An audit of “Modification of oral medicines for patients with swallowing difficulties or on enteral tubes” – A clinical pharmacist’s point of view

D. Suryaprabha1,*, K. Saravanan2, R. Keerthana3, C. Archana3

1Senior Executive-Clinical Research, Kauvery Hospitals, India

2Clinical Pharmacist–CST, Kauvery Hospitals, India

3Clinical Pharmacist, Kauvery Hospital, Trichy-Tennur, India

*Correspondence: Tel: +91 98414 86267 Email: suryaprabha@kauveryhospital.com

Abstract

Background: Oral medicines are frequently modified prior to administration to patients with swallowing difficulties or on enteral tubes. But such decisions should be taken only after due consideration of the pharmaceutical properties of drugs. To assess compliance with guidelines for the administration of medications to patients who are unable to swallow solid oral medicines, and to provide necessary guidelines and awareness.

Methods: An observational audit was undertaken during daily medication rounds on patients with swallowing difficulties or on enteral tubes. Total number of prescriptions audited were 114 for one week. On each occasion that an oral medicine was modified, the preparation method was assessed against instructions given on the “Do not Crush List”.

Results: In this study, totally 114 prescriptions were audited. Among them 56 prescriptions were not in compliance with the caution ‘Do Not Crush Medications’.

Conclusion: From that study we concluded that 51% were adhering to the guidelines and 49% were not.

Keywords: ‘Do Not Crush”, Enteric coated, Pharmacokinetics, Sublingual, Enteral feeding tube

Background In this study, totally 114 prescriptions were audited. Among them 56 prescriptions were not in compliance with the caution ‘Do Not Crush Medications’.

These medications also cannot be chewed usually due to their specific formulations and their pharmacokinetic properties [1].

These are Time-release drugs that use a special technology to release small amounts of the medication into a person’s system over a long period of time.

Modified-release dosage is a mechanism that (in contrast to immediate-release dosage) delivers a drug with a delay after its administration (delayed-release dosage) or for a prolonged period of time (extended-release [ER, XR, XL] dosage) or to a specific target in the body (targeted-release dosage) [2].

Sustained-release dosage forms are dosage forms designed to release (liberate) a drug at a predetermined rate in order to maintain a constant drug concentration for a specific period of time with minimum side effects. This can be achieved through a variety of formulations, including liposomes and drug-polymer conjugates (an example being hydrogels). Sustained release’s definition is more akin to a “controlled release” rather than “sustained”.

Extended-release dosage consists of either sustained-release (SR) or controlled-release (CR) dosage. SR maintains drug release over a sustained period but not at a constant rate. CR maintains drug release over a sustained period at a nearly constant rate.

Enteric coated tablets are formulated because certain drugs can be irritating to stomach or degraded by stomach acid or more absorbed in the intestine than stomach. These enteric coating tablets or capsule beads the drug’s release can be delayed until it reaches the small intestine. Prefixes include EN and EC.

Some medications have objectionable tastes and smell, and are sugar coated to improve tolerability example. Ranitidine.

Additionally, sublingual and effervescent medications should not be crushed because it will decrease the medications’ effectiveness [4].

Why you shouldn’t rush to crush [5]:

  1. May cause serious side effects
  2. May prevent the medicines from working properly
  3. May slow down recovery from illness

What to do instead of crushing [5]:

  1. Most tablets and capsules are available as liquids or injectable.
  2. Ask pharmacist advice to choose an alternative.

Why do they need to swallowed whole? [5]

  1. They are designed to release medicine slowly into your body over time and crushing them could cause an overdose.
  2. Your stomach acid could stop them working without their special coating example: EC medications.
  3. They could be harmful to the lining of your stomach without their special coating example: Divalproex.
  4. They may taste unpleasant without their special coating example: Ranitidine.
  5. You could get side effects from inhaling powder from crushed medicines example: Chemo drugs.

Methods

An observational audit was undertaken during daily medication rounds on patients on a feeding tube. Total number of prescriptions audited was 114 and for one week. For each occasion that an oral medicine was modified, the preparation method was assessed against recommendations for “Do Not Crush List”.

Results

In this study, totally 114 prescriptions were audited and in that 56 prescriptions were ‘Do Not Crush Medications’. From that study it was concluded that 51% adhered to the guidelines and 49% did not (Fig. 1). Table 1 explains about the adherence and non-adherence. Table 2 explains the suspected drugs used in the audit, their formulation and alternative suggestions.

Fig. 1. Comparison of adherence of ‘Do Not Crush Medications’.

Table 1. Audit Report

Total no of prescriptions audited 114
Total no of patients where ‘do not crush medications’ given by enteral route 56
Percentage of non-adherence (%) 49.12
Percentage of adherence (%) 50.88

Table 2. Suspected drugs and their alternatives [3]

Suspected Drugs Formulation Alternative
Pantoprazole EC Enteric coated Injectables or ranitidine
Nifidipine – Retard Prolonged release Changed to other BP medications
Sodium Bi Carbonate Enteric coated Plain tablets
Metoprolol ER Extended release Plain tablets
Nitroglycerin XR or CR Extended release Plain tablets
Acebrophylline ER Extended release Plain tablets
Trimetazidine MR Extended release Plain tablets
Metformin + Glimepiride PR Extended release Plain tablets

Conclusion

A 114 prescriptions were audited in that 49% of prescriptions did not adhere to the guidelines. Each drug must be analyzed as to the best possible way to be administered without tampering with its properties [6].

Many drugs have special types of formulations. Before prescribing and administration of these medications, there is a need to check the special instructions given by the manufacturer’s recommendations. This shall ensure the medications therapeutic benefits and clinical outcomes.

Key Message

  1. Increasingly many orally administered drugs are special formulations
  2. Some such formulations cannot be crushed and administered either orally or by an enteric tube
  3. That may harm the patient or make the drug ineffective or both
  4. Lack of understanding may lead to inappropriate administration
  5. It is important to be aware of them. The manufacturer’s information leaflet invariably provides the necessary information
  6. ‘Do not crush’ list is provided to all wards

An audit indicated a significant percentage of non-compliance with guidelines

Acknowledgement We thankful to Dr. Venkita S. Suresh and P. Vairamuthu, MD Office who helped us in preparing the article.

References

  1. Downey CE, Thakerar A, Kirsa S. Don’t rush to crush: audit of modification to oral medicines for patients with swallowing difficulties. 2015: https://doi.org/10.1002/jppr.1085
  2. Kaufman MB. To Crush or Not to Crush. The Hospitalist. 2009.
  3. Gracia-Vásquez SL. Medications that should not be crushed. Med Uni. 2017;9(75):50–63.
  4. Oral Dosage Forms That Should Not Be Crushed. 2020: ISMP.org.
  5. Guidelines for the Administration of Drugs through enteral feeding tubes. 2nd Ed., 2003, NHS.
  6. Bowman C. Administration of drugs to patients with swallowing difficulties. J Malta College Pharm Practice. 2007;12:42–45.

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