MEDICATION ADMINISTRATION IN PATIENTS WITH SWALLOWING DIFFICULTIES/DYSPHAGIA

Preference - Crush tablets or open capsules first; then use licensed and therapeutic alternative after this and special use should be last resort due to cost implications TO SEARCH:HOLD DOWN CONTROL AND PRESS F THEN TYPE ITEM REQUIRED. For more information please ring pharmacy or ring manufacturers. SPECIAL THERAPEUTIC LICENSED DETAILS CAN INJECTION DRUG CRUSH AVAILABL ALTERNATIVE? BE USED ORALLY? ALTERNATIVE? OR E (PRICE) OPEN? () (CORRECT AS JUNE 2011)

ABACAVIR

Yes

Manufacturer states no reason why crushing tablets would create stability concerns as long as administered immediately. Can chew tablets with first mouthful of food. Tablets do not disperse easily in water but require gentle agitation for approx 5 minutes. Suspension can be flushed down 8Fr NG tube

Liquid available

ACARBOSE

Yes

Consider changing to insulin if appropriate

ACEBUTOLOL ACETAZOLAMIDE

Yes

Change to other betablocker available in liquid if absolutely necessary If taking MR capsules convert to normal release. These disintegrate quickly in 10ml water which settles quickly and flushes down 8Fr NG tube without blockage but rinse all through to ensure total dose given Disperse in 10ml water within 5 minuts to give dispersion which flushes via 8Fr NG tube without blockage Injection can be taken orally or enterally see handbook. May be stored in fridge for up to 24 hours

Non-MR can be dispersed in water

ACENOCOUMAROL

Yes

ACETYLCYSTEINE

See over

Tablets are effervescent 600mg Injection solution diluted to 50mg/ml can be given BUT special orally or enterally. Very bitter. blackcurrant Orange syrup, orange juice or coke used Syrup available

600mg tablets (100) 21

ACICLOVIR ACITRETIN

Dispersible tablets Open capsules immediately before use and take contents with food No Not water-soluble and are degraded by light. WARNING: not to be handed by women of childbearing potential.

Syrup available

5mg/5ml x 75ml 59

ALFACALCIDOL ALFUZOSIN

One-Alpha injection administered orally or via feeding tube Convert MR to standard release (commence at 2.5mg tds as risk of hypotension) Blue film-coating can be washed off tablets to make them easy to crush. Disperse in 1-2 minutes Disperse in 10ml water for 5 minutes to form dispersion that flushes down 8FR NG tube without blockage Powder has anaesthetic effect on lips and oral mucosa

Yes - injection

Non-MR can be dispersed in water Yes

ALIMEMAZINE

Syrup available

ALLOPURINOL

Yes

ALVERINE AMANTADINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION) AMILORIDE AMINOPHYLINE

Yes Yes

Convert to mebeverine if necessary Syrup available

Yes Do not crush MR

Syrup available Theophylline liquid

AMIODARONE

Yes

Very bitter taste mix with fruit juice or jam if neccessary

100mg/5mg x 100 ml 76

AMITRIPTYLINE

Yes

Bitter taste. MR capsules can be emptied out but swallow granules whole. Tablets do not disperse but can be crushed and disperse in 10ml water. Give immediately as light sensitive. Disperse in 10ml of water in 2 minutes to give dispersion that settles flushes down an 8Fr NG tube without blockage. Can be chewed if possible. WARNING: not to be handed by women of childbearing potential. Tablets disperse in 10ml water to give clear dispersion that lfushes down 8Fr NG tube without blockage.

Syrup available

AMLODIPINE

Yes

Syrup available

ANASTROZOLE

Yes

ARTHROTEC ASASANTIN RETARD

No No Dispersible aspirin and liquid dipyridamole.Granules may be given whole, not chewed NB may clog tube.

NSAID plus gastro protection

ASCORBIC ACID

Yes

ATOMOXETINE ATENOLOL ATORVASTATIN

Yes Yes Yes

Open capsules Syrup available Rinse residual tablet material down NG/PEG tube (does not disperse completely). Be aware that the insoluble powder may cause blockage. Or can sprinkle on cold, soft food.

ATROPINE

Injection may be given orally and enterally

AZATHIOPRINE

Yes but

Tablet can be crushed but should not be done on ward due to risk of exposure Syrup available. Problems with feeds Syrup available Manufacturer advises that the capsules are NOT opened as the drug contains an AZO (DYE)BOND and can badly stain skin, teeth etc that it comes into contact with Disperse in 2 minutes when placed in 10ml water & give fine dispersion Syrup available Use alternative treatment if necessary e.g. sulasalazine see liquid available

50mg/5ml x 150ml 12

AZITHROMYCIN BACLOFEN BALSALAZIDE

No

Yes No

BENDROFLUMETHIAZIDE

Yes

Other thiazides Indapamide. Loop diuretics furosmide and bumetanide oral solutions available

BENZTROPINE

Injection may be given orally and enterally although manufacturer cannot recommend. Yes When crushed finely the powder mixes easily with water and flushes down 8Fr NG tube

BETAHISTINE

BEZAFIBRATE

Yes if Non-MR Risk of tube blockage with MR change to non-MR and can be dispersed in 10ml water and shake for 5 minutes to form coarse dispersion that may block fine-bore tubes but can be flushed through 8Fr NG tube Very insoluble Crush finely and suspend in water. . WARNING: not to be handed by women of childbearing potential No Do not crush EC irritant effect on stomach Risk of tube blockage due to film coating. But do disintegrate rapidly in 10ml water to form fins suspension that flushes down 8Fr NG tube without blockage. NB Parlodel tablets are autocatalytic and will begin to disintegrate as soon as they are broken up- administer immediately. Mix contents with water when powder if wetted; forms fine dispersion that fushes easily via 8Fr NG tube without blockage Suppositories available

BICULTAMIDE

BISACODYL BISOPROLOL

Yes

Atenolol liquid

BROMOCRIPTINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)

Yes

BUDESONIDE

Yes

Opening capsules may cause the drug to be released in the wrong part of the intestine. Do not open MR capsules. May mix granules with fruit juice. Granules may stick to the side of enteral feeding tube.

BUMETANIDE BURINEX A BUSPIRONE CABERGOLINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION) CALCIUM CARBONATE

Yes Yes Administer as separate components as liquid Take 5 minutes Tablets do not disperse readily in water but if shaken in 10ml water for 5 minutes will give clear solution which flushes via 8Fr NG tube without blockage. Calcichew, Cacit and Tiraloc disperse in water. Same applied for Vitamin D components also e.g. Cacit D3 granules. Injection may be given Injection can also be given orally or enterally orally or enterally. Tablets disperse in 10ml water within 5 minutes and given via 8Fr NG tube without blockage. When mixed with water resulting paste too think to administer via feeding tubes.

Syrup available

Yes Yes

Yes

Syrup available- CalciumSandoz

CALCIUM FOLINATE

Yes

CALCIUM RESONIUM

No

Enema available

CANDERSARTAN CAPECITABINE

Yes

Insoluble in water administer immediately Dissolve without crushing tablet in small amount of warm water. Takes approx 15 minutes Tablets disperse in 10ml water within 2 minutes to give suspension that flushes down 8Fr NG tube. Can also be given S/Ldose should be halved and given twice as frequently e.g., 12.5 mg tds=6.25 mg 6 times a day

Consider changing to ACEI

Yes see next column

CAPTOPRIL

Yes

Normal tablets are special 2mg x 100 23 25mg/5ml x 100ml 27

5mg/5ml 65

CARBAMAZEPINE

No

Suppositories or liquid available. 125mg rectal dose is equivalent to 100mg oral dose. Maximum dose by rectal route is 250mg qds. If patient has been taking MR tablets give the same total daily dose divided into three or four doses. PEG/NG enteral feeds may affect carbamazepine absorption leave two-hour gap before and after dose, especially with Isocal and Ensure plus. NB also risk of adsorption onto PVC feeding tubes. If this is long term use, then measure levels and adjust dose accordingly. Liquid should be mixed with equal volume of water just prior to administration and flushed down tube well to minimise adsorption onto tubes.

