Meds That Should Not Be Crushed

Full update February 2023

Crushing pills can improve ease of administration, but some shouldn’t be crushed. Crushing extended-release meds can result in administration of a large dose all at once. Crushing delayed-release meds can alter the mechanism designed to protect the drug from gastric acids or prevent gastric mucosal irritation. Crushing sublingual or buccal tabs can alter effectiveness. Crushing pills based on certain technologies (i.e., amorphous solid dispersion or nanocrystals) can alter bioavailability.9 Crushing bitter-tasting meds can be unpleasant for the patient. Crushing irritating or hazardous meds can be harmful to the individual crushing the meds. (If hazardous meds [e.g., carcinogenic] must be crushed, follow USP Chapter <800> standards in healthcare settings or advising outpatients on proper procedures. Hazardous meds below explicitly state not to crush in the product information. The NIOSH hazardous meds list is at https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB2016161.

This table has some common meds that should not be crushed; many more may not be listed. Brand names are representative and may not be all-inclusive. The most current product labeling for US and Canadian products was used to confirm information, in addition to listed references.

Modified-release:Indicates extended-release or delayed-release formulation.7

Medications That Should Not Be Crushed1-6,9,10

Generic Name

Brand Name

Dosage Form

Comments

Acamprosate

Campral

Tablet

  • Modified-release

Acetaminophen

Tylenol Arthritis Pain

Extended-Release (US)

Tablet

  • Modified-release

Albuterol

VoSpire ER (US)

Tablet

  • Modified-release

Alendronate

Fosamax

Tablet

  • Irritant (oropharyngeal)

Alfuzosin

Uroxatral (US),
Xatral (Canada)

Tablet

  • Modified-release

Alprazolam

Xanax XR (US)

Tablet

  • Modified-release

Ambrisentan

Letairis (US),

Volibris (Canada)

Tablet

  • Teratogenic

Amoxicillin/Clavulanate

Augmentin XR (US)

Tablet

  • Modified-release
  • Scored tablets can be split

Apremilast

Otezla (US)

Tablet

  • Antineoplastic

Aprepitant

Emend (US)

Capsule

  • Nanocrystal

Aspirin

Ecotrin

Tablet

  • Modified-release
  • Irritant (gastric)

Aspirin/Dipyridamole

Aggrenox

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Atomoxetine

Strattera

Capsule

  • Irritant (ocular)

Axitinib

Inlyta

Tablet

  • Antineoplastic

Belladonna Alkaloids

Donnatal Extentabs (US)

Tablet

  • Modified-release

Benzonatate

Tessalon Perles (US)

Capsule

  • Local anesthetic effect could increase the risk of choking

Bisacodyl

Dulcolax

Capsule

Tablet

  • Modified-release
  • Irritant (gastric)

Bosutinib

Bosulif

Tablet

  • Antineoplastic

Budesonide

Entocort EC (US),

Entocort (Canada)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Budesonide

Uceris (US)

Tablet

  • Modified-release

Buprenorphine

Belbuca(US)

Film

  • Sublingual dosage form

Bupropion

Aplenzin (US),

Budeprion SR (US), Wellbutrin SR, XL,

Zyban

Tablet

  • Modified-release

Cabozantinib

Cabometyx, Cometriq (US)

Capsule, Tablet

  • Antineoplastic

Carbamazepine

Carbatrol (US),

Equetro (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Carbamazepine

Tegretol XR (US),

Tegretol CR (Canada)

Tablet

  • Modified-release

Carvedilol

Coreg CR (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Cefuroxime

Ceftin

Tablet

  • Bad taste

Chlorpheniramine Maleate

Chlor-Trimeton Allergy

12 Hour (US)

Tablet

  • Modified-release

Ciprofloxacin

Cipro

Tablet

  • Bad taste

Ciprofloxacin

Cipro XR (US),

Cipro XL (Canada)

