Crushing, Opening, and Splitting Oral Dosage Forms

Crushing, opening, and splitting oral dosage forms are commonly used strategies by patients, caregivers, and healthcare professionals to address the challenges posed by dysphagia, a prevalent concern in hospice care settings. While these techniques (i.e., dosage form manipulations) can be beneficial, it’s essential to understand which medications are safe to manipulate and the proper ways to do so. Incorrect handling of medications can lead to unexpected consequences or undesirable results and impact patients’ quality of life. Additionally, deprescribing of medications no longer aligned with patient goals can reduce swallowing burden for patients.

Assess Patient Situation: Concern Introduction

SM is a 76-year-old female with a primary diagnosis of cerebrovascular accident (CVA). Over the past week, her ability to swallow has worsened, making it difficult for her to continue her oral medication regimen. Her caregivers have reported troubling episodes of gagging and coughing after she takes her medications. Recognizing the urgency of the situation, SM’s hospice nurse is looking for guidance on safely administering her current medications and recommendations for alternative treatments where appropriate.

Review Drug Information

Check Prescribing/Product Information:

When seeking information on how to administer medication, reviewing the prescribing information in the product label (i.e., package insert or drug label) maintained by the manufacturer is the best place to start. The DailyMed database contains labeling, submitted to the Food and Drug Administration (FDA) by companies, for FDA-approved products and some additional products regulated, but not approved, by the FDA.¹ When reviewing medications for alternative routes of administration, pay careful attention to the following sections:

• Dosage and Administration – This is the section in which manufacturers typically advise dosage form modification. Guidance on appropriate delivery vehicles (e.g., water, juice, soda, or soft foods) to enhance palatability is also found here. Be mindful as the choice in delivery vehicle may affect drug pharmacokinetics and absorption. Some examples include:¹
  • “Swallow capsules whole with fluid.”
  • “Do not divide, crush, chew, or place in water.”
  • “The capsule may also be administered by carefully opening the capsule and sprinkling the entire contents on a spoonful of applesauce.”
  • “Mix with 4 ounces (1/2 cup) of water, ginger ale, lemon/lime soda, lemonade or orange juice ONLY.”
• Dosage Forms and Strengths – Specific properties of the dosage form such as the “release” type (e.g., immediate-release, extended-release), whether capsules contain powder or beads/pellets, and if the tablet is scored for splitting.
• Description – A summary of “Dosage and Administration” and “Dosage Forms and Strengths” with detail on chemical properties and inactive ingredients.
• How Supplied/Storage and Handling – Medications considered hazardous or that have specific storage requirements will have guidance here. The NIOSH [National Institute for Occupational Safety and Health] List of Hazardous Drugs in Healthcare Settings, 2024 is another resource recommended for identifying hazardous drugs and handling them appropriately.² Examples of medications with handling guidance include:^1,2
  • “Females should not handle crushed or broken PROSCAR [finasteride] tablets when they are pregnant” due to potential absorption of finasteride and risk to a male fetus
  • “Nitroglycerin should be kept in the original glass container and must be tightly capped after each use” to prevent loss of potency

Even medical professionals may sometimes find it difficult to parse the information to determine what is permissible and what is contraindicated regarding dosage form manipulation. Table 1 provides a summary of common attributes of oral dosage forms that typically should not be crushed, opened, or split.

Table 1: Common Attributes of Oral Dosage Forms That Should Not Be Crushed, Opened, or Split^1-11

Check Additional Resources/Literature:

Guidance for crushing, opening, and splitting medications may not be available in the product label, or may not be apparent. Reasons for this may be that the practice is considered “off-label” or may lack the strong, supporting evidence the FDA requires for inclusion in the labeling. If clear guidance is not available, it may be necessary to consult additional resources.

