Pearls

Pills to powder: A clinician’s reference for crushable psychotropic medications

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Many patients experience difficulty swallowing pills, for various reasons:

• discomfort (particularly pediatric and geriatric patients)
• postsurgical need for an alternate route of enteral intake (nasogastric tube, gas­trostomy, jejunostomy)
• dysphagia due to a neurologic disorder (multiple sclerosis, impaired gag reflex, dementing processes)
• odynophagia (pain upon swallowing) due to gastroesophageal reflux or a structural abnormality
• a structural abnormality of the head or neck that impairs swallowing.1

If these difficulties are not addressed, they can interfere with medication adherence. In those instances, using an alternative dosage form or manip­ulating an available formulation might be required.


Crushing guidelines
There are limited data on crushed-form prod­ucts and their impact on efficacy. Therefore, when patients have difficulty taking pills, switching to liquid solution or orally disin­tegrating forms is recommended. However, most psychotropics are available only as tablets or capsules. Patients can crush their pills immediately before administration for easier intake. The following are some general guidelines for doing so:2

• Scored tablets typically can be crushed.
• Crushing sublingual and buccal tablets can alter their effectiveness.
• Crushing sustained-release medi­cations can eliminate the sustained-release action.3
• Enteric-coated medications should not be crushed, because this can alter drug absorption.
• Capsules can generally be opened to administer powdered contents, unless the capsule has time-release properties or an enteric coating.

The accompanying Table, organized by drug class, indicates whether a drug can be crushed to a powdered form, which usu­ally is mixed with food or liquid for easier intake. The Table also lists liquid and orally disintegrating forms available, and other routes, including injectable immediate and long-acting formulations. Helping patients find a medication formulation that suits their needs strengthens adherence and the therapeutic relationship.


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