Tablet

  • Modified-release

Clarithromycin

Biaxin XL

Tablet

  • Modified-release

Clonidine

Kapvay (US)

Tablet

  • Modified-release

Colestipol

Colestid

Tablet

  • Modified-release

Cyclobenzaprine

Amrix (US)

Capsule

  • Modified-release

Cyclophosphamide

generics

Capsule

Tablet

  • Antineoplastic

Dabigatran

Pradaxa

Capsule

  • Intact product must be taken to avoid increased exposure

Dalfampridine

Ampyra (US)

Tablet

  • Modified-release

Darifenacin

Enablex

Tablet

  • Modified-release

Dasatinib

Sprycel

Tablet

  • Antineoplastic
  • Teratogenic

Deferasirox

Exjade

Tablet

  • Tablet is for oral suspension

Desvenlafaxine

Pristiq

Tablet

  • Modified-release

Dexlansoprazole

Dexilant

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Dexmethylphenidate

Focalin XR (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Dextroamphetamine

Dexedrine

Capsule

  • Modified-release

Dextroamphetamine/

Amphetamine

Adderall XR

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Diclofenac

Voltaren XR (US),

Voltaren SR (Canada)

Tablet

  • Modified-release

Diclofenac/Misoprostol

Arthrotec

Tablet

  • Modified-release
  • Irritant (gastric)
  • Teratogenic

Didanosine

Videx EC

Capsule

  • Modified-release

Diflunisal

Generics

Tablet

  • Irritant (gastric)

Diltiazem

Cardizem CD,

Cartia XT (US),

Dilacor XR (US),

Dilt-XR (US),

Taztia XT (US),

Tiazac

Capsule

  • Modified-release
  • Can be opened for administration of intact granules (Taztia XT and Tiazac)

Diltiazem

Cardizem

Cardizem LA (US),

Tiazac XC (Canada)

Tablet

  • Modified-release

Dimethyl Fumarate

Tecfidera

Capsule

  • Modified-release

Disopyramide

Norpace CR (US)

Capsule

  • Modified-release

Divalproex

Depakote Sprinkle (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Divalproex

Depakote (US),

Depakote ER (US),

Epival ECT (Canada)

Tablet

  • Modified-release

Docusate Sodium

Colace

Capsule

  • Bad taste

Donepezil

Aricept

(23 mg strength only)

Tablet

  • Intact product must be taken to avoid increased rate of absorption

Doxazosin

Cardura XL (US)

Tablet

  • Modified-release

Doxycycline

Doryx (US),

Apprilon (Canada)

Capsule, Tablet

  • Modified-release
  • Scored tablets can be split

Duloxetine

Cymbalta

Capsule

  • Modified-release

Dutasteride

Avodart,

Jalyn

Capsule

  • Teratogenic
  • Irritant (mucous membrane)

Elbasvir/Grazoprevir

Zepatier (US)

Tablet

  • Amorphous solid dispersion

Elexacaftor/Tezacaftor/

Ivacaftor

Trikafta

Tablet

  • Amorphous solid dispersion

Enzalutamide

Xtandi

Capsule

  • Antineoplastic

Ergotamine

Ergomar (US)

Tablet

  • For sublingual administration

Erythromycin

Erythromycin

delayed-release

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Erythromycin

E.E.S.

Tablet

  • Bad taste

Erythromycin

Ery-Tab (US),

PCE

Tablet

  • Modified-release

Esomeprazole

Nexium

Capsule (US),

Tablet (Canada)

  • Modified-release
  • Capsule can be opened for administration of intact granules

Eszopiclone

Lunesta (US)

Tablet

  • Bad taste

Etravirine

Intelence

Tablet

  • Amorphous solid dispersion
  • Tablet may be dispersed in water
  • Scored tablets can be split

Everolimus

Afinitor

Zortress (US)