CARBIMAZOLE

Yes

Tablets disperse in 10ml and shaken vigorously for 5 minutes 0 give via 8Fr NG tube without blockage

Syrup available

30mg/5ml x 100ml 7

CARBOCISTEINE CARVEDILOL

No Yes Disperses in 1-5 minutes immediately before administration as small particles will form in water

Liquid available

CEFALEXIN CEFUROXIME

No Yes Disperse in water and administer however should be avoided as risk of sensitisation Capsule contents have low aqueous solubility and poor stability, but can be removed just prior to administration. May be added to cold or roomtemperature apple sauce if swallowing difficulties

Liquid available Liquid and injection available

CELECOXIB

No

Change to rofecoxib liquid

CELIPROLOL CETIRIZINE

Yes No Tilomed brand disintergrate if shaken in 10ml water for 5 minutes. Liquid available

CHLORAL HYDRATE

No

Consider alternative in elderly patient e.g. benzos, - temazepam

200mg/5ml x 200ml 2

200mg/5ml x 50ml 15

500mg/5ml x 200ml 8

CHLORDIAZEPOXIDE CHLOROQUINE

Yes Yes Crush to ensure film-coating is broken. Very bitter taste Liquid available do not give at same time as antacids Injection can be given orally. Liquid available. Acid solution. Direct interaction of drug and feed causing coagulation in the tube. Dilute with equal volume of water Suppositories, injection and liquid available Take care to give all, as it will sediment quickly. Do not give via tubes as it will adsorb to the plastic Flush tube well after dose may block Incompatible with feeds stop one hour before and after. Dilute with same volume of sterile water and flush post dose Liquid and injection Injection can be given enterally. May be reduced available. absorption when cimetidine administered directly into jejunum. Concentrate for infusion and liquid available

CHLORPHENAMINE

No

CHLORPROMAZINE CHLORTALIDONE CICLOSPORIN CILAZAPRIL CIMETIDINE

No

Yes

Yes

Yes

Yes

CINNARIZINE

Yes

Disperse in 10ml water and flushes easily via 8FR Ng tube

Change to Promethazine Hydrochride

CIPROFIBRATE CIPROFLOXACIN

Yes Yes disperse in 30-60ml of sterile water and take Ciprofloxacin absorption may be reduced by up to 25% by interaction with Jevity, Ensure and Resource and also chelated by ions in tap water. Liquid available

Stop feed for 1 hour before and 2 hours after dose. Consider increasing dose if feed needs to be continued. Use distilled water for dissolving tablets/flushing tubes.

CITALOPRAM

Yes

The powder is poorly soluble so care should be taken to not block tube. 8 drops of the liquid is equivalent to 20mg tablet. REF. Can add water to required number of drops. Flush tube well to prevent clogging.

Oral drops available

CLARITHROMYCIN

Yes

Liquid available, may clog tube so dilute with same volume of water prior to administration Unpleasant taste and odour try masking with flavoured syrup e.g. blackcurrant, cherry. Suspension has been discontinued in the UK but can be imported through IDIS from other countries 75mg/5ml x 80ml 9

CLINDAMYCIN

Yes

Capsules open easily and powder pours from capsule when squeezed; care must be taken to ensure entire contents are emptied out. Mixes easily with water and flushes via 8Fr Ng tube without blockage

CLOBAZAM

Yes

5mg/5ml x 150ml 35 5mg/5ml x 100ml 3

CLOMETHIAZOLE CLOMIPRAMINE

No Yes (non-MR Small capsules mix with water capsules only) and flush down 8Fr NG tube without blockage. Yes Injection solution may be given orally or enterally after dilution with 1ml water for injection. Excipients include ethanol, glacial acetic acid, benzyl alcohol and propylene glycol.

Liquid available Consider changing to alternative tricyclic

CLONAZEPAM

Liquid and injection available. Do not mix suspension with water - it will create an emulsion and the active ingredient will precipitate out.

125mcg/5ml x 150ml 130

2mg/5ml x 150ml 46 500mcg/5ml x 150ml 39

CO-AMILOFRUSE CO-AMILOZIDE

Yes Yes

Give components separately as liquids

CO-AMOXICLAV

Yes

Liquid and dispersible tablets available. 250/62 syrup is designed for children - for dysphagic adults use dispersible tablets. NG/PEG if syrups are used, thin with an equal quantity of water before putting down tube (avoids crusting of tube with syrup).

CO-APROVEL CO-BENELDOPA (Madopar ' preparations) SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION

No No

Give separate components and see on here Dipsersible tablets available. Administer immediately once dissolved. Do not empty the MR capsule the capsule shell is part of the MR mechanism. NB dispersible tablets have a quicker onset and shorter duration of action and cannot be substituted for normal release without a review of therapy. Give at different time to feed as may interfere with absorption of levodopa. Do not open capsules

CO-CARELDOPA (Sinemet preparations) SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION CO-CODAMOL CO-DANTHRAMER CO-DYRAMOL CODEINE

Yes

Administer immediately once dissolved. Do not crush M/R products

Yes dispersible available Liquid available - now very limited indications for this drug No Liquid available or convert to soluble/liquid components Dispersion occurs slowly Liquid available

Yes

COLECALCIFEROL CO-PHENOTROPE CO-TENIDONE CO-TRIAMTERIZDE CO-TRIMOXOZOLE COLCHICINE

See Calcium and Vitamin D Yes Disperse in water and flush down 8Fr NG tube without blockage.

30units/1ml x 100ml 100

Yes however should suspend in Yes No Yes Disperses in 2 minutes when placed in 10ml water to give coarse dispersion that breaks up further when drawn into syringe. Flushes down 8Fr Ng tube without blockage. Suggest using alternative analgesic e.g. co-codamol 8/500 soluble Powder may be mixed with food Injection available and or syrup (to mask bitter taste) can be given enterally but manufacturers do not for administration. recommend. Liquid and dispersible tablets available

CO-PROXAMOL COVERSYL CYCLIZINE CYCLOPENTHIAZIDE CYCLOPHOSPHAMIDE

Yes No Yes

Switch to perindopril and indapamide 50mg suppositories x 12 46

Yes No

Injection can be used to prepare solution for oral use. It has been used enterally.

50mg/5ml x 100ml 56

CYPROPHEPTADINE CYPROTERONE DANTROLENE

Yes Yes Yes Powder may be emptied from capsule and mixed - with orange juice or other acidic liquid. Protect from light, use immediately Disintegrates in water and flushes down 8Fr NG tube without blockage

DAPSONE DEFLAZACORT

Yes Yes

DEFERIPRONE DEMECLOCYCLINE

No Yes Remove capsule contents, mix with water and flush down tube. Contents do not disperse in water and tube blockage has been reported. Flush well Consider whether the patient is fluid restricted as this is often the case if this drug is being used to treat SIADH Irritant to the mucosa- DO NOT open for oral administration Absorption reduced by calciumWithhold feed 1 hour before and 2 hours post dose

Liquid available

DESMOPRESSIN DEXAMETHASONE DIAZEPAM

Yes

Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube

Nasal or sublingual route available

Yes

Disintegrates within 5 minutes Can dilute and administer Liquid available. in 10 ml water and give via 8Fr the injection orally or enterally. Ng tube. Settles quite quickly PEG/NG syrup/crushed tablets not recommended as drug may adsorb onto tubing. APS brand disperses within 2 minutes in 10 ml water and give via 8Fr Ng tube Injection has been given enterally, however manufacturers do not recommend. Drug loss may occur if administered through long PVC tubes as it is significantly absorbed onto PVC. It may also contribute to blockage of tubes Liquid available but may absorb into plastic tubing. Suppositories available as well as IM or IV preps. 10mg/5ml x 200ml 29

Yes

2.5mg/5ml x 500ml 14 Liquid, dispersible tablet, suppositories , injection and emulgel available 50mg/5ml x 150ml 30

DICLOFENAC

No

Tablets are E/C or M/R and should not be crushed. Injections should be limited to max. 2 days treatment. Some MR capsules can be emptied and the contents given, but for some brands the capsule shell is involved in the slow release mechanism so cannot be emptied.

