Specials alternatives guidance

Transcription

1 Specials alternatives guidance The guidance document contains a list of commonly prescribed medicines and alternative methods of administration for patients with swallowing difficulties, feeding tubes or for patients prescribed unlicensed specials medication. Each entry takes into account alternative medicines, formulations, cost and licensing. This list is not exhaustive and will be reviewed and updated accordingly. Please note: This document is subject to clinical interpretation and judgement on an individual basis and the specific needs and best interests of the individual patient should be taken into account. Manipulation of a licensed product will be outside of the product s marketing authorisation. However, there is evidence and clinical experience detailed in reputable sources (e.g. NEWT) confirming that formulation manipulation of this nature can take place without compromising the effectiveness of the medicine. Administration notes: Crushing tablets: Crush tablets using a suitable device (e.g. tablet crusher, pestle and mortar or between two metal spoons) and transfer into a medicine cup/pot. Mix well with 15 30ml water and administer to the patient. Rinse the device with water and administer this also. Opening capsules: Gently ease open the capsule to release its contents into a medicine cup/pot. Mix with 15 30ml water and administer to the patient. Rinse the medicine cup/pot with water and administer this also. 1 P a g e

2 Drug Alendronic Acid Alternative Assess clinical need - consider withholding if swallowing difficulty/feeding tube is temporary. Do not crush the tablets, risk of oesophageal damage (NEWT, Jan 2014). 1. Alendronic acid 70mg effervescent tablets sugar free (LICENSED) 2. Alendronic acid 70mg/100mL oral solution unit dose sugar free (LICENSED, LESS COST-EFFECTIVE). Allopurinol Alogliptin Amiodarone Amitriptyline Hydrochloride 1. Crush the tablets well and mix with water, give immediately (UNLICENSED*) (NEWT, Dec 2015) 2. Allopurinol oral suspension 100mg/5mL or 300mg/5mL (UNLICENSED, HIGH COST). Shelf life is 28 days once Diabetes type 2 guidance: 1. No information available. Review indication and consider alternative options. See individual entries. 1. Crush and disperse tablets in water. May have a bitter taste so can be mixed with juice if desired. Give immediately (UNLICENSED*, LOW COST) (NEWT, June 2016) 2. Amiodarone 100mg/5ml oral suspension (UNLICENSED, HIGH COST MOST COST EFFECTIVE STRENGTH) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, Jan 2016) 2. Amitriptyline sugar free oral solution 25mg/5mL or 50mg/5mL (LICENSED, HIGH COST). Shelf life is 28 days once 1. Crush and disperse tablets in water. Give immediately as drug is light sensitive (UNLICENSED*, LOW COST) (NEWT, June 2017) Amlodipine 2. Amlodipine 5mg/5mL or 10mg/5mL oral solution sugar free (LICENSED, HIGH COST). Shelf life is 30 days once 1. Amoxicillin suspension 125mg/1.25mL, 125mg/5mL sugar free or 250mg/5mL sugar free (LICENSED). Shelf Amoxicillin life is 7 days once reconstituted. Apixaban 1. Crush and disperse tablets in water (UNLICENSED*) (NEWT, June 2016) Aripiprazole Atenolol Atorvastatin 1. Aripiprazole orodispersible tablets sugar free (LICENSED, HIGH COST) 2. Aripiprazole 1mg/mL solution (LICENSED, VERY HIGH COST) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) 2. Atenolol 25mg/5mL oral solution sugar free (LICENSED, HIGH COST). Shelf life is 28 days once opened 1. Crush and disperse tablets in water. Atorvastatin tablets are not very soluble and a residue may be left, potentially blocking enteral feeding tubes. Flush well after dosing (UNLICENSED*, LOW COST) (NEWT, May 2013) 2. Atorvastatin 10mg or 20mg sugar free chewable tablets (LICENSED, HIGH COST) New post-transplant patients: Do not prescribe in primary care Secondary care only Existing post-transplant patients and other indications Shared care: - Inflammatory Bowel Disease (IBD) in adults: - Adult Rheumatology: CYTOTOXIC DO NOT CRUSH TABLETS (NEWT, Sep 2012) 1. Azathioprine oral suspension 50mg/5mL (UNLICENSED, MOST COST-EFFECTIVE STRENGTH). Shelf life is 28 days once Baclofen 1. Baclofen 5mg/5mL oral solution sugar free (LICENSED, LOW COST). Shelf life is 28 days once Azathioprine Bendroflumethiazide Betahistine Hydrochloride Bisoprolol Fumarate Bumetanide 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, Feb 2015) 2. Bendroflumethiazide 2.5mg/5ml oral suspension (UNLICENSED, HIGH COST). Shelf life is 28 days once 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, May 2010) Betahistine 8mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 30 days once 1. Consider switching to atenolol 25mg/5ml oral solution sugar free (LICENSED, LOW COST) 2. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, Aug 2012) 3. Bisoprolol 2.5mg/5mL oral solution (UNLICENSED, HIGH COST - MOST COST-EFFECTIVE STRENGTH). Shelf life is 28 days once 1. Crush tablets and mix with water (UNLICENSED*, LOW COST) (NEWT, Aug 2012) 2. Bumetanide 1mg/5ml oral solution sugar free (LICENSED, HIGH COST) Candesartan Cilexetil 1. Crush tablets and mix with water (UNLICENSED*) (NEWT, Aug 2012) Captopril Carbamazepine 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) 2. Captopril 5mg/5ml or 25mg/5ml oral solution sugar free (LICENSED, HIGH COST) If used as epilepsy treatment, a product change poses a risk of fits: 1. Carbamazepine 100mg/5mL oral suspension sugar free (LICENSED) Note: Carbamazepine MR tablet 400mg twice daily is equivalent to Carbamazepine liquid 200mg four times a day. (NEWT July 2016) 2. Carbamazepine 125mg or 250mg suppositories (LICENSED, HIGH COST) Note: Carbamazepine 100mg tablet or liquid is equivalent to one carbamazepine 125mg suppository. (NEWT July 2016) 2 P a g e