Tablet

  • Amorphous solid dispersion
  • Irritant (mucous membrane)
  • Teratogenic

Felodipine

Plendil

Tablet

  • Modified-release

Fenofibrate

TriCor (US)

Tablet

  • Nanocrystal

Fentanyl

Abstral

Tablet

  • Sublingual dosage form

Fentanyl

Actiq (US)

Lozenge

  • Lozenge should be sucked, not chewed

Fentanyl

Fentora

Tablet

  • Buccal dosage form

Ferrous Gluconate

Fergon (US)

Tablet

  • Modified-release
  • Irritant (gastric)

Ferrous Sulfate

Feosol (US),

Feratab (US)

Tablet

  • Modified-release
  • Irritant (gastric)

Fesoterodine

Toviaz

Tablet

  • Modified-release

Fexofenadine/

Pseudoephedrine

Allegra-D

Tablet

  • Modified-release

Finasteride

Propecia,

Proscar

Tablet

  • Teratogenic

Fluoxetine

Prozac Weekly (US)

Capsule

  • Modified-release

Fluvastatin

Lescol,

Lescol XL

Capsule, Tablet

  • Modified-release (Lescol XL)

Fluvoxamine

Luvox CR (US)

Capsule

  • Modified-release

Gabapentin

Gralise (US),

Horizant (US)

Tablet

  • Modified-release

Galantamine

Razadyne ER (US),

Reminyl ER (Canada)

Capsule

  • Modified-release

Glecaprevir/Pibrentasvir

Mavyret (US)

Tablet

  • Amorphous solid dispersion

Glipizide

Glucotrol XL (US)

Tablet

  • Modified-release

Guaifenesin

Mucinex (US)

Tablet

  • Modified-release

Guaifenesin/

Dextromethorphan

Mucinex DM (US)

Tablet

  • Modified-release

Guaifenesin/

Pseudoephedrine

Mucinex D (US)

Tablet

  • Modified-release
  • Scored tablets can be split

Guanfacine

Intuniv (US),

Intuniv XR (Canada)

Tablet

  • Modified-release

Hydromorphone

Exalgo (US),

Jurnista (Canada)

Tablet

  • Modified-release

Hydroxyurea

Droxia (US),

Hydrea

Capsule

  • Irritant (cytotoxic)

Hyoscyamine

Levbid (US)

Capsule

Tablet

  • Modified-release
  • Scored tablets can be split

Ibandronate

Boniva (US)

Tablet

  • Irritant (oropharyngeal)

Ibuprofen

Advil,

Motrin

Tablet

  • Bad taste

Imatinib

Gleevec

Tablet

  • Antineoplastic
  • Irritant (mucous membrane)
  • Scored tablets can be split

Indinavir

Crixivan

Capsule

  • Bad taste
  • Can be opened for administration of intact granules

Indomethacin

Indocin SR (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Isavuconazonium Sulfate

Cresemba

Capsule

  • High risk of instability or reduced absorption

Isosorbide Dinitrate

Dilatrate-SR (US)

Capsule

  • Modified-release

Isosorbide Dinitrate

Isordil Sublingual (US)

Tablet

  • Sublingual dosage form

Isosorbide Mononitrate

Imdur

Tablet

  • Modified-release
  • Scored tablets can be split

Isotretinoin

Absorica (US),

Accutane (Canada),

Amnesteem (US),

Clarus (Canada),

Epuris (Canada)

Capsule

  • Irritant (esophageal)
  • Teratogenic

Itraconazole

Sporanox

Capsule

  • Amorphous solid dispersion

Ivacaftor

Kalydeco

Tablet

  • Amorphous solid dispersion

Ivosidenib

Tibsovo (US)

Tablet

  • Amorphous solid dispersion

Lamotrigine

Lamictal XR (US)

Tablet

  • Modified-release

Lansoprazole

Prevacid

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Lansoprazole

Prevacid SoluTab (US),

Prevacid FasTab (Canada)

