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 Crushed^1-6,9,10
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

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]

Meds That Should Not Be Crushed

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