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 |
|
Acetaminophen |
Tylenol Arthritis Pain Extended-Release (US) |
Tablet |
|
Albuterol |
VoSpire ER (US) |
Tablet |
|
Alendronate |
Fosamax |
Tablet |
|
Alfuzosin |
Uroxatral (US), |
Tablet |
|
Alprazolam |
Xanax XR (US) |
Tablet |
|
Ambrisentan |
Letairis (US), Volibris (Canada) |
Tablet |
|
Amoxicillin/Clavulanate |
Augmentin XR (US) |
Tablet |
|
Apremilast |
Otezla (US) |
Tablet |
|
Aprepitant |
Emend (US) |
Capsule |
|
Aspirin |
Ecotrin |
Tablet |
|
Aspirin/Dipyridamole |
Aggrenox |
Capsule |
|
Atomoxetine |
Strattera |
Capsule |
|
Axitinib |
Inlyta |
Tablet |
|
Belladonna Alkaloids |
Donnatal Extentabs (US) |
Tablet |
|
Benzonatate |
Tessalon Perles (US) |
Capsule |
|
Bisacodyl |
Dulcolax |
Capsule Tablet |
|
Bosutinib |
Bosulif |
Tablet |
|
Budesonide |
Entocort EC (US), Entocort (Canada) |
Capsule |
|
Budesonide |
Uceris (US) |
Tablet |
|
Buprenorphine |
Belbuca(US) |
Film |
|
Bupropion |
Aplenzin (US), Budeprion SR (US), Wellbutrin SR, XL, Zyban |
Tablet |
|
Cabozantinib |
Cabometyx, Cometriq (US) |
Capsule, Tablet |
|
Carbamazepine |
Carbatrol (US), Equetro (US) |
Capsule |
|
Carbamazepine |
Tegretol XR (US), Tegretol CR (Canada) |
Tablet |
|
Carvedilol |
Coreg CR (US) |
Capsule |
|
Cefuroxime |
Ceftin |
Tablet |
|
Chlorpheniramine Maleate |
Chlor-Trimeton Allergy 12 Hour (US) |
Tablet |
|
Ciprofloxacin |
Cipro |
Tablet |
|
Ciprofloxacin |
Cipro XR (US), Cipro XL (Canada) |
Tablet |
|
Clarithromycin |
Biaxin XL |
Tablet |
|
Clonidine |
Kapvay (US) |
Tablet |
|
Colestipol |
Colestid |
Tablet |
|
Cyclobenzaprine |
Amrix (US) |
Capsule |
|
Cyclophosphamide |
generics |
Capsule Tablet |
|
Dabigatran |
Pradaxa |
Capsule |
|
Dalfampridine |
Ampyra (US) |
Tablet |
|
Darifenacin |
Enablex |
Tablet |
|
Dasatinib |
Sprycel |
Tablet |
|
Deferasirox |
Exjade |
Tablet |
|
Desvenlafaxine |
Pristiq |
Tablet |
|
Dexlansoprazole |
Dexilant |
Capsule |
|
Dexmethylphenidate |
Focalin XR (US) |
Capsule |
|
Dextroamphetamine |
Dexedrine |
Capsule |
|
Dextroamphetamine/ Amphetamine |
Adderall XR |
Capsule |
|
Diclofenac |
Voltaren XR (US), Voltaren SR (Canada) |
Tablet |
|
Diclofenac/Misoprostol |
Arthrotec |
Tablet |
|
Didanosine |
Videx EC |
Capsule |
|
Diflunisal |
Generics |
Tablet |
|
Diltiazem |
Cardizem CD, Cartia XT (US), Dilacor XR (US), Dilt-XR (US), Taztia XT (US), Tiazac |
Capsule |
|
Diltiazem |
Cardizem Cardizem LA (US), Tiazac XC (Canada) |
Tablet |
|
Dimethyl Fumarate |
Tecfidera |
Capsule |
|
Disopyramide |
Norpace CR (US) |
Capsule |
|
Divalproex |
Depakote Sprinkle (US) |
Capsule |
|
Divalproex |
Depakote (US), Depakote ER (US), Epival ECT (Canada) |
Tablet |
|
Docusate Sodium |
Colace |
Capsule |
|
Donepezil |
Aricept (23 mg strength only) |
Tablet |
|