Tablet

  • Should be dissolved in the mouth, not chewed

Lenalidomide

Revlimid

Capsule

  • Teratogenic

Levetiracetam

Keppra

Tablet

  • Bad taste

Levetiracetam

Keppra XR (US)

Tablet

  • Modified-release

Levodopa/Carbidopa

Sinemet CR

Tablet

  • Modified-release
  • Scored tablets can be split

Levomilnacipran

Fetzima

Capsule

  • Modified-release

Lithium Carbonate

Lithobid (US),

Lithmax (Canada)

Tablet

  • Modified-release

Lopinavir/Ritonavir

Kaletra

Tablet

  • Amorphous solid dispersion
  • Reduced bioavailability with crushing8

Loratadine/

Pseudoephedrine

Claritin-D (US),

Claritin Allergy and Sinus (Canada)

Tablet

  • Modified-release

Lovastatin

Altoprev (US)

Tablet

  • Modified-release

Lubiprostone

Amitiza (US)

Capsule

  • Stability is compromised

Lumacaftor/Ivacaftor

Orkambi

Tablet

  • Amorphous solid dispersion

Memantine

Namenda XR

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Mesalamine

Asacol,

Lialda (US)

Pentasa

Capsule (US),

Tablet (Canada)

  • Modified-release
  • Capsules can be opened for administration of intact granules (Delzicol, Pentasa [US])

Mesalamine

Asacol,

Lialda (US)

Tablet

  • Modified-release

Metformin

Fortamet (US),

Glucophage XR (US), Glumetza

Tablet

  • Modified-release

Methylphenidate

Metadate CD (US),

Ritalin LA (US),

Biphentin (Canada)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Methylphenidate

Concerta,

Metadate ER (US), Methylin ER (US),

Ritalin SR

Tablet

  • Modified-release

Metoprolol Succinate

Toprol-XL (US)

Tablet

  • Modified-release
  • Scored tablets can be split

Metoprolol Tartrate

Lopressor SR (Canada)

Tablet

  • Modified-release

Metronidazole

Flagyl ER (US)

Tablet

  • Modified-release

Minocycline

Solodyn (US)

Tablet

  • Modified-release

Mirabegron

Myrbetriq

Tablet

  • Modified-release

Morphine Sulfate

Kadian

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Morphine Sulfate

MS Contin

Tablet

  • Modified-release

Mycophenolate

CellCept

Capsule, Tablet

  • Teratogenic

Mycophenolic Acid

Myfortic

Tablet

  • Modified-release
  • Teratogenic

Naproxen

EC Naprosyn (US), Naprelan

Tablet

  • Modified-release

Nevirapine

Viramune XR

Tablet

  • Modified-release

Niacin

Niaspan,

Niaspan FCT (Canada)

Tablet

  • Modified-release

Nicardipine

Cardene SR (US)

Capsule

  • Modified-release

Nicotine

Nicorette (US)

Lozenge

  • Should be dissolved in the mouth, not chewed

Nifedipine

Adalat CC (US),

Procardia XL (US),

Adalat XL (Canada)

Tablet

  • Modified-release

Nilotinib

Tasigna

Capsule

  • Antineoplastic
  • Modified-release
  • Can be opened for administration of intact granules

Nisoldipine

Sular (US)

Tablet

  • Modified-release

Nitroglycerin

Nitrostat

Tablet

  • Sublingual dosage form

Olaparib

Lynparza

Tablet

  • Amorphous solid dispersion

Omeprazole

Prilosec (US),

Prilosec OTC (US),

Losec (Canada)

Capsule, Tablet

  • Modified-release
  • Capsule can be opened for administration of intact granules (Prilosec)

Orphenadrine

Norflex ER (US)

Tablet

  • Modified-release

Oxybutynin

Ditropan XL

Tablet

  • Modified-release

Oxycodone

OxyContin (US),

Oxy Neo (Canada),

Xtampza ER (US)

