Oral route is the most common route for drug administration. Medications in the form of tablet, capsule and syrup are preferred due to its advantages, such as non-invasiveness, cost-effectiveness, stability and convenience. Problem emerges when some patients find these medications difficult to swallow. Trouble with swallowing pills can affect many children, elderly, individuals with disabilities and patients requiring the use of nasogastric tube. Mixing the contents of a capsule with food or adding a crushed tablet to a drink may seem like a better option to some caregivers and patients. However, it is not safe to crush a tablet or open a capsule without checking it first with healthcare professionals. 

Generally, tablets and capsules need to be swallowed whole with a glass of water. Public are advised to not cut, crush or chew medication unless told by the doctor or pharmacist to do so. With the latest pharmaceutical technology and drug delivery system, manufacturers are able to manipulate medication formulation to achieve the desired effects. There are medications that are designed to be released at a specific rate or specific location within the digestive tract such as the stomach or small intestine. Therefore, crushing tablets or opening capsules which are not designed to be taken this way may cause serious side effects and prevent the medications from working properly.

It is essential to understand the rationale before deciding whether it is safe to crush the tablet or open the capsule. Listed below is the formulation of tablet and capsule that should never be crushed, chewed or opened.

1. Modified-release tablet

Modified-release tablet as the name indicates may have multiple layers of coating to alter the rate at which the medication is released. It is designed to release medication over an extended period of time to allow less frequent administration and improve patients’ compliance. This group of medication can be identified by two letters at the end of the name such as MR, LA, CR, XR or SR. If a modified-release tablet is crushed or chewed, the whole dose can be released too quickly in the body and patients are more likely to experience side effects of overdose.

2. Enteric-coated tablet

These medications have a special coating on the outside to protect the tablet from gastric acid in the stomach. Some medications are intended for site-specific delivery such as the intestine. Without enteric coating, medications will dissolve in the stomach and undergo metabolism before reaching the target location. This will in turn cause less medications available to be absorbed into bloodstream and reduce treatment effectiveness.

Besides that, enteric coating also protects stomach lining from the irritating effects of certain medications such as non-steroidal anti-inflammatory drugs (NSAIDS). This coating allows the medications to pass through the acidic stomach intact and dissolve in the intestine. 

3. Capsule

Patients are not encouraged to open a capsule because there is risk of medication loss. This can lead to patients not getting the full therapeutic dose for their treatment. Instead of powder and liquid, some capsules contain modified-release granules or beads. Mixing the granules in food or drinks may results in treatment failure.

4. Cytotoxic Tablet

Cytotoxic medications are used for the treatment of cancer and autoimmune diseases. This medication works by interfering with cell replication and hence, destroying tumours and cancer. Most cytotoxic tablets are developed with a site-specific delivery system to target a few specific tissues. Crushing this medication can damage cells in the digestive tract and cause severe irritation.

5. Sublingual and Buccal tablet

Sublingual tablet is a medication that is placed under patient’s tongue whereas buccal administration involves placing the medication between gums and cheek where it dissolves and get absorbed into the bloodstream. This formulation is used to develop medications that require rapid absorption and fast onset of action such as glyceryl trinitrate tablet (GTN). GTN is used for acute relief of chest pain in heart attack patient.

Other than that, tablet coating can also mask unpleasant bitter taste and odours. Its smooth surface makes the tablet easier for patient to swallow as well. Some active ingredients are sensitive to heat or moisture, hence crushing the tablet exposed the ingredients to degradation.

Things to consider.

Always read instruction in the leaflet to check if it is suitable to cut or grind a medication. Not all tablets can be cut safely. As a general rule, if the tablet has a score mark or groove down the middle, it can be split in half. Use a pill cutter to aid with tablet splitting, avoid using kitchen knife or scissors. Be sure to talk to the doctor or pharmacist before doing so. It may also be possible to get medication in another form, such as a powder, cream, or liquid, so do not hesitate to ask your healthcare provider.

In a situation where medications are safe to be crushed, patients or caregivers should use suitable solvents as some medications may have interactions with milk or orange juice. Simple syrup can be used to dissolve crushed medications due to its viscosity and ease of handling.

As a conclusion, not all tablets can be crushed or cut. Crushing some medications may lead to patients getting side effects and treatment failure. Take medication as advised by the doctor and pharmacist. Any inquiries about medicines and other related issues can be made to the National Pharmacy Call Centre at 1-800-88-6722, every Monday to Friday, from 8 am to 5 pm (except on public holidays).