient (e.g. oral liquids, soluble tablets, patches etc).
- Crushing a tablet, dissolving it in water, or opening a capsule may be an unlicensed use.
Info sources
✦ The Specialist Pharmacy Service (SPS) offers a suite of advice on using medicines safely and effectively in patients with swallowing difficulties. This includes guidance on choosing formulations of medicines for adults with swallowing difficulties, choice of medicines within therapeutic classes that are suitable for use in adults with swallowing difficulties, and use of thickeners in patients with swallowing difficulties. Also on the SPS website, a Medicines Q&A reviews the therapeutic options for patients unable to take solid oral dosage forms, while another Q&A provides a summary of medicines that require extra care when switching between liquid and tablet/capsule formulations, another discusses options for administration of medicines in patients who need thickened fluids, and another provides information on injections that can be given orally or via enteral feeding tubes.✦ Subscribe to the NEWT Guidelines website as an individual or ask your practice/ employer to subscribe. It will answer many of these questions for you. NEWT identifies alternative products that may be suitable for your patient as well as many tablets that disperse in water without the need for crushing. It was written by NHS pharmacists and costs as little as £60.
✦ Members of the Royal Pharmaceutical Society (RPS) have free access to the Handbook of Drug Administration via Enteral Feeding Tubes which answers some of these questions. You must log on to the RPS site to access it.
✦ Colchester Hospital University NHS Trust (PDF) that was last updated in 2018. Decide for yourself whether guidelines like this are ok to use; some have not been updated for a few years.
✦ The Medicines for Children website has advice and videos on giving certain medicines, including to kids who can't swallow. Some of this advice may be suitable for adults too. Search the site by drug name.
✦ Occasionally a Summary of Product Characteristics for a medicine will give the manufacturer's advice about crushing tablets or opening capsules.
Decision making
It is not possible to cover every eventuality, but the four questions below may help you make decisions about a patient that cannot swallow tablets or capsules. It is not comprehensive guidance.
1. Can the medicine be stopped? (It is no longer required, not essential, or there are non-drug options.)
No Yes ⇨ Stop the medicine if it is safe and appropriate (e.g. consider withdrawal reactions).
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2. Do the info sources above advise you what to do? (e.g. crushing tablets, dissolving them in water, or opening capsules.)
No Yes ⇨ Proceed according to advice given if it is suitable for your patient.
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3. Is there a different presentation of the medicine, or a similar medicine, that's suitable? (e.g. oral liquids, soluble tablets, patches etc.)
No Yes ⇨ Change the formulation if appropriate.
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4. Is it modified-release, enteric-coated, or cytotoxic? (Usually these tablets can't be crushed or capsules opened for safety reasons.)
No Yes ⇨ Contact the prescriber
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Contact your nearest NHS medicines advice service to discuss, or if you are not sure what to do.
General advice
✦ Practical advice on dispersing tablets in water or crushing them is provided free on the NEWT website.✦ The implications of crushing tablets and opening capsules, and the formulations for which this is unsuitable, are described in summary guidance from the Royal Pharmaceutical Society (2011). SPS also offers general background information about crushing tablets, opening capsules etc.
✦ Covert administration of a medicine requires careful consideration. The Care Quality Commission (CQC) states it should be a last resort and offers guidance; SPS also summarises current advice on this subject.
✦ Patient information. The NHS website has a brief guide for patients with problems swallowing tablets, highlighting that tablets shouldn't be divided or crushed, or capsules opened up, unless a pharmacist advises it.