Capsule, Tablet

  • Modified-release

Oxymorphone

Opana ER (US)

Tablet

  • Modified-release

Paliperidone

Invega

Tablet

  • Modified-release

Pancreatic Enzymes

Creon,

Pancreaze (US),

Pertzye (US),

Zenpep (US)

Capsule

  • Modified-release
  • Irritant (oral mucosal)
  • Can be opened for administration of intact granules

Pantoprazole

Protonix (US),

Pantoloc (Canada)

Tablet

  • Modified-release

Paroxetine

Paxil CR

Tablet

  • Modified-release

Pazopanib

Votrient

Tablet

  • Antineoplastic

Pentoxifylline

Trental (US)

Tablet

  • Modified-release

Piroxicam

Feldene (US)

Capsule

  • Irritant (oropharyngeal)

Pomalidomide

Pomalyst

Capsule

  • Antineoplastic
  • Teratogenic

Posaconazole

Noxafil DR (US)

Posanol (Canada)

Tablet

  • Amorphous oral dispersion
  • Modified-release

Potassium Chloride

Micro-K (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Potassium Chloride

Klor-Con (US)

Tablet

  • Modified-release

Praziquantel

Biltricide

Tablet

  • Bad taste
  • Scored tablets can be split

Propafenone

Rythmol SR (US)

Capsule

  • Modified-release

Propranolol

Inderal LA,

InnoPran XL (US)

Capsule

  • Modified-release

Pseudoephedrine

Sudafed 12 Hour, 24 Hour (US)

Tablet

  • Modified-release

Pseudoephedrine/

Brompheniramine

LoHist 12D (US)

Tablet

  • Modified-release

Pseudoephedrine/

Desloratadine

Clarinex D (US)

Tablet

  • Modified-release

Pseudoephedrine/

Fexofenadine

Allegra D

Tablet

  • Modified-release

Pyridostigmine

Mestinon Timespan (US),

Mestinon SR (Canada)

Tablet

  • Modified-release

Quetiapine

Seroquel XR

Tablet

  • Modified-release

Rabeprazole

Aciphex (US),

Aciphex Sprinkle (US),

Pariet (Canada)

Capsule, Tablet

  • Modified-release

Raloxifene

Evista

Tablet

  • Bad taste
  • Teratogenic

Ranolazine

Ranexa (US)

Tablet

  • Modified-release

Regorafenib

Stivarga

Tablet

  • Amorphous solid dispersion
  • Antineoplastic

Risedronate

Actonel

Tablet

  • Irritant (oropharyngeal)

Risedronate

Atelvia (US),

Actonel DR (Canada)

Tablet

  • Modified-release
  • Irritant (oropharyngeal)

Risperidone

Risperdal M

Tablet

  • Must be allowed to dissolve on the tongue

Ritonavir

Norvir

Tablet

  • Amorphous solid dispersion

Ropinirole

Requip XL (US)

Tablet

  • Modified-release

Sirolimus

Rapamune

Tablet

  • Nanocrystal

Solifenacin

Vesicare

Tablet

  • Bad taste

Sulfasalazine

Azulfidine EN-Tabs (US),

Salazopyrin EN (Canada)

Tablet

  • Modified-release

Suvorexant

Belsomra (US)

Tablet

  • Amorphous solid dispersion

Tacrolimus

Astagraf XL (US)

Prograf

Capsule

  • Amorphous solid dispersion

Tamsulosin

Flomax (US),

Flomax CR (Canada)

Capsule, Tablet

  • Modified-release

Tapentadol

Nucynta ER

Tablet

  • Modified-release

Temozolomide

Temodar (US),

Temodal (Canada)

Capsule

  • Irritant (cytotoxic)