DICYCLOVERINE DIGOXIN

Yes Yes Bioavailability of liquid differs from that of the tablets i.e. 65% for tablets vs. 75% for liquid. The company recommends that dose changes are not generally necessary monitor levels after change. Do not dilute liquid. IM NOT recommended. Contact pharmacy for information on IV use. If converting from IV to oral give 20% reduced dose Leave a two hour gap in the feed before and after administering the dose.

Liquid available Liquid and Injection available

DIHYDROCODEINE DILTIAZEM

Yes (but not MR) No but see next column Preparations that are once or twice daily all MR, so crushing/dissolving is not recommended; an alternative calcium channel blocker should be considered. Three times daily formulation is not mr and can be crushed. May crush Tildiem 60mg tablets & flush down tube with water. If patient on SR prep then convert to plain 60mg tablets. Due to differences in bioavailability of the MR preps give 60mg TDS and adjust accordingly Tildiem LA Capsules- open and sprinkle content in water or mix in soft food. However due to size of micropellets may block feeding tubes1. DO NOT crush the pellets Do not crush M/R forms (e.g. Tildiem retard)

Liquid available

 Adizem SR/XL -capsule contents can be mixed in water or soft food. DO NOT crush the pellets. Due to size of pellets may block feeding tubes Patient should stay dedicated to one brand due to differing bioavailabilities Alternatively change to amlodipine

DIPYRIDAMOLE

Yes (Non MR Crush or disperse tablet in only) water (Persantin). Sugar coated so may block tube. Flush well after dose. Dispersion occurs slowly Persantin Retard may be opened and contents taken in soft food or suspended in water Granules should not be crushed or dissolved in hot water May block tube Dipyridamole/aspirin capsules (Asasantin) may be opened and the contents given in a small quantity of liquid or food. Care should be taken to not crush the granules as the dipyridamole component is a sustained release granule. Do not dissolve in hot water. Anecdotal reports that the granules may block PEG or NG Tablets may be crushed, but taste is unpleasant-this may be masked by mixing with an acidic beverage e.g. orange juice.

Diluted injection can be administered orally or by feeding tube. Should be given on empty stomach therefore enteral feeds should be withheld for one hour before and one hour after dose.

Liquid dipyridamole available.

DISODIUM ETIDRONATE(also included in Didronel PMO pack) DOCUSATE DOMPERIDONE

Yes

PEG/NG feed should be stopped for 2 hours before and 2 hours after administration of etidronate as drug interacts with calcium in feed. Liquid available Liquid (high sorbitol content and may cause diarrhoea) and suppositories available DO NOT use Aricept Evess for feeding tube administration as these tablets will only dissolve in an environment where digestive enzymes are present ie the mouth. They will not dissolve in water.

No Yes

DONEPEZIL

DOSULEPIN

Yes

Crushing tablets/emptying capsules not recommended as powder is local anaesthetic avoid hot drinks after. Can sprinkle on small amount of food. Tablets may be crushed and mixed/washed down with distilled water as the chloride ions in tap water will precipitate out the active drug. REF. Sudden hypotensive effect when crushed tablets given by enteral route monitor patients BP

Consider other antidepressant

25mg/5ml x 500ml 29

DOXAZOSIN

Yes

When converting from MR to plain halve the dose and titrate upwards according to response Do NOT crush MR preparations.

DOXEPIN

Yes

Can open capsule and mix the powder with water. The resulting solution has a bitter taste which is difficult to mask. Can remove capsule contents to flush down tube. They should NOT be opened for oral administration as the hyclate salt present is irritant to the oesophagus. Doxycycline binds to calcium ions and may have reduced Doxycycline binds to calcium ions and may have reduced absorption when given via enteral feeding tubes. Prescribe at higher end of standard dosage range. Can be put in thick and easy. But break in feeding not necessary Dispersible tablets available

Consider other antidepressant

DOXYCYCLINE

Yes

DULOXETINE

Yes

Open capsules and mix with apple juice or sauce. Entericcoated beads inside should not be chewed or crushed. Give immediately. NG no information, try opening capsule and flushing NG tube with apply juice. Do NOT empty capsules, may irritate GI tract

DUTASERIDE

DYDROGESTERONE EFAVIRENZ

Yes NO Liquid available conversion necessary

ENALAPRIL

Yes

Give immediately after crushing and mixing with water. Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube Caution: Tablet powder will stain orange, so avoid spillage on clothes etc., and contact with lips etc. May also stain tube. Wear gloves. May be added to jam, honey or orange juice. PEG/NG tubes: tablet powder mixes in water but does not dissolve fully, so ensure all residue is rinsed thoroughly down tube. See guidelines at end of table

Consider other ACEI.

2mg/5ml x 100ml 62

ENTACAPONE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)

Yes

EPLERENONE EPROSARTAN ERGOCALCIFEROL

Yes Yes No

Crush and suspend in water. Can also mix with apple sauce Change to ACEI Daily supplements with Calcium and Vitamin D or injection. 1500units/1ml x 20ml 3

3000units/1ml x 120ml 122

3000 units/1ml x 20ml 21

ERYTHROMYCIN ESCITALOPRAM ESMOPRAZOLE

No Yes Powder is poorly soluble so care should be taken to not block tube. MUPS formulation so will dissolve, but leave EC beads. Lansoprazole Fastabs best for use down tubes.

Liquid available Citalopram drops

No

Alternative PPI

ETHAMBUTOL ETHOSUXIMIDE ETIDRONATE

Yes No Yes Stop feed 2 hours before and after dose. Flush line well with plain water post dose Avoid antacids and mineral supplements 2 hours before and after administration. Liquid available

ETOPOSIDE

No (cytotoxic)

Injection - Unpleasant taste. Can be given enterally or in orange juice for oral administration. A conc. of 0.4mg/ml or less avoids the risk of precipitation

EXEMESTANE EZETIMIBE FAMCICLOVIR

Yes Yes Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube Tablets do not disperse in water easily. Hard to crush but will crush with persistence and will suspend in water and give via 8Fr Ng tube Ranitidine (40mg famotidine = ranitidine 300mg) Drug is formulated in a MR matrix, so crushing is NOT advised - conversion to alternative drug may be necessary Can given capsule contents in orange Crush tablet and give via tube if necessary Liquid available. Change to Sytron (sodium feredetate) 10ml=200mg FeSO4. Amlodipine

Yes

FAMOTIDINE FELODIPINE

Yes

No

FENOFIBRATE FERROUS SULPHATE

Yes

No

FEXOFENADINE

Yes

Change to other antihistamine available as liquid Tablets may be crushed and dispersed in water, however tablet powder should NOT be handled by pregnant women, or those with any possibility of being pregnant. Disintegrates within 5mins 10 ml water and give via 8Fr Ng tube Ensure all drug is rinsed out of crusher and administered. Bitter taste. Tablets hard to crush but can be ground to fine powder which mixes well with water and give via 8Fr Ng tube

FINASTERIDE

Yes

FLAVOXATE

Yes

FLECAINIDE

Yes

Tablets may be crushed/injection used orally (same dose)-may have a local anaesthetic effect. Do not mix with tap water due to chelation of ions. Use distilled water .Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube

Injection has been administered enterally undiluted. This should be used in emergency, and monitor for clinical/adverse effects. If giving via enteral feeding tube, always flush with deionised water, do not mix with alkali solutions, sulphate, phosphate,or chloride ions. Do not mix drug with medications prior to administration

25mg/5ml x 500ml 47

FLUCLOXACILLIN

Yes

PEG/NG ideally, stop feed for 1 hour before and after dose of flucloxacillin, as food impairs drug absorption.

