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
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 .
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) .
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 .
Why you shouldn’t rush to crush :
What to do instead of crushing :
Why do they need to swallowed whole? 
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".
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
|Total no of patients where ‘do not crush medications’ given by enteral route
|Percentage of non-adherence (%)
|Percentage of adherence (%)
Table 2. Suspected drugs and their alternatives 
|Injectables or ranitidine
|Nifidipine – Retard
|Changed to other BP medications
|Sodium Bi Carbonate
|Nitroglycerin XR or CR
|Metformin + Glimepiride PR
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 .
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.
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.