• Ask your pharmacist! Pharmacists are trained in how to review and interpret drug information and frequently field questions about dosage form manipulation. Also, all pharmacies and pharmacy support services, like Enclara, subscribe to drug information databases to assist patients and clinicians.
• Access a Drug Information Database or Resource – Most subscription-based databases (e.g., Clinical Pharmacology,¹² UpToDate® Lexidrug™,¹³ TRC Healthcare (Pharmacist’s Letter, Prescriber’s Insight)¹⁴ and route of administration handbooks (e.g., Handbook of Drug Administration via Enteral Feeding Tubes⁵) offer guidance on dosage form manipulation. Listed below are a few open access resources to trial:
  • Blaszczyk A, et al. Crushed tablet administration for patients with dysphagia and enteral feeding: Challenges and considerations. Drugs Aging. 2023 Sep 14;40(10):895–9073
    • This resource provides practice guidance on manipulating oral dosage forms
    • Includes a list of other open access and subscription resources; it is important to employ clinical judgment when considering the application of content from open access resources.
  • Consumer Med Safety.org – provided by the Institute for Safe Medication Practices (ISMP) and is designed to help the consumer avoid mistakes when taking medicines¹⁵ The website includes medication safety tips and featured resources. Despite being designed for the layperson, it is full of useful resources that can inform clinicians. Examples include:
    • Is It Safe to Crush Medicine Tablets So They Are Easier to Swallow?
    • Tablet Splitting When Two Halves Don’t Equal a Whole

Review Alternative Options

When prescribing/product information or literature explicitly states that crushing, opening, or splitting the dosage form is harmful or prohibited or the patient/caregiver cannot reliably crush, open, or split dosage form(s) when it is permissible to do so, it is recommended to assess whether the medication is appropriate and clinically necessary.

• When the medication is beneficial if continued (e.g., medications used to palliate symptoms or to prevent discomfort), take a stepwise approach to choosing new therapy:
  • First, consider switching to an oral liquid, orally disintegrating tablet, buccal or sublingual form of the same or similar medication. If not feasible, then:
  • Consider alternative routes of administration already present, such as via an enteral feeding tube or parenteral access. If not feasible, then:
  • Consider off-label routes of administration such as rectal, via ostomy, intranasal, via nebulization, or subcutaneous.
• When the medication has no short-term benefits if continued (e.g., medications used to cure or prolong life; discontinuing relieves adverse effects), consider the following:
  • Does the medication require tapering?
    • If no, recommend discontinuing
    • If yes, refer to drug information or a pharmacist for guidance on tapering
  • Is patient/caregiver resistant to change?
    • If no, recommend discontinuing
    • If yes, introduce deprescribing topic with reassessment for opportunities for dose reduction, trial period(s) off medication with restart if warranted, and/or discontinuation

Assess Patient Situation: Information Gathering

SM’s caregivers have reported that she is able to swallow fluids and small tablets without significant difficulty. They are primarily focused on managing her pain and seizure activity, as both have been issues since her CVA. Careful titration has been necessary to achieve her current medication dosages. SM’s current medication list includes:

• Bisacodyl (Dulcolax®) 5 mg; Take 1 tablet by mouth every day for constipation
• Levetiracetam (Keppra®) 500 mg; Take 1 tablet by mouth twice a day for seizure control
• Atorvastatin (Lipitor®) 20 mg; Take 1 tablet by mouth every day for cholesterol
• Gabapentin (Neurontin®) 300 mg; Take 1 capsule by mouth at bedtime for nerve pain
• Warfarin (Coumadin®) 1 mg; Take 1 tablet by mouth every day to prevent blood clots
• Morphine immediate-release (MSIR®) 15 mg; Take 1 tablet by mouth every 4 hours as needed for pain
• Morphine extended-release (MS Contin®) 60 mg; Take 1 tablet by mouth every 12 hours for pain

Apply Clinical Judgment:

Altering dosage forms for administration may be associated with unpredictable risks and outcomes. It is essential to assess and balance both risks and benefits on a case-by-case basis. Choosing the appropriate medication formulation, using proper techniques, and assessing the appropriate route of administration and delivery vehicles are vital to maintaining medication effectiveness and preventing serious adverse effects. Just because you can physically crush, open, or split a medication dosage form doesn’t mean it is safe to do so. Modifying the dosage form without assessing the patient’s situation and reviewing drug information can lead to:

• Toxicity: Overdose due to disruption of timed-release properties
• Dosing Issues: Uneven or subtherapeutic dosing resulting from improper manipulation
• Deactivation: Loss of medication efficacy
• Exposure risks: Contact with irritants, hazardous, or teratogenic components
• Interactions: Unintended interactions with the delivery vehicle

When clinical judgment is applied, often the safer alternative may be to deprescribe or discontinue the medication, switching to a different medication or dosage form, or changing the route of administration.