Liquid and injection available

FLUCONAZOLE

Yes

Interacts with Jevity - stop feed for one hour before and one hour after. Disintegrates within 2 minutes in 10 ml water and give via 8Fr Ng tube Prozac liquid available. Dilute with the same volume of sterile water and flush post dose Open capsule and disperse in water or fruit juice do immediately prior to administration Dissolves slowly- 5 minutes Irritant to eyes and skin. Wear protective clothing

Liquid and injection available

FLUDROCORTISONE

Yes

FLUOXETINE

Yes

FLUPENTHIXOL

Yes

FLURBIPROFEN

Yes (open capsules, do not crush tablets) Yes

Flush well post dose. Disintegrate if shaken in water for 5 minutes and give via 8Fr Ng tube Do not crush beads as may block tube

FLUTAMIDE FLUVASTATIN

Yes

Tablets may be crushed and given mixed with milk or fruit juice May be difficult to remove all capsule contents. Do not put MR down tubes.

FLUVOXAMINE FOLIC ACID FORCEVAL

Yes

No information on enteral tube admin No information on enteral tube admin Capsule contents may be administered by snipping end of capsule off and withdrawing contents (gelatinous), but will not be whole dose. Also tastes foul, so giving in jam etc. would be a good idea! No information on enteral tube admin No information on enteral tube admin Injection and liquid available Liquid available - 500mg sodium fusidate tablets are approximately equivalent to 750mg fusidic acid suspension Do not put down tube due to the risk of congealing and blocking the tube. Mixing with Ribena or other strong-flavoured liquid may mask the very bitter taste of the powder. Use immediately due to hydrolysis. Powder may also be sprinkled on cold, soft food. REF Open capsules and mix with 10ml water, mixes easily and flushes down 8Fr NG tube Will disperse in 5 minutes when places in 10ml water which can flush down 8Fr NG tube Carcinogenic and teratogenic Liquid available Liquid available

Consider alternative SSRI

Yes

Yes

Consider alternative liquid multivitamin

FOSINOPRIL FUROSEMIDE FUSIDIC ACID

Yes

Change to other ACEI

Yes

No

FYBOGEL GABAPENTIN

No

Yes

GALANTAMINE GANCICLOVIR

Yes

No

GLIBENCLAMIDE

Yes

Give just before the start of a feed. REF Monitor blood glucose levels as may be more effective crushed Watch for associated increase in bioavailability (monitor blood glucose carefully). REF Preferably swith to insulin for better glycaemic control May take 5 minutes to disperse DO NOT CRUSH Disperses readily in water once finely crushed. Buccal, S/L Spray, patches Injection given orally

5mg/5ml x 150ml 118

GLICLAZIDE

Yes

GLIMEPIRIDE GLIPIZIDE GLYCERYL TRINITRATE GLYCOPYRRONIUM

Yes Yes No Yes

Tablets are special 1mg x 100 64

2mg x 100 99

GRANISETRON GRISEOFULVIN

Yes No

Give injection orally or give IV Change to alternative drug such as terbinafine 125mg/5ml x 100 30 500mg tablets 52

HALOPERIDOL HYDRALAZINE

Yes Yes Crushing tablets leads to more rapid absorption of drug and possible rapid fall in BP \caution review choice of therapy? Absorption is decreased in the presence of food leave a one hour gap before and after the dose. Reconstitued injection can by given orally or enterally

Liquid and injection available

HYDROCHLORTHIAZIDE HYDROCORTISONE

Yes

Disperse in water

Yes

Will disperse in 5 minutes when Injection available and placed in 10ml water which can can be given orally or enterally. Contains flush down 8Fr NG tube significant amount of phosphate

10mg/5ml x 100ml 105

HYDROXYCHOLOQUINE HYDROXYUREA

Yes

Yes

Caution: care with handling avoid contact of drug powder with skin, mucous membranes, inhalation etc. - drug is cytotoxic. May be difficult to crush as sugar coated. Risk of tubeblockage so flush well. Injection may be used orally. Tablets are sugar coated so may be hard to crush. REF Liquid available

HYDROXYZINE HYOSCINE N BUTYLBROMIDE

Yes

Yes

HYOSCINE HYDROBROMIDE

Yes

Tablets can be sucked and will be absorbed through oral mucosa.

Injection available and may be used orally or enterally. Content of ampoule may be stored in fridge for up to 24 hours once opened. Injection solution may be Patches and injection given orally and enterally available

IBUPROFEN IMATINIB IMIPRAMINE

No

Can however crush and disperse brufen tablets Disperse in water or apple juice at least 50ml of fluid for 100mg tablet If giving down tube, put some syrup down first to decrease adsorption on tubing. Do not crush MR preps

Liquid and brufen granules available

Yes

Yes

Liquid available

Consider alternative tricyclic antidepressant

INDAPAMIDE

Yes

INDOMETHACIN

Yes

INDORAMIN IRBESARTAN

Yes Yes

MR capsules may be emptied and the granules swallowed whole. MR capsules irritant on stomach do not open. Can sprinkle on soft food to mask taste. Crush and suspend in water Will disperse in 5 minutes when placed in 10ml water larger particles break up when draw into syringe and can flush down 8Fr NG tube Will disperse in 5 minutes when placed in 10ml water which can flush down 8Fr NG tube Normal release tablets can be crushed and will dissolve but do not crush MR. Release properties may change so monitor patient. Capsules can be cut or pierced and mixed in food or stirred into warm milk. Can also freeze and cut into halves or quarters Low solubility

Suppository available

25mg/5ml x 100 14

Consider changing to ACE inhibitor

ISONIAZID

Yes

50mg/5ml x 500ml 26

ISOSORBIDE MONONITRATE

Yes

GTN patch

ISOTRETINOIN

No

ISRADIPINE ITRACONAZOLE

Yes

Stop feed 2 hours pre and post Open capsules and dose but possible reduced absorption dissolve contents. Yes Yes Also fix with yoghurt or soft food Stop feed 2 hour before and after dose

Liquid available

IVABRADINE KETOCONAZOLE

LABETOLOL

No

It is not recommended to crush due to film coating and rapid oxidisation. The injection solution can be used orally, mixed with orange juice to mask taste. REF can be dispersed in water if tablets are ground down enough but may block tube. Very insoluble in water therefore crush tablets and flush down tube Use liquid in order to avoid exposure of operator to active constituents of crushed tablets. Dispersible tablets available and even non-dispersible will dissolve once crushed. Dispersible tablets can be chewed. Granules may be emptied from the capsule and swallowed (without crushing or chewing) with water or in soft food e.g. a spoonful of apple sauce.

Injection can be used orally or enterally if necessary. Injection can also be given with fruit juice or squash to disguise bitter taste.

LACIDIPINE LAMIVUDINE

Yes

Consider alternative calcium channel blocker Liquid available

No

LAMOTRIGINE

Yes

LANSOPRAZOLE

Yes see next column

Granules from capsule (do not crush may be flushed down tubes (except v. fine bore tubes) preferably with apple juice (manufacturer recommends 40ml; this reduces adhesion of granules compared to water).

Fastabs are best for tubes, as the microspheres are smaller than in the capsules. Dissolve in apple juice or orange juice, put down tube and then flush again with the fruit juice. (Juice is better than water as it makes the granules less sticky) PEG/NG- sachets not suitable for tube administration, as the suspension is too viscous. Fast tabs are not absorbed sublingually not supposed to be broken up in the mouth and the drug is not absorbed there.

LEFLUONOMIDE

Yes

Monitor patient for signs of exaggerated or diminished effects. Will disperse in 5 minutes when placed in 10ml water which can flush down 8Fr NG tube Light sensitive so use immediately

LERCANIDIPINE

Yes

LEVETIRACETAM

Yes

Tablets can be crushed and sprinkled into soft food such as apple puree or yoghurt but do have bitter taste. Liquid can also be added to food. 500mg tablets will disperse in 5 minutes when placed in 10ml water which can flush down 8Fr NG tube Only sparingly soluble with insoluble excipients. Will stain skin, teeth, tongue and tube. See handbook for further details on brand. Bitter taste with metallic aftertaste. Stop feed 2 hours pre and post dose. If administer via tube consider changing to another quinolone as takes few minutes to dissolve. This forms milky dispersion which can flush down 8Fr NG tube

Liquid available

LEVODOPA

Yes

LEVOFLOXACIN

Yes

Injection and liquid

LEVOMEPROMAZINE

Yes

Will disperse in 2 minutes when placed in 10ml water which can flush down 8Fr NG tube but may block finer tubes.