Doxazosin |
Cardura XL (US) |
Tablet |
|
Doxycycline |
Doryx (US), Apprilon (Canada) |
Capsule, Tablet |
|
Duloxetine |
Cymbalta |
Capsule |
|
Dutasteride |
Avodart, Jalyn |
Capsule |
|
Elbasvir/Grazoprevir |
Zepatier (US) |
Tablet |
|
Elexacaftor/Tezacaftor/ Ivacaftor |
Trikafta |
Tablet |
|
Enzalutamide |
Xtandi |
Capsule |
|
Ergotamine |
Ergomar (US) |
Tablet |
|
Erythromycin |
Erythromycin delayed-release |
Capsule |
|
Erythromycin |
E.E.S. |
Tablet |
|
Erythromycin |
Ery-Tab (US), PCE |
Tablet |
|
Esomeprazole |
Nexium |
Capsule (US), Tablet (Canada) |
|
Eszopiclone |
Lunesta (US) |
Tablet |
|
Etravirine |
Intelence |
Tablet |
|
Everolimus |
Afinitor Zortress (US) |
Tablet |
|
Felodipine |
Plendil |
Tablet |
|
Fenofibrate |
TriCor (US) |
Tablet |
|
Fentanyl |
Abstral |
Tablet |
|
Fentanyl |
Actiq (US) |
Lozenge |
|
Fentanyl |
Fentora |
Tablet |
|
Ferrous Gluconate |
Fergon (US) |
Tablet |
|
Ferrous Sulfate |
Feosol (US), Feratab (US) |
Tablet |
|
Fesoterodine |
Toviaz |
Tablet |
|
Fexofenadine/ Pseudoephedrine |
Allegra-D |
Tablet |
|
Finasteride |
Propecia, Proscar |
Tablet |
|
Fluoxetine |
Prozac Weekly (US) |
Capsule |
|
Fluvastatin |
Lescol, Lescol XL |
Capsule, Tablet |
|
Fluvoxamine |
Luvox CR (US) |
Capsule |
|
Gabapentin |
Gralise (US), Horizant (US) |
Tablet |
|
Galantamine |
Razadyne ER (US), Reminyl ER (Canada) |
Capsule |
|
Glecaprevir/Pibrentasvir |
Mavyret (US) |
Tablet |
|
Glipizide |
Glucotrol XL (US) |
Tablet |
|
Guaifenesin |
Mucinex (US) |
Tablet |
|
Guaifenesin/ Dextromethorphan |
Mucinex DM (US) |
Tablet |
|
Guaifenesin/ Pseudoephedrine |
Mucinex D (US) |
Tablet |
|
Guanfacine |
Intuniv (US), Intuniv XR (Canada) |
Tablet |
|
Hydromorphone |
Exalgo (US), Jurnista (Canada) |
Tablet |
|
Hydroxyurea |
Droxia (US), Hydrea |
Capsule |
|
Hyoscyamine |
Levbid (US) |
Capsule Tablet |
|
Ibandronate |
Boniva (US) |
Tablet |
|
Ibuprofen |
Advil, Motrin |
Tablet |
|
Imatinib |
Gleevec |
Tablet |
|
Indinavir |
Crixivan |
Capsule |
|
Indomethacin |
Indocin SR (US) |
Capsule |
|
Isavuconazonium Sulfate |
Cresemba |
Capsule |
|
Isosorbide Dinitrate |
Dilatrate-SR (US) |
Capsule |
|
Isosorbide Dinitrate |
Isordil Sublingual (US) |
Tablet |
|
Isosorbide Mononitrate |
Imdur |
Tablet |
|
Isotretinoin |
Absorica (US), Accutane (Canada), Amnesteem (US), Clarus (Canada), Epuris (Canada) |
Capsule |
|
Itraconazole |
Sporanox |
Capsule |
|
Ivacaftor |
Kalydeco |
Tablet |
|
Ivosidenib |
Tibsovo (US) |
Tablet |
|
Lamotrigine |
Lamictal XR (US) |
Tablet |
|
Lansoprazole |
Prevacid |
Capsule |
|
Lansoprazole |
Prevacid SoluTab (US), Prevacid FasTab (Canada) |
Tablet |
|
Lenalidomide |
Revlimid |
Capsule |
|
Levetiracetam |
Keppra |
Tablet |
|
Levetiracetam |
Keppra XR (US) |
Tablet |
|
Levodopa/Carbidopa |
Sinemet CR |
Tablet |
