NAPLEX Question of the Week: To Crush or Open? That is the Question.

Proper administration of medications is an important component of the NAPLEX which is the focus of this week's question.

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A woman comes into your community pharmacy to pick up her mother’s new prescriptions for ibuprofen 800 mg PO Q8H PRN and Myrbetriq 25 mg PO QD. You see on her profile she is also taking Kapspargo Sprinkle 50 mg PO QD and Coreg CR 10 mg PO QD. The woman says that she is the caretaker for her 85 year old mother who is recently struggling to swallow pills and will be currently undergoing a swallow study next week. She wants to know which of her mother’s medications she could crush (or open for capsules without crushing internal contents) to make it easier on her. Which of the following medications would you tell the woman would be permissible to crush or open if a capsule without crushing internal contents?  Select all that apply.

A. Ibuprofen  

B. Mybetriq 

C. Kapspargo Sprinkle 

D. Coreg CR  

E. None of the above. None of these medications are able to be crushed/opened for easier administration.  

 

The correct answers are Answers A, C, and D.  

 

In general, medications that should not be crushed/opened fall into one of these categories: extended release tablets, sublingual tablets, foul-tasting medications, irritating to the stomach, effervescent tablets, and potentially hazardous. You should consult medication specific drug monographs, such as the package insert, before crushing or opening any medications.  

Ibuprofen tablets can be crushed and mixed with a small amount (~10 mL) of water or other liquid that the patient can swallow, making Answer A correct. It is important to note that ibuprofen tablets when crushed may have a foul taste, making it difficult for some patients to swallow. If this is an issue for this patient, you could recommend an over-the-counter ibuprofen suspension.  Additionally, ibuprofen would not be optimal for this patient due to her age and risks associated with toxicity (GI bleeding or nephrotoxicity) according to Beers Criteria. Therefore this medication could potentially be stopped.

Myrbetriq, or mirabegron, is a beta-3 adrenergic receptor agonist used for the treatment of overactive bladder. It causes a relaxation of bladder smooth muscle which increases bladder capacity. Myrbetriq is an extended release tablet and should not be crushed or split. The tablet should be swallowed whole with water, making Answer B incorrect.  

Kapspargo Sprinkle is an extended release capsule of metoprolol succinate. Although this is considered an extended release medication, the package insert states that these capsules may be opened and placed in a small amount (1 teaspoonful) of soft food such as applesauce, pudding or yogurt, making Answer C correct. The mixture must be administered within 60 minutes of making and should not be stored for future use.  

Coreg CR is an extended release capsule of carvedilol. The package insert states that the capsule may be opened and the contents sprinkled on a spoonful of applesauce, making answer choice D correct. The mixture should be swallowed immediately and not chewed. The patient should drink fluids after swallowing the mixture to ensure the full dose is completely swallowed.  Another administration pearl with Coreg CR compared to immediate release Coreg is that the CR dosage form should not be taken within 2 hours of any type of alcohol in order to avoid dose dumping.

A good resource for this topic is Lexicomp entitled "Oral Medications that should not be crushed or altered".

See everyone next week!

Dr. B

Christopher M. Bland

Clinical Associate Professor, University of Georgia College of Pharmacy

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