Injection can be given orally and enterally. Note that excipients degrade to products which theoretically may induce asthma attacks when given enterally. No reports of attacks ever having been induced this way have been recorded by the manufacturers and the risk is considered to be small

Consider alternative antipsychotic

12.5mg/5ml x 100ml and 50ml both 42

LEVOTHYROXINE

Yes

Long half life so can be omitted for up for 5 days. Will disperse in 5 minutes when placed in 10ml water and shaken, this can flush down 8Fr NG tube Monitor for side effects

Liquid and injection (dose conversion necessary) available

LINEZOLID

Yes

Liquid available but may be too thick for feeding tubes. 2.5mg/5ml x 100ml 47

LISINOPRIL

Yes

5mg/5ml x 100ml 23

LITHIUM

No

Withhold feed 1 hour before and 2 hours post dose

Liquid available but dose conversion necessary. Monitor blood levels closely. 520mg/5ml as lithium citrate -equivalent to 200mg of lithium carbonate. Liquid available

LOFEPRAMINE LOPERAMIDE

No

Has very bitter taste and hard to crush as film coating Caution in stoma patients.

No

Liquid available but large sugar content so caution in diabetics. Flushes down NG tube without resistance. Liquid available

LORATADINE LORAZEPAM LOSARTAN

Yes Yes Yes Can also be used sublingually but needs moist mouth Mix with 10ml water to form fine suspension which flushes down 8Fr NG tube without blockage Crushed tablets should be dissolved in water and given immediately Capsule contents can be mixed with soft food

Injection can be given S/L.

Consider alternative anxiolytic

LOXAPINE

Yes

MAGNESIUM

Yes

Liquid available

4mmol chewable tablet x 50 16

5mmol/5ml x 200ml 60

Normal tablets x 100 39

MEBENDAZOLE MEBEVERINE

No Yes but only non-MR Fairly soluble in water. Change MR to normal release tablets or liquid. Stop feed for 30 minutes pre and post dose Dissolves slowly approx 5 minutes. Suspension will flush via 8Fr NG tube without blockage. Only suspend contents in water virtually insoluble. Can mix with food or jam Tablets may be crushed and given in water, fruit juice or jam. May take 5 minutes for tablets to dissolve. Tablets may be crushed and mixed with yoghurt, fruit juice or jam. Circadin tablets should not be crushed as controlled release. Depo-Provera has been used orally, although little data available.

Liquid available Liquid available

MEDROXYPROGESTERONE

Yes

MEFENAMIC ACID MEGESTROL ACETATE

Yes

Suspension available

Yes

MELATONIN

Yes

All specials

MELOXICAM

Yes

Disperse in 10ml water within 5 minutes and flushes down 8Fr NG tube without blockage.

Suppositories also available. Use suppositories for the shortest time possible Oral drops available. 5mg=10 drops

Alternative NSAIDS

MEMANTINE MENADIOL MERCAPTOPURINE

No

Yes

5mg/5ml x 50ml 80 Do not crush as cytotoxic. Place tablet in water, however unstable in aqueous solutions. Use immediately. Suspension available

No

MESALAZINE

No

Tablets should not be crushed. If colon only affected a rectal preparation could be tried, or patient could be converted to sulphasalazine, which comes in a liquid. Pentasa brand tablets disperse very quickly in water; however, this leaves small beads in the liquid which must be swallowed or put down the tube intact. These are better than the sachets, which have larger granules. See enteral feeding book for more information.

Suppositories foam enema, sachets

METFORMIN

Yes

May block tube and may increase availability

Sachets available and much cheaper than liquid

METHOTREXATE

No

Cytotoxic therefore do not crush. Place in water and disperse. In rheumatoid conditions consider S/C or I/M.

Injection can be diluted with water and administered orally. Extended expiry can be given if preservative used. Can be given enterally although manufacturers cannot recommend. Absorption from injection gives similar plasma concentration to tablet formulation.

10mg/5ml x 50ml 52

20mg/5ml x 100ml 73

METHOTRIMEPRAZINE METHYLDOPA

Yes Yes

Tablets disperse in water. Injection has been use orally. May block tube as tablet coating may not dissolve. Interacts with Ensure, Ensure plus and Osmolite - stop feed for two hours before and one hour after. REF Suspension available

METHYLPREDNISOLONE METHYLPREDNISOLONE

Yes

Tablets will disperse in water. Do not crush M/R tablets Injection The manufacturers are aware that SoluMedrone has been mixed with orange juice and water when given orally because it has an unpleasant taste which almost nothing will disguise. If orange juice is used, it must be added just before taking due to its low pH

Yes

METOCLOPRAMIDE

Yes

Dispersion occurs slowly.

Injection can be used enterally

Injection and liquid available

METOLAZONE

Yes

Tablets can be crushed but be aware that the increased bioavailability may lead to increased postural hypotension. May need to be shaken for 5 minutes. Can flush via 8Fr NG tube without blockage. Do not crush MR formulations. Do not crush MR formulations Injection can be given orally. Liquid also available but do not use in C.diff. or NJ/jejunostomy patients. Administer 1 hour before food to allow break down.

Syrup available

METOPROLOL METRONIDAZOLE

Yes Yes

METYRAPONE

Yes

Capsule can be cut open and the contents administered if necessary.

MEXILITINE

Yes

Open capsules and dissolve contents in distilled water. Can flush down feeding tube.

Injection can be given orally. It has also been administered enterally. It has a very unpleasant taste. When the injection is being given to patients with swallowing difficulties, it should be given at least 30 minutes before food as it has a local anaesthetic action in the mouth

MIANSERIN

Yes

Tablets may be crushed, but difficult. Mix with plenty of water.

MIDAZOLAM

Injection can be given orally. The injection has a bitter taste so should be diluted with apple or blackcurrant juice, raspberry or cherry syrup, chocolate sauce or cola

10mg/5ml buccal syrup x 5ml 40

12.5mg/5ml x 100 86

MINOXIDIL

Yes

Disperse in water within 2 minutes to give dispersion which flushes via 8Fr NG tube without blockage.

MIRTAZPINE

Yes

Bitter taste and local anaesthetic effect

Dispersible tablets available but may block tubes. Tablets are special

MISOPROSTOL

Yes

Tablets may be crushed (and dispersed in water if necessary) IMMEDIATELY before use.

Caution: powder should not be handled by pregnant women. Change to lansoprazole if for this indication

MOCLOBEMIDE

Yes

Solution flushes down 8Fr NG tube without blockage

MODAFINIL MONTELUKAST

Yes Yes

Use suspension immediately Give immediately as unstable in water. Granules can be mixed in soft food or place directly onto the tongue and swallow.

MORPHINE M/R TABLETS/CAPSULES

Try the MR capsules (Zomorph) which can be opened and the granules sprinkled on soft food or washed down with liquid. NB if using MXL capsules the liquid used should be enteral feed, not water. This is due to the high lipophilicity of the granules which would lead to tube blockage. MR tablets should not be crushed.

Sachets are not always suitable for use down tubes due to high viscosity. The MST sachets, once reconstituted with 10ml water, will pass down a Ryles tube (4.75mm internal diameter) and NG tubes of 1.05mm internal diameter or more. Interacts with Jevity and Pulmocare stop feed for two hours before and one hour after.

MOXIFLOXACIN

Yes

Tablets have a bitter taste. 400mg tablet will dissolve in 20mls of water. Stop feed one hour before and 2 hours after administration.

