Clinical Decision Support • ISMP-Aligned • v2.4.1

Can I Crush It?

The Deterministic Ledger of Oral Dosage Form Modification & Enteral Administration

2,847Formulations Indexed

98.3%Evidence Coverage

ISMPGuideline Aligned

24 / 7Clinical Support

01 - The Terminal

Search & Filter

Search by generic name, brand name, or clinical rationale. Apply filters to narrow by formulation class. Results update in real time.

0 results

Type to search or select a filter above. Indexed against USP <795> and ISMP guidelines.

02 - ISMP-Aligned Clinical Ledger

Oral Dosage Form Modification Registry

Full registry indexed by generic name with formulation type, crush status, clinical rationale, and evidence-based alternatives. Aligned with ISMP Guidelines for Oral Dosage Forms.

Medication↕	Formulation↕	Crush Status↕	Clinical Rationale↕	Recommended Action↕
Metformin XRGlucophage XR	ER	DO NOT CRUSH	Sustained release mechanism - dose dumping hazard	Metformin IR tablet (can be crushed) or metformin liquid
OmeprazolePrilosec	EC	DO NOT CRUSH	Enteric coated - acid degradation in gastric fluid	Omeprazole oral suspension powder or sodium bicarbonate suspension
AmoxicillinAmoxil	IR	CRUSHABLE	Standard immediate release - no modified release mechanism	Amoxicillin oral suspension (preferred for enteral)
Nifedipine XRProcardia XL	SR	DO NOT CRUSH	Sustained release - dose dumping with hypotension risk	Nifedipine IR capsule (pierce and express liquid) or amlodipine
LevothyroxineSynthroid	IR	CAUTION	Mucosal irritant potential; narrow therapeutic index	Levothyroxine oral solution or scored tablet (quarter if needed)
Diltiazem CDCardizem CD	SR	DO NOT CRUSH	Sustained release - dose dumping with bradycardia risk	Diltiazem IR tablet BID or diltiazem liquid formulation
MycophenolateCellCept	IR	DO NOT CRUSH	Teratogenic dust - aerosolization and inhalation hazard	Mycophenolate oral suspension (preferred) or IV formulation
WarfarinCoumadin	IR	CRUSHABLE	Standard IR tablet - stable when crushed and suspended	Warfarin oral suspension (compounded) or liquid formulation
KCl XRK-Dur	SR	DO NOT CRUSH	Mucosal irritant - high local potassium concentration	Liquid potassium chloride or Micro-K Extencaps (sprinkle)
PantoprazoleProtonix	EC	DO NOT CRUSH	Enteric coated - acid-labile formulation	Pantoprazole oral suspension (compounded) or IV formulation
PrednisoneDeltasone	IR	CRUSHABLE	Standard IR tablet - well-characterized bioequivalence	Prednisone oral solution or methylprednisolone liquid
Morphine XRMS Contin	SR	DO NOT CRUSH	Sustained release - fatal dose dumping with respiratory depression	Morphine IR solution (immediate release) or PCA
DoxycyclineVibramycin	EC	DO NOT CRUSH	Enteric coated - esophageal irritation risk if crushed	Doxycycline oral suspension or IV formulation
SertralineZoloft	IR	CRUSHABLE	Standard IR tablet - stable in suspension formulations	Sertraline oral concentrate (25 mg/mL)
Carbamazepine XRTegretol XR	SR	DO NOT CRUSH	Sustained release - dose dumping with seizure breakthrough	Carbamazepine IR tablet BID-QID or oral suspension
SpironolactoneAldactone	IR	CRUSHABLE	Standard IR tablet - bitter taste, mask with vehicle	Spironolactone oral suspension (compounded)
FurosemideLasix	IR	CRUSHABLE	Standard IR tablet - well-absorbed in suspension form	Furosemide oral solution (10 mg/mL)
Venlafaxine XREffexor XR	ER	DO NOT CRUSH	Sustained release - withdrawal and dose dumping risk	Venlafaxine IR tablet BID or desvenlafaxine
BisacodylDulcolax	EC	DO NOT CRUSH	Enteric coated - colon-specific release mechanism	Bisacodyl suppository or liquid glycerin suppository
AzathioprineImuran	IR	CRUSHABLE	Cytotoxic - requires PPE for handling	Azathioprine oral suspension (compounded; use in hood)
CyclosporineNeoral/Sandimmune	IR	CAUTION	Variable absorption; narrow therapeutic index	Cyclosporine oral solution (100 mg/mL) or IV formulation
PhenytoinDilantin	IR	CAUTION	Narrow therapeutic index; tube feeding binding interaction	Phenytoin oral suspension (enteral feeding hold 2 h)
EsomeprazoleNexium	EC	DO NOT CRUSH	Enteric coated - acid-labile; granules in capsule may be mixed with soft food	Esomeprazole oral suspension (packets) or IV formulation
Bupropion XLWellbutrin XL	ER	DO NOT CRUSH	Sustained release - seizure risk with dose dumping	Bupropion IR tablet BID-TID (with caution)
TacrolimusPrograf	IR	CAUTION	Narrow therapeutic index; inhalation hazard (immunosuppressed)	Tacrolimus oral suspension (compounded) or IV formulation

