‘To crush or not to crush, that is the question!’ An algorithm can help with the proper administration of solid oral medicines in patients where the oral route is compromised

Dysphagia occurs in any age group although it is more common among elderly people. An ageing population is associated with the risk of an increasing incidence of dysphagic patients for whom it is necessary to implement a medication review that includes a careful evaluation of pharmaceutical forms. Dysphagia can severely undermine nutrition, impair quality of life, and affect patients’ ability to take solid oral dosage forms, thus compromising medication adherence.¹

When therapeutic alternatives other than solid oral pharmaceutical forms do not exist, tablet crushing becomes an option to be seriously investigated. This action may seem a futile act, too often delegated to the nursing staff without adequate support,² but it requires great attention, basically for two reasons. First, the staff assigned to this task must be adequately trained in order to avoid medication errors and/or exposure to potentially dangerous drugs. Second, crushing a tablet that cannot be crushed (eg, modified-release tablets) can result in therapeutic failure with potentially very serious risks to the patient’s health.³

In Italy, through a specific Recommendation, the Ministry of Health has issued a series of correct procedures to be implemented to avoid therapy errors related to incorrect handling of oral pharmaceutical forms.⁴

Despite this, there is no clear guidance on how to solve many difficult clinical challenges. The information given in the drug’s Summary of Product Characteristics (SPC) is sometimes partial and does not always make it clear how the drug can be crushed and what steps must be taken to correctly crush the product.

Several sources have attempted to implement the manufacturer’s information with other sources of information, providing comprehensive guidelines on the possible crushability of tablets.⁵

One limitation of these systems and databases relates to their timely updating due to the rapid introduction of increasing numbers of oral medicines and even more generics onto the market.

We therefore propose a decision-making algorithm (figure 1) that can be used as a guide when assessing the crushability of an oral medication. This algorithm is being applied in a pilot study in a surgical department in Bolzano Hospital in northern Italy.

Figure 1.

Decision-making algorithm that can be used as a guide when assessing the crushability of an oral medication. EV, author to define; IM, intramuscular.

We have divided the process into three steps:

• Step 1: for the medication under evaluation, the possibility of crushing it is indicated in the SPC;

• Step 2: more manageable pharmaceutical forms are available for the medication under evaluation;

• Step 3: neither of the two previous cases.

In the latter step, a careful case-by-case assessment is required, based on any supporting data in the literature and/or using databases dedicated to this topic, including a more in-depth and critical examination of the excipients.⁵ If a solution cannot be found, the physician should be advised to consider switching to other medications in the same therapeutic class or discontinuing therapy.

By means of this algorithm, we believe that the clinical pharmacist will be able to correctly and promptly assess which solution to implement when a tablet needs to be crushed.

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