MOXONIDINE

Yes

Crush well to minimise risk of blocking tube. Mix one tablet with 50ml water and allow to dissolve for 2 minutes. Solution flushes down 8Fr NG tube without blockage Reconstituted injection solution has been used enterally with a dextrose 5% flush before and after administration. Care should be taken when handling the powder (teratogenic risk). Contamination should be removed promptly by washing with soap and water (eyes plain water

MYCOPHENOLATE

NABILONE NADOLOL NAFTIDROFURYL

Yes Yes No

Remove capsule contents and disperse in water Crush and disperse in water Do not open capsule- powder is irritant and anaesthetic to mouth/throat mucosa-ask Dr to review need for this drug. If drug absolutely necessary open capsule and disperse contents with water but drink large amount of fluid following dose.

NALIDIX ACID NAPROXEN NATEGLINIDE NEBIVOLOL

No Yes but not MR or EC Yes Yes Administer solution immediately. Doesnt dissolve very well flush. Can take 5 minutes for tablet to completely disperse Suspension and suppositories available

NEFOPAM

Yes

Dispersion occurs slowly, may need to be shaken. Ensure adequate rinsing of container.

Give IM injection orally. 20mg IM = 60mg oral.

NEFAZODONE

Yes

Special tablets 100mg x 60 56

NEOMYCIN NEOSTIGMINE NEVIRAPINE NICARDIPINE

Yes Yes Yes Yes The powder can be removed from the capsule and dissolved, preferably in orange juice Dispersion occurs slowly (at least 5 minutes). Use in care with enteral feeding tube as may cause blockage. Insoluble in water

NICORANDIL

Yes

NICOUMALONE

Yes

NIFEDIPINE

Yes

Do not crush MR tablets (NB Adalat Retard may be crushed and dispersed in water, as this does not affect the release mechanism.) Adalat LA cannot be crushed. Normal release capsules can be bitten (by the patient) or snipped (by staff if patient unable to bite) open and the liquid contents swallowed/given sub-lingually. However, nifedipine is very short acting in this form and to avoid sudden drop in BP, change to longer acting calcium channel blocker may be preferable. Please ask NG/PEG tubes - Capsule contents (oil) may be drawn up in syringe and flushed down tube with N-saline, not water, but see notes above. It is not advised to open Coracten preparations as the capsules contain mini-tablets which may be lost. There is also a danger that the patient may chew them and this would release a greater dose. If it is necessary to open the capsules there is no difference in effect if the mini-tablets are swallowed whole. See handbook of drug administration for more information

Consider alternative calcium channel blocker

20mg/1ml x 30ml oral drops 17

NIMODIPINE

Yes

Use immediately as extremely light sensitive. Give injection in non-PVC or glass apparatus. Also applied to tablets in solution. For PEG/NG tubes, ensure tablets are in fine powder after crushing fragments of film coating can block tubes. Liquid available

NITRAZEPAM

Yes

NITROFURANTOIN NIZATIDINE

No

Large granules may block fine bore tubes. May block tubes as excipients are insoluble

Liquid available

Yes

Consider changing to alternative H2 antagonist

NORETHISTERONE

Yes

Suspension flushes via 8Fr NG tube without blockage

NORFLOXACIN NORFLOXACIN

Yes

Flush well as poorly soluble. Stop feed 1 hour before and 2 hours after. Unpleasant taste. Do not disperse well in water give crushed tablets

Yes

NORTRIPTYLINE OFLOXACIN

No Yes Do not disperse readily. Stop feed for one hour before and 2 hours after administration.Use de-ionised bottled water to avoid drug chelation with ions See notes under ciprofloxacin for PEG/NG tubes. Normal tablets will dissolve, but not as fast as velotabs

Consider alternative tricyclic

OLANZAPINE

Yes

OLSALAZINE

Yes

Avoid mixing with acidic solution (eg orange juice) as active drug is alkaline. Disperse in warm sterile water. Capsule contents and dispersed tablets will stain bright orange

OLMESARTAN

No

Change to another ACEI

OMACOR

Burning/bitter taste therefore not recommended. Very difficult to pierce and empty capsule. Oil not compatible with most plastics and oxidises quickly in air. Could dissolve capsules in hot, not boiling water, in a china cup, and administer immediately. Drink entire contents as oil doesnt dissolve in water. Dispersible tablets PEG/NG tubes :- Manufacturer recommends one of two methods of administration to avoid tube blockages Dissolve the tablet in 25ml water in the syringe, invert syringe to disperse drug pellets, and immediately run 5-10ml down tube. Invert syringe to mix contents again, run a further 5-10ml down tube. Repeat until all the liquid has been passed down the tube. Rinse syringe and flush tube with a further 25ml water. (This method is intended to avoid syringe and tube blockages by compacted pellets) Dissolve the tablet in the syringe in 5ml water and add 5ml wholemilk yoghurt. Mix gently and pass down the tube. Flush with 10ml water to rinse down any remaining drug pellets. NB: Lansoprazole Fastabs are best for tube use. REF

Liquid available Maxepa Is it vital the patient has it? liquid 20 for 150ml

OMEPRAZOLE

10mg/5ml x 50ml 138!

ONDANSETRON

No

Crush or disperse tablet in water.

Injection has been used Injection, suppositories, enterally. This may be syrup or melt tablets. preferable for administration via enteral tubes terminating in the jejunum as the syrup contains sorbitol. The injection is acidic, so flush well before and after each dose to prevent precipitation of the drug when giving via enteral feeding tube

ORLISTAT

Yes

Open and stir into water or fruit juice or flush contents down the tube

ORPHENADRINE OXPRENOLOL

Yes Yes (not mr forms) Tastes very bitter

Oral solutions available

OXYBUTYNIN OXYCODONE

Yes (not mr forms) No Do not open oxynorm capsules due to possibility of powder becoming airborne. Tablets may be crushed for administration down tubes only. It is not recommended that they be crushed for oral administration due to the risk of oesophageal ulceration and oesophagitis. Consider changing to alternative such as doxycycline. Also must stop feed 1 hour before and 2 hours after.

Liquid and patch available

Liquid form available.

OXYTETRACYCLINE

No

PANCREATIC ENZYMES

Yes

Creon - empty the granules from the capsule. If giving with an enteral feed, give half the dose before the feed and half after. If the patient has a jejunal tube, crush the granules (or dissolve in sodium bicarbonate) and mix with feed. Tablets must be swallowed whole and may not be crushed. Patient should be changed to alternative e.g. lansoprazole or omeprazole. For use through enteral tubes it is better to use the soluble tablets as the liquid is too thick Powder is bitter and has anaesthetic effect Take at least 5 minutes PEG/NG If possible stop feed for 1 hour before and 2 hours after administration absorption is unpredictable with enteral feeds if not possible, consider higher dose or alternative antibiotic. REF Slow to disperse. Can administer in Jam or yoghurt.

Pancrex powder

PANTOPRAZOLE

No

PARACETAMOL PAROXETINE PENICILLAMNINE PENICILLIN V

No

Suppositories and soluble tablets Liquid available

500mg/5ml x 200 2

Yes

Yes Yes

PERGOLIDE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION) PERINDOPRIL PHENELZINE

Yes

Yes Yes

Leave a feed gap of two hours before and after dose. Slow to disperse. Use immediately. No information on enteral tube administration

Other ACEI or A2RB

PHENOBARBITAL

Yes

Liquid available but may be inappropriate in children due to high alcohol content

50mg/5ml alcohol free x 50ml 8

50mg/5ml normal liquid x 200ml 2

50mg/5ml x 60ml 3

50mg/5ml S/F x 150ml 25

PHENOXYBENZAMINE PHENYTOIN

Yes Yes but difficult to crush and do not disperse readily in water

No information about whether this may block tube Injection should be given preferably by slow IV injection, and patients should be ECG and BP monitored. If given by IV infusion an in-line filter must be used. 90mg syrup is equivalent to 100mg capsule e.g. patient previously on 300mg in capsules should be given 45ml syrup. Chewable tablets

PEG/NG Phenytoin absorption is significantly reduced if administered with enteral feeds. Give phenytoin as a single daily dose; stop feed two hours before giving and do not restart until 2 hours after dose. Alternatively, this could be managed by stopping feed overnight e.g. between 10pm and 6am, and giving phenytoin at midnight. Interacts especially with Osmolite, Isocal, Ensure and Jevity.