Tezacaftor/Ivacaftor

Symdeko

Tablet

  • Amorphous solid dispersion

Theophylline

Theo-24 (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Theophylline

Generics

Tablet

  • Modified-release

Tipranavir

Aptivus

Capsule

  • Bad taste

Tolterodine

Detrol LA

Capsule

  • Modified-release

Topiramate

Topamax

Capsule, Tablet

  • Bad taste
  • Capsules can be opened for administration of intact granules

Topiramate

Qudexy XR (US),

Trokendi XR (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules (Qudexy XR)

Tramadol

ConZip (US),

Ryzolt (US),

Ultram ER (US),

Zytram XL (Canada)

Capsule, Tablet

  • Modified-release

Trazodone

Generics

Tablet

  • Bad taste
  • Scored tablets can be split

Trazodone

Oleptro

Tablet

  • Modified-release
  • Scored tablets can be split

Valganciclovir

Valcyte

Tablet

  • Irritant
  • Teratogenic, carcinogenic

Valproic Acid

Depakene

Capsule

  • Irritant (oropharyngeal)

Vandetanib

Caprelsa

Tablet

  • Antineoplastic
  • Irritant

Vemurafenib

Zelboraf

Tablet

  • Amorphous solid dispersion

Venetoclax

Venclexta

Tablet

  • Amorphous solid dispersion

Venlafaxine

Effexor XR

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Verapamil

Verelan,

Verelan PM (US)

Capsule

  • Modified-release
  • Can be opened for administration of intact granules

Verapamil

Calan SR (US),

Covera-HS (US),

Isoptin SR

Tablet

  • Modified-release
  • Scored tablets can be split

Vismodegib

Erivedge

Capsule

  • Teratogenic

Vorinostat

Zolinza

Capsule

  • Irritant (skin and mucous membrane)

Zileuton

Zyflo CR (US)

Tablet

  • Modified-release

Zolpidem

Ambien CR (US)

Tablet

  • Modified-release

Zolpidem

Intermezzo (US)

Tablet

  • Sublingual dosage form

References

  1. McPherson ML. Don't crush that tablet! Am Pharm. 1994 May;NS34(5):57-8.
  2. Miller D, Miller H. To crush or not to crush? What to consider before giving medications to a patient with a tube or who has trouble swallowing. Nursing. 2000 Feb;30(2):50-2.
  3. Beckwith MC, Feddema SS, Barton RG, Graves C. A guide to drug therapy in patients with enteral feeding tubes: dosage form selection and administration methods. Hosp Pharm 2004;39:225-37.
  4. ISMP. Oral dosage forms that should not be crushed. November 2018. https://www.ismp.org. (Accessed November 1, 2019).
  5. Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2023. http://www.clinicalkey.com. (Accessed January 19, 2023).
  6. NIOSH list of antineoplastic and other hazardous drugs in healthcare settings, 2016. https://www.cdc.gov/niosh/docs/2016-161/pdfs/2016-161.pdf?id=10.26616/NIOSHPUB2016161. (Accessed January 19, 2023).
  7. USP. Nomenclature guidelines. February 1, 2018. Nomenclature Guideline Outline (uspnf.com). (Accessed January 19, 2023).
  8. Best BM, Capparelli EV, Diep H, et al. Pharmacokinetics of lopinavir/ritonavir crushed versus whole tablets in children. J Acquir Immune Defic Syndr. 2011 Dec 1;58(4):385-91.
  9. Uttaro E, Pudipeddi M, Schweighardt A, Zhao F. To crush or not to crush: A brief review of novel tablets and capsules prepared from nanocrystal and amorphous solid dispersion technologies. Am J Health Syst Pharm. 2021 Feb 19;78(5):389-394.
  10. Uttaro E, Zhao F, Schweighardt A. Filling the Gaps on the Institute for Safe Medication Practices (ISMP) Do Not Crush List for Immediate-release Products. Int J Pharm Compd. 2021 Sep-Oct;25(5):364-371.

Cite this document as follows: Clinical Resource, Meds That Should Not Be Crushed.Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber’s Letter.February 2023. [390224]

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