|
Levomilnacipran |
Fetzima |
Capsule |
|
Lithium Carbonate |
Lithobid (US), Lithmax (Canada) |
Tablet |
|
Lopinavir/Ritonavir |
Kaletra |
Tablet |
|
Loratadine/ Pseudoephedrine |
Claritin-D (US), Claritin Allergy and Sinus (Canada) |
Tablet |
|
Lovastatin |
Altoprev (US) |
Tablet |
|
Lubiprostone |
Amitiza (US) |
Capsule |
|
Lumacaftor/Ivacaftor |
Orkambi |
Tablet |
|
Memantine |
Namenda XR |
Capsule |
|
Mesalamine |
Asacol, Lialda (US) Pentasa |
Capsule (US), Tablet (Canada) |
|
Mesalamine |
Asacol, Lialda (US) |
Tablet |
|
Metformin |
Fortamet (US), Glucophage XR (US), Glumetza |
Tablet |
|
Methylphenidate |
Metadate CD (US), Ritalin LA (US), Biphentin (Canada) |
Capsule |
|
Methylphenidate |
Concerta, Metadate ER (US), Methylin ER (US), Ritalin SR |
Tablet |
|
Metoprolol Succinate |
Toprol-XL (US) |
Tablet |
|
Metoprolol Tartrate |
Lopressor SR (Canada) |
Tablet |
|
Metronidazole |
Flagyl ER (US) |
Tablet |
|
Minocycline |
Solodyn (US) |
Tablet |
|
Mirabegron |
Myrbetriq |
Tablet |
|
Morphine Sulfate |
Kadian |
Capsule |
|
Morphine Sulfate |
MS Contin |
Tablet |
|
Mycophenolate |
CellCept |
Capsule, Tablet |
|
Mycophenolic Acid |
Myfortic |
Tablet |
|
Naproxen |
EC Naprosyn (US), Naprelan |
Tablet |
|
Nevirapine |
Viramune XR |
Tablet |
|
Niacin |
Niaspan, Niaspan FCT (Canada) |
Tablet |
|
Nicardipine |
Cardene SR (US) |
Capsule |
|
Nicotine |
Nicorette (US) |
Lozenge |
|
Nifedipine |
Adalat CC (US), Procardia XL (US), Adalat XL (Canada) |
Tablet |
|
Nilotinib |
Tasigna |
Capsule |
|
Nisoldipine |
Sular (US) |
Tablet |
|
Nitroglycerin |
Nitrostat |
Tablet |
|
Olaparib |
Lynparza |
Tablet |
|
Omeprazole |
Prilosec (US), Prilosec OTC (US), Losec (Canada) |
Capsule, Tablet |
|
Orphenadrine |
Norflex ER (US) |
Tablet |
|
Oxybutynin |
Ditropan XL |
Tablet |
|
Oxycodone |
OxyContin (US), Oxy Neo (Canada), Xtampza ER (US) |
Capsule, Tablet |
|
Oxymorphone |
Opana ER (US) |
Tablet |
|
Paliperidone |
Invega |
Tablet |
|
Pancreatic Enzymes |
Creon, Pancreaze (US), Pertzye (US), Zenpep (US) |
Capsule |
|
Pantoprazole |
Protonix (US), Pantoloc (Canada) |
Tablet |
|
Paroxetine |
Paxil CR |
Tablet |
|
Pazopanib |
Votrient |
Tablet |
|
Pentoxifylline |
Trental (US) |
Tablet |
|
Piroxicam |
Feldene (US) |
Capsule |
|
Pomalidomide |
Pomalyst |
Capsule |
|
Posaconazole |
Noxafil DR (US) Posanol (Canada) |
Tablet |
|
Potassium Chloride |
Micro-K (US) |
Capsule |
|
Potassium Chloride |
Klor-Con (US) |
Tablet |
|
Praziquantel |
Biltricide |
Tablet |
|
Propafenone |
Rythmol SR (US) |
Capsule |
|
Propranolol |
Inderal LA, InnoPran XL (US) |
Capsule |
|
Pseudoephedrine |
Sudafed 12 Hour, 24 Hour (US) |
Tablet |
|
Pseudoephedrine/ Brompheniramine |
LoHist 12D (US) |
Tablet |
|
Pseudoephedrine/ Desloratadine |
Clarinex D (US) |
Tablet |
|