Dilute syrup with equal volume of water and flush tube before and after drug administration.

Phenytoin is less effective if given down NJ tube consider reviewing therapy. More convenient if dose changed to single daily dose.

PHYTOMENADIONE

Yes

Konakion MM Paed Injection orally. Flush well after each dose if giving via enteral feeding tube Not very soluble in water

20mg/1ml x 5ml 11

PIMOZIDE

Yes

PINDOLOL PIOGLITAZONE

Yes Yes Monitor blood glucose levels carefully if crushing tablets. For better glycaemic control switch to insulin. Suppositories or IM. Melts available Probably more accurate to change dose to equate to half or quarter of tablet Liquid available Do not crush Slow K. Light sensitive so use immediately Kay-Cee-L liquid

PIROXICAM PIVMECILLINAM

Yes

Yes

PIZOTIFEN POTASSIUM PRAMIPEXOLE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION) PRAVASTATIN PRAZOSIN

Yes Yes but only Sando-K Yes

Yes Yes

Use immediately Insoluble so ensure wash down with water or mix with jam etc

Other Statin

PREDNISOLONE

Yes

Soluble tablets available. Do not crush E/C. Plain tablets disperse in water. Unpleasant taste. Give immediately after dissolved in sterile water. Disperse in water (poorly soluble) Liquid available 250mg/5ml xz 200ml 43

PREGABALIN

Yes

PRIMIDONE

Yes

PROCHLORPERAZINE

No

Buccal tablets, syrup, effervescent granules

PROCYCLIDINE PROGUANIL PROMAZINE PROMETHAZINE PROPAFENONE PROPRANTHELINE PROPRANOLOL

Yes Yes No Yes Dispersion flushes via 8Fr NG tube without blockage Local anaesthetic action and bitter taste

Liquid available

Liquid available Liquid, injection available

Yes

Yes No Granules from MR capsules can be swallowed whole. Flush down tube or mix with soft food. Can give injection orally; it has been mixed in raspberry syrup when given orally. However little information on it so not recommended. Liquid available.

PROPYLTHIOURACIL PSEUDOEPHEDRINE PYRAZINAMIDE

Yes No Yes Leave a one hour feed gap either side of dose. Liquid available 500mg/5ml x 300ml 52

PYRIDOSTIGMINE

Yes

Liquid available

5mg/5ml x 150ml 38 60mg/5ml x 150ml 37

PYRIDOXINE

Yes

Dispersion occurs slowly

10mg/5ml x 100ml 67

QUETIAPINE

Yes

Bitter taste therefore mix with soft food. Flush down tube. Can crush. Do not crush XL formulation Change to other ACEI Do not crush m/r tablets Only crush if necessary and going to need for long term. Crush or disperse in 200ml warm water as this will aim flushing. May block the tube. E/c will be destroyed and stops breakdown of product in stomach acid Unpleasant taste. Care handling and crushing maybe teratogenic. Discotinue if immobile. Bitter taste. Place contents directly on mouth or bread. Injection may be given enterally Injection, dispersible tablets, syrup (may cause diarrhoea).. Change to other PPI

QUINAPRIL QUINIDINE QUININE

No Yes Yes

RABEPRAZOLE

No

RALOXIFINE

Yes

RAMIPRIL RANITIDINE

Yes

Yes

REBOXETINE REPAGLINIDE

Yes Yes Crushing will speed absorption so monitor blood sugar carefully. NB if patient has a tube, note where it emerges in GI tract, as absorption will be faster in duodenum than stomach.

RIFABUTIN

Yes

RIFAMPICIN

No

Crush tablets/open capsules can cause sensitisation. Stop feed one hour before and 30 minutes post dose. Can crush or disperse Rifinah and Rifater.

Syrup available

RILUZOLE

Yes

Tablets may be crushed and given, preferably in sugar/soft food, as drug is not very soluble in water. Crush and mix into soft food Do not give via feeding tube. Review need. 35mg tablets disperse in 10ml water within 5 minutes to give fine dispersion. Quicklets available and injection, liquid. Solution and patch Mix with soft food and crush and mix with water for use down enteral feeding tubes.

RISEDRONATE

No

RISPERIDONE RIVASTIGMINE ROPINIROLE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION) ROSIGLITAZONE ROSUVASTATIN SALBUTAMOL

No

Yes Yes

Yes

May increase effect. Consider sliding scale. Use immediately as light sensitive Do not crush MR preparations convert to liquid and give in 3-4 divided doses. Consider changing to nebulised therapy Open capsules and dissolve contents in water, use immediately and discard remainder Liquid

Yes

Yes

SECOBARBITAL

Yes

SELEGILINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION) SENNA SERTRALINE

Yes

Liquid available

Yes Yes Tablets may be crushed but powder is poorly soluble in water (Lustral). Can mix with food, e.g. jam. Powder tastes bitter and has local anaesthetic effect. Ensure all powder is given if giving down tube Not recommended in feeding tubes Tablets will disperse in water, give immediately

Liquid available Consider other drug available in syrup e.g. fluoxetine, citalopram oral drops.

SEVELAMAR SILDENAFIL

No

Yes

25mg/5ml x 100ml 83

5mg/5ml x 100ml 83 5mg/5ml x 50ml 23

SIMVASTATIN

Yes

Give immediately as light sensitive and give via 8Fr NG tube. Take significant time to disperse. Readily soluble in water

SITAGLIPTIN SIROLIMUS SODIUM BICARBONATE SODIUM CHLORIDE

Yes Yes

Injection can be given orally or enterally Injection may be given orally or enterally

SODIUM PHENYTLBUTYRATE SODIUM CROMOGLICATE

Contents can be removed, dissolved in hot water, then diluted in cold water before taking Yes Open capsules and disperse contents. Stop feed for two hours before and after and take care not to give any calcium, milk etc in that period. Only mix with water. Can be opened and flushed via enteral feeding tube. Fucidin syrup comes as fusidic acid which is not as well absorbed as sodium fusidate: 500mg in tablets = 750mg in syrup

Injection may be given orally

SODIUM CLODRONATE

SODIUM FUSIDATE

Yes

Liquid available

SODIUM PICOSULFATE

No

Liquid available

SODIUM VALPROATE

No

Epilim liquid may be administered rectally. Contact pharmacy for details. REF When switching g from oral to IV, the IV dose is the same as the oral dose. Epilim chrono formulations are interchangeable with other conventional or prolonged release formulations of equivalent daily doses.

Crushable tablets and injection

SOLIFENACIN

Yes

Dissolves quickly in water, however irritant to the eyes.

Consider switching to oxybutynin

SOTALOL SPIRONOLACTONE

Yes

Consider licensed beta blocker preparations Can take 5 minutes for tablet to completely disperse. Will flush down 8 FR NG tube without blockage. 25mg/5ml x 125ml 45

Yes

50mg/5ml x 125ml 48

STALEVO

Yes

Suspend in water. Only sparingly soluble with insoluble excipients. Will stain skin, teeth, tongue and tube. Max with yoghurt, milk, honey, jam, orange juice or water. Give immediately. See Parkinson information at end of document. Open capsules and mix into water or food. Contents pour freely, mix with water when stirred and flush via 8Fr NG tube without blockage. No information regarding administration via tube but no reason why the product could not be administered via this route. Stop feed 2 hours before and after administration.

STAVUDINE

no

STRONTIUM

SUCRALFATE

Yes

Stop feed for one hour before and after dose due to the risk of bezoar formation. Likely to block tube and no suitable for JEJ administration. Do not crush E/c. Suppositories/enema for lower-bowel disease. Suspension available

Suspension available

SULFASALAZINE

Yes

SULINDAC SULPIRIDE

Yes Yes Can be dispersed to form fine dispersion which can be drawn up and flushes via 8Fr NG tube without blockage. Open capsules and mix contents with small amount of water. Do not inhale and wear maxk and gloves. Tablets may be crushed and given mixed with jam or yoghurt. Liquid available

TACROLIMUS

See next

TAMOXIFEN

Yes

Handle drug powder with care (avoid dust being inhaled, on skin etc. as far as possible use mask, gloves and eye protection).