Assess Patient Situation: Treatment Plan

After reviewing the drug information for each medication, treatment options were discussed with SM’s hospice nurse and her caregivers. The team aimed to simplify the medication list while prioritizing SM’s comfort, making minimal changes to her pain management and seizure medications. Comfort medications that are crushable tablets or capsules that can be opened will be mixed with a small amount of juice or water before administration. Non-crushable medications will be replaced with similar alternatives or administered by a different route.

Summary:

Effective medication management for patients with swallowing difficulties requires thorough review of drug information and an understanding of the common attributes of oral dosage forms that should not be manipulated. Identifying medications that are unsuitable for crushing, opening, and splitting is critical to ensuring patient safety and therapeutic efficacy. Moreover, collaboration amongst the patient, caregivers, and healthcare team is essential in making informed prescribing and deprescribing decisions that align with the hospice and patient’s goals of care. By working together and prioritizing comprehensive evaluations, we can enhance medication adherence and improve the overall quality of life for patients in hospice care settings.

To learn more about approaches to dysphagia and alternate routes of administration, access these Palliative Pearls:

• Dysphagia and Thickened Liquids
• Medication Administration via Feeding Tube
• Approach to Rectal Administration: A Refresher
• Drug Administration and Ostomies
• Subcutaneous Administration of Ondansetron Case
• Approach to Polypharmacy: A Refresher
• Deprescribing guidance. In: Dementia Medications & Deprescribing: A Revision

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REFERENCES

1. DailyMed [online]. National Institute of Health: National Library of Medicine. Accessed Apr 10, 2025. Site link
2. Ovesen JL, Sammons D, Connor TH, et al. NIOSH list of hazardous drugs in healthcare settings, 2024. Cincinnati, OH: U.S. Centers for Disease Control and Prevention, National Institute for Occupational Safety and Health, DHHS (NIOSH) Publication No. 2025-103 (Supersedes 2016-161). Article link
3. Blaszczyk A, Brandt N, Ashley J, et al. Crushed Tablet Administration for Patients with Dysphagia and Enteral Feeding: Challenges and Considerations. Drugs Aging. 2023 Oct;40(10):895-907. Article link
4. Institute for Safe Medication Practices. Crushing or splitting the wrong tablet can be a deadly error. Long-Term Care AdviseERR™. 2017 Apr;5(4):1-4. Article link
5. White R, Brandnam V. Handbook of Drug Administration via Enteral Feeding Tubes. 3rd London: Pharmaceutical Press; 2015.
6. Klang MG. Developing guidance for feeding tube administration of oral medications. JPEN J Parenter Enteral Nutr. 2023 May;47(4):519-540. Article link
7. Lomax K. To crush or not to crush? That is the medication administration question. Pharmacy Times. 2021 Jul 1. Article link
8. Clinical Pharmacology [database online]. Tampa, FL: Elsevier/Gold Standard, Inc.; 2025.
9. Article, Know When to Give Patients a “Green Light” to Cut or Crush Meds. Pharmacist’s Letter, November 2020.
10. Clinical Resource, Tablet Splitting: “To Split or Not to Split”. Pharmacist’s Letter/Prescriber’s Letter. November 2020.
11. Rosenquist R. Abuse-deterrent opioids. In: UpToDate, Fishman S, Crowley M, et al, (Eds), Wolters Kluwer. (Accessed on April 18, 2024).
12. Clinical Resource, Meds That Should Not Be Crushed. Pharmacist’s Letter/Pharmacy Technician’s Letter/Prescriber’s Letter. February 2023.
13. UpToDate® Lexidrug™. Wolters Kluwer. Accessed Apr 10, 2025. Site link
14. Pharmacist’s Letter & Prescriber Insights. TRC Healthcare. Accessed Apr 10, 2025. Site link
15. Consumer Med Safety.org. Institute for Safe Medicine Practices (ISMP). Accessed Apr 10, 2025. Site link