Pseudoephedrine/ Fexofenadine |
Allegra D |
Tablet |
|
Pyridostigmine |
Mestinon Timespan (US), Mestinon SR (Canada) |
Tablet |
|
Quetiapine |
Seroquel XR |
Tablet |
|
Rabeprazole |
Aciphex (US), Aciphex Sprinkle (US), Pariet (Canada) |
Capsule, Tablet |
|
Raloxifene |
Evista |
Tablet |
|
Ranolazine |
Ranexa (US) |
Tablet |
|
Regorafenib |
Stivarga |
Tablet |
|
Risedronate |
Actonel |
Tablet |
|
Risedronate |
Atelvia (US), Actonel DR (Canada) |
Tablet |
|
Risperidone |
Risperdal M |
Tablet |
|
Ritonavir |
Norvir |
Tablet |
|
Ropinirole |
Requip XL (US) |
Tablet |
|
Sirolimus |
Rapamune |
Tablet |
|
Solifenacin |
Vesicare |
Tablet |
|
Sulfasalazine |
Azulfidine EN-Tabs (US), Salazopyrin EN (Canada) |
Tablet |
|
Suvorexant |
Belsomra (US) |
Tablet |
|
Tacrolimus |
Astagraf XL (US) Prograf |
Capsule |
|
Tamsulosin |
Flomax (US), Flomax CR (Canada) |
Capsule, Tablet |
|
Tapentadol |
Nucynta ER |
Tablet |
|
Temozolomide |
Temodar (US), Temodal (Canada) |
Capsule |
|
Tezacaftor/Ivacaftor |
Symdeko |
Tablet |
|
Theophylline |
Theo-24 (US) |
Capsule |
|
Theophylline |
Generics |
Tablet |
|
Tipranavir |
Aptivus |
Capsule |
|
Tolterodine |
Detrol LA |
Capsule |
|
Topiramate |
Topamax |
Capsule, Tablet |
|
Topiramate |
Qudexy XR (US), Trokendi XR (US) |
Capsule |
|
Tramadol |
ConZip (US), Ryzolt (US), Ultram ER (US), Zytram XL (Canada) |
Capsule, Tablet |
|
Trazodone |
Generics |
Tablet |
|
Trazodone |
Oleptro |
Tablet |
|
Valganciclovir |
Valcyte |
Tablet |
|
Valproic Acid |
Depakene |
Capsule |
|
Vandetanib |
Caprelsa |
Tablet |
|
Vemurafenib |
Zelboraf |
Tablet |
|
Venetoclax |
Venclexta |
Tablet |
|
Venlafaxine |
Effexor XR |
Capsule |
|
Verapamil |
Verelan, Verelan PM (US) |
Capsule |
|
Verapamil |
Calan SR (US), Covera-HS (US), Isoptin SR |
Tablet |
|
Vismodegib |
Erivedge |
Capsule |
|
Vorinostat |
Zolinza |
Capsule |
|
Zileuton |
Zyflo CR (US) |
Tablet |
|
Zolpidem |
Ambien CR (US) |
Tablet |
|
Zolpidem |
Intermezzo (US) |
Tablet |
|
References
- McPherson ML. Don't crush that tablet! Am Pharm. 1994 May;NS34(5):57-8.
- 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.
- 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.
- ISMP. Oral dosage forms that should not be crushed. November 2018. https://www.ismp.org. (Accessed November 1, 2019).
- Clinical Pharmacology powered by ClinicalKey. Tampa (FL): Elsevier. 2023. http://www.clinicalkey.com. (Accessed January 19, 2023).
- 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).
- USP. Nomenclature guidelines. February 1, 2018. Nomenclature Guideline Outline (uspnf.com). (Accessed January 19, 2023).
- 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.
- 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.
- 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]