A number of medications are formulated to have specific release properties and it is important that these properties are taken into account when modifying the dose form in order to maintain a therapeutic effect and avoid adverse events. Some medications may pose a risk to staff safety if modified or modified incorrectly.

Patients who are unable to or have difficulty swallowing medication are given modified dose forms that are safe and which maintain a therapeutic effect.

Enteric Coated: the coating is designed to resist gastric acid to protect the drug and/or reduce gastric side effects.

Oral/enteral dispenser: a syringe designed to draw up and administer liquid medicines intended for oral or enteral use. The dispenser has an purple plunger and includes the words "oral" or "enteral" on the barrel. It has a unique tip that does not allow connection to IV administration ports and has a specific connection with enteral feeding tubes.

Modify: crushing, dispersing or using liquid forms of a medication in order to facilitate safe administration to the patient. When authorised by a prescriber, this may include changing to an alternate formulation of the medication such as patches, intranasal sprays, suppositories or injections.

Slow or Extended Release: specifically designed to release the drug over a period of time (usually up to 12 or 24 hourly). Abbreviation used to indicate slow or extended release include MR, SR, LA, CR, CD, XR, XL, CONTIN.

The Australian Don't Rush to Crush Handbook is the primary reference used to provide guidance on how to modify a dose form. It provides details of alternative dose forms that are available, and if modification is required, the most effective ways of doing so. This may include crushing the medication, dissolving the medication, switching to another dose form (such as a liquid) and even switching the medication to an alternative (e.g. injection, patch).

Any oral or enteral medication that is modified into a liquid form must be administered using an oral dispenser as per Medication Administration - CPP0287.

The following information provides some general guidance;

• Medications with special release properties (e.g.enteric coated, modified/slow release) are generally not able to be modified without affecting the release rate. Some do retain their release properties when dissolved, but not if crushed.
• Some products cannot be modified because of extremely bitter taste, irritation to the oral mucosa or staining of teeth or mucosal tissue.
• Avoid adding medications to meals as there is always a risk that the whole meal is not eaten and entire dose is not taken.
• Carcinogenic, teratogenic or hormonal medications must not be modified without specialist advice, due to the risk of unacceptable exposure. Modification may be acceptable for some of these medications if wearing a mask, gloves, using a dedicated mortar and pestle and modifying the product in an area away from other staff and patients/residents.
• Patients requiring ‘thicken fluids’ may require modified dose form.
• All patients administered a modified dose form must be monitored for therapeutic effect, and for adverse effects.
• Consider the impact of the dose modification on the patient's diet requirements (i.e. thickness of the food). Consult dietetics/speech pathology if unsure.

Practical tips when crushing medications;

• Use correct ergonomic techniques when crushing medication. Retain the mortar and pestle on a waist high bench to maintain a comfortable posture.
• It is important that as much of the dose is administered as possible. Strategies to facilitate this include:

• a) Placing a patty pan into the mortar and the medication put into the patty pan. Another patty pan is placed over this and then medication is then crushed. The contents can then be administered to the patient.

  b) Taking into account any requirements for thickened feeds, rinse mortar (generally with a small amount of water) and give contents to patient.

• Mortar and pestles must be cleaned thoroughly to remove all residue and be left to dry. Using the patty pan method makes cleaning easier.

Enteral feeding;
Refer to Enteral Feeding - Continuous And Intermittent - CPP0453 for guidance on administering medications for patients with enteral feeding tubes in situ.

Australian Don't Rush to Crush Handbook

Mortar and pestle (if crushing is a suitable modification). The mortar must allow complete and reproducible recovery of the powdered material. A non porous type is preferred (stainless steel).
An alternative is to use "patty pans".

If a patient is preferring not to take medication in its whole form, explore the reason why. If the patient has an appropriate reason, follow the procedure below.

If a patient is unable to take a medication in its prescribed formulation because they are having difficulty swallowing, refer to speech pathology. Once an assessment has been undertaken and dose modification is required, follow the procedure below.

If a patient is being given medications via an enteral feeding tube, refer to Enteral Feeding - Continuous And Intermittent - CPP0453 then follow the procedure below.

1. Consult the Australian Don't Rush to Crush Handbook for advice on dose modification. If further advice is needed, contact the clinical pharmacist/pharmacy department. For patients on specialised feeds, also consult speech pathology/dietetics.

2. If modification of the dose form is required, the clinical pharmacist (when available) will annotate the medication chart with details of the required modification in the pharmacy section. If a pharmacist is not available, the nurse should document on the medication chart how the medication was administered (e.g. crushed, dispersed). If an alternative dose form is required (e.g. sublingual instead of oral) a medical officer is required to make the appropriate change on the medication chart. Where appropriate, pharmacy will provide directions on how to modify the dose form(s).

3. Include details of any modified dose forms in clinical handover.