TAMSULOSIN

Yes

MR capsules - the granules may be emptied out and mixed with cold water, but swallow whole, do not chew granules.(Small granules, so should go down NG or PEG tube too). May give sudden hypotensive effect if administered via PEG/NG. May block feeding tubes flush well. Tablets not very soluble but will flush via 8Fr NG tube without blockage. Absorb moisture after crushing to give immediately.

TELMISARTAN

Yes

TEMAZEPAM TENOFOVIR

Yes Disperse in 100ml water, orange juice or grape juice and take immediately. Disperse in 5 minutes and flush via 8Fr Ng tube without blockage.

Liquid available

TERBINAFINE TERAZOSIN TETRABENAZINE

Yes Yes Yes May take 5 minutes to disperse. Insoluble excipients Dispersion occurs slowly at least 5 minutes

THALIDOMIDE

No

Manufacturers advise that capsules should not be opened.

However, they do provide the following information:

Thalidomide is not very soluble and may therefore block NG tubes. It may be given by NG by: Using a syringe suitable for connecting to the NG tube, remove the plunger and empty the contents of the capsule into the syringe. Add water or enteral feed, replace plunger and administer. Flush the syringe and the NG tube until the capsule contents have been completely administered. To avoid blockage administer only 1-2 capsules at a time.

The contents of thalidomide may be mixed with soft food and given orally. Give immediately as stability unknown.

 When administering staff should wear disposable gloves and masks, and the empty capsules should be disposed of in a cytotoxic waste bin. Pregnant members of staff should not handle the drug.

THEOPHYLLINE

Do not crush M/R tablets

60mg/5ml x 300ml 136

M/R capsules. The granules can be emptied from the capsule and swallowed (whole) with soft food e.g., yoghurt. If converting to syrup from a M/R product, dosage regime will need to be adjusted monitor levels. Divide total daily dose by 3 and give TDS.

DILUTE WITH equal volume of water

Do not crush Nuelin SA, Slophylline capsules may be opened and flushed through tube. Do not crush granules and may block tube, Flush well. Absorption may be decreased by 60-70% but increased absorption has also been reported. Aminophylline injection has been given orally and enterally.

Interacts with Osmolite, Ensure and Ensure plus so stop feed for one hour before and after

THIAMINE THIOGUANINE TIAGABINE TIBOLONE TIMOLOL TIZANIDINE TOLBUTAMIDE

Yes No Yes

30 minutes before food Suspension available May take 5 minutes gives fine dispersion that flushes down 8Fr NG tube without blockage. Suspend in water Liquid available

Yes No

Consider changing to alternative beta blocker Crush to fine powder for NG/PEG tubes. Crush and disperse in water

Yes

Yes

TOLTERODINE

Yes

Normal release prep can be crushed. XL capsules contain uniform time-release beads and can be opened and the intact beads administered. Settles quickly but draws up and flushes via 8Fr Ng tube without blockage. Do not administer sprinkle beads via tubes as these stick and cause blockage. Sprinkle Sprinkles in liquid or on soft food. Capsule contents stick to plastic tubes so not suitable for PEG/NG. Normal tablets can be crushed too.

Consider alternative Oxybutynin Elixir.

TOPIRAMATE

Yes

10mg/5ml x 100ml 42

25mg/5ml x 100ml 40

TORASEMIDE

Yes

Crush and disperse in water. Slurry is formed so rinsing of tube essential.

TRAMADOL

No

TRANDOLAPRIL

Yes

Remove capsule contents and disperse in water. Bitter taste. Soluble tablets are most suitable for administration via enteral tubes. Capsule contents can be mixed with fruit squash to mask bitter taste or mixed in water to give via PEG/NG. May cause sudden hypotension if patient dehydrated. Capsules very small and difficult to open.

Injection, sachets, orodispersbiel tablets

Consider changing to alternative ACEI.

TRANEXAMIC ACID

Yes

Tablets disperse in 2-5 minutes. Can use injection orally or enterally immediately after dilution. Store in fridge and use within 24 hours.

TRAZODONE

Yes-only open Bitter taste capsules and mix with water

Liquid available

TRIFLUOPERAZINE

Yes

Do not crush MR tablets. Spansules are s/r and cannot be opened/crushed. Disperse tablet in water and will flush down 8Fr NG tube without blockage. Liquid available

TRIHEXYPHENIDYL

Yes

TRIMEPRAZINE TRIMETHOPRIM

No Yes Stop feed for 30 minutes before and after administration of liquid. Well absorbed via enteral feeding tubes Open capsules and suspend in water or crush and suspend tablets in water. Has local anaesthetic action With disperse in 100ml water, orange or grape juice. Bitter taste.

Liquid available Liquid available

TRIMIPRAMINE

Yes

Consider tricyclic antidepressants

TROSPIUM

Yes

URSODEOXYCHOLIC ACID

Yes

Open capsules and suspend in water. Do not disperse in water. May block fine bore tubes. Capsules (Ursofalk) can be opened and contents sprinkled on to food.

Liquid available

VALACICLOVIR

No but see next

Quite difficult to crush and powder does not suspend well, therefore not advised. If crushed and suspend in water, dose must be given immediately owing to the rapid rate of hydrolysis. Can flush down 8Fr NG tube without blockage but must be draw into syringe immediately. Check references

VALSARTAN VANCOMYCIN

Yes Yes

Tastes bitter Injection can be used orally for Clostridium difficile- can also use via nasogastric tube. Consult pharmacy. Capsule contents are gelformed and not suitable for feeding tube administration.

Change to ACEI 125mg/5ml x 300ml 60

VENLAFAXINE

Normal release YES M/r -NO

Mix with jam and or liquid

Mirtazepine Orodispersible Tablets

Capsule contents (MR granules) may be emptied out and given in smooth food e.g. yoghurt granules not to be crushed or chewed. To convert from M/r to normal release, total daily dose is given as two divided doses and adjusted as necessary.

VERAPAMIL

Yes

Only crush normal release tablets. Bitter taste and local anaesthetic action in mouth. Do not crush MR tablets. Doses should be divided throughout the day. Ordinary tablets may be crushed and dissolved in water but a drink of juice should be given afterwards to remove bitter taste/local anaesthetic effect. The beads from the MR capsules may be given, swallowed whole. May block tube. Stop feed 1 hour before and post dose.

Liquid available Injection may be given orally or enterally. Give on an empty stomach; withhold enteral feeds for one hour before and one hour after each dose

VIGABATRIN

Yes

Disperse contents of sachet in water as well as crushing tablets and dispersing in water. Can put contents of sachet down 8Fr NG tube without blockage.

VITAMIN B COMPOUND VITAMIN E VORICONAZOLE

Yes

Ensure full dose is given as active substance present in very low concentrations

Liquid available

No No

Liquid available Liquid available take 1 hour before food or 1 hour after. Stop feed 1 hour before and 12 hours post dose. Monitor INr closely as crushing may increase absorption. Vitamin K content of Osmolite and other feeds may antagonise anticoagulant effect of warfarin. Liquid available

WARFARIN

Yes

ZAFIRLUKAST

Yes

May be difficult to crush, may result in increase peak levels.

ZESTORETIC ZIDOVUDINE ZINC SULPHATE ZOPICLONE

Yes No No Syrup available Effervescent tablets and injection available If for N/G or PEG tube use, crush as finely as possible, mix with water and give QUICKLY the powder is designed to thicken in water. This may cause tube blocking so is very important. Hard to crush and bitter taste. Try other hypnotic e.g. Temazepam / Nitrazepam

Yes

Do not crush Zimovane as bioavailability may be altered.

ZOLPIDEM ZONISAMIDE

Yes Yes Open capsule and suspend contents in water. Has been added to food and apple juice

ZUCLOPENTHIXOL

Yes

May block tube as not very soluble

REFERENCES
NEWT guidelines Enteral feeding book Previous Dysphagia guidelines Cornwall dysphagia guidelines Waltham Forest guidelines NELM Q and A which injections can be used orally Manufacturers