Indexed against USP <795> (Nonsterile Compounding), USP <797> (Sterile), USP <800> (Hazardous Drugs), and ISMP Guidelines for Oral Dosage Forms That Should Not Be Crushed. Evidence graded per published bioavailability and stability studies.

03 - Enteral Administration Protocols

Nursing Reference: Tube Administration

Standardized protocols for administering medications via gastrostomy (G-tube), jejunostomy (J-tube), and nasogastric (NG) tubes. Flush volumes, obstruction prevention, and drug-specific precautions.

G-Tube / PEG Protocol

Pre-Flush15-30 mL warm water

Post-Flush30-60 mL warm water

Particle SizePowder must pass through 20-mesh screen

VehicleWarm water; avoid acidic juices (clog risk)

Clog PreventionFlush between each medication; never mix multiple drugs

J-Tube / PEJ Protocol

Pre-Flush15-30 mL warm water

Post-Flush15-30 mL warm water

Particle SizeLiquid formulations only; no crushed tablets

VehicleWater or commercial liquid preparation

Clog PreventionSmaller lumen (8-14 Fr); higher clog risk - use liquid formulations

NG-Tube Protocol

Pre-Flush15-30 mL warm water

Post-Flush15-30 mL warm water

Particle SizeFine powder; dissolve in 15-30 mL warm water

Placement CheckConfirm distal tip position before administration

Bypass ConsiderationSmall bowel absorption may bypass gastric pH

Critical Warnings

Phenytoin / Tube Feeding Binding

Hold enteral feeding for 2 hours before and 2 hours after phenytoin administration. Phenytoin binds to tube feed proteins, reducing absorption by up to 70%.

Hazardous Drug PPE Requirements

NIOSH Group 1 drugs (mycophenolate, cyclophosphamide, tacrolimus) require double gloves and gown during crushing. Use a closed-system transfer device when preparing suspensions.

Never Combine in Syringe

Do not mix multiple crushed medications in the same syringe. Incompatible excipients may form gels, precipitates, or increase clog risk.

ASPEN and AGA guidelines recommend flushing with 15-30 mL water before and after each medication. Never use formula or juice as a flush vehicle. Use liquid formulations when available; crush only immediate-release tablets. Document all formulation modifications.

04 - Pharmacist Consultation

Therapeutic Alternatives & Compounding

Therapeutic substitution guidance, liquid formulation availability, and compounding references for pharmacists managing enteral administration challenges.

Therapeutic Substitutions

Oral tabletOral liquid / suspension

First-line - same drug, liquid form

SR/ER tabletIR tablet (adjusted frequency)

Check bioequivalence; BID-TID dosing

EC tabletIV or liquid with PPI co-therapy

Acid degradation bypass with alternative route

Non-crushableTherapeutic class switch

Same class, available as liquid

Liquid Formulation Reference

Commercial suspensions available for most antibiotics and antiepileptics

Oral concentrates: sertraline (25 mg/mL), haloperidol (2 mg/mL), methadone (10 mg/mL)

Compounded suspensions stable 7-30 days refrigerated (per USP <795>)

Choose suspending vehicle based on drug solubility and patient allergies

Compounding Guidelines

USP <795>: nonsterile compounding - beyond-use date 7-30 days

USP <800>: hazardous drug handling - negative pressure room required

Common vehicles: Ora-Sweet, Ora-Plus, methylcellulose 0.5%, simple syrup NF

Document all compounded formulations per state board requirements

When a medication cannot be crushed and no liquid equivalent exists, consult the institutional formulary for therapeutic interchange options or contact pharmacy for compounded suspension preparation. Bioavailability of compounded suspensions should be verified against published data.

Disclaimer

This tool provides clinical decision support based on published evidence, USP <795>/<797>/<800> guidelines, and ISMP recommendations. It does not replace professional clinical judgment. Always verify medication-specific information against your institution's approved formulary and consult a clinical pharmacist for complex enteral administration cases. Formulation modifications must be documented in the patient's medical record. Bioavailability and stability data vary by formulation; verify beyond-use dates for all compounded preparations.