3 Carbimazole Carvedilol Chloral hydrate Chlorphenamine Maleate Chlorpromazine Ciclosporin (eye) Citalopram Hydrobromide Clindamycin Clobazam Clonazepam Clopidogrel Coal tar/betametasone (topical) Co-Amoxiclav (Amoxicillin/Clavulanic Acid) Co-Beneldopa (Benserazide/Levodopa) Co-Careldopa (Carbidopa/Levodopa) 1. Crush and disperse tablets in water (UNLICENSED*, HIGH COST) (NEWT, April 2015) 2. Carbimazole 10mg/ 5ml oral suspension (UNLICENSED, VERY HIGH COST) 1. Consider switching to atenolol 25mg/5ml oral solution sugar free (LICENSED, LOW COST) 2. Crush and disperse tablets in water. Give immediately (UNLICENSED*, LOW COST) (NEWT, June 2016) 3. Carvedilol 5mg/5ml oral suspension (UNLICENSED, HIGH COST) To be initiated by specialist. Restricted to paediatrics only. 1. Chloral hydrate 500mg/5ml oral solution (UNLICENSED, LOW COST) 2. Chloral hydrate 143.3mg/5ml oral solution BP (LICENSED, HIGH COST) 1. Chlorphenamine 2mg/5mL oral solution (LICENSED) (NEWT, Aug 2012) which can be purchased over-thecounter (OTC) as per OTC guidance: Tablets should not be crushed. 1. Chlorpromazine 25mg/5ml or 100mg/5ml oral solution (LICENSED) To be initiated by specialist (Note: different strengths, all preservative free) 1. Ciclosporin 0.05% eye drops (UNLICENSED, LOW COST), Ciclosporin 0.1% eye drops 0.3ml unit dose x 30 (LICENSED, HIGH COST), CICLOSPORIN eye ointment 0.2% (UNLICENSED, HIGH COST) 1. Citalopram 40mg/mL oral drops sugar free (LICENSED). Note: 8mg (4 drops) is equivalent to 10mg Citalopram tablet. (NEWT May 2010) 2. Crush and disperse tablets in water (UNLICENSED*) (NEWT, May 2010) Prescribe on microbiology advice only. 1. Open capsules and disperse contents in water. Mix with juice or maple syrup to mask taste. Give immediately (UNLICENSED*) (NEWT, Aug 2016) 2. Clindamycin 75mg/5ml oral suspension (UNLICENSED, HIGH COST) Prescribe for epilepsy treatment only. A product change poses a risk of fits: 1. Clobazam 10mg/5ml oral suspension sugar free (LICENSED, HIGH COST, MOST COST-EFFECTIVE PREPARATION) 1. Crush and disperse tablets in at least 30mL of water (UNLICENSED*, HIGH COST) (NEWT, March 2015) 2. Clonazepam 500micrograms/5mL or 2mg/5mL oral solution (LICENSED, VERY HIGH COST). Shelf life is 28 days once 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST). (NEWT, April 2014) 2. Clopidogrel 75mg/5mL oral solution (UNLICENSED, HIGH COST). Shelf life is 28 days once opened, 3. For paediatrics only - Clopidogrel 1mg/ml oral suspension (UNLICENSED, HIGH COST) Initiation by specialist only 1. Prescribe LICENSED options to be used together - Options include: Betamethasone valerate 0.025% cream/ointment (LICENSED) or Betamethasone valerate 0.1% cream/ointment (LICENSED) plus coal tar solution 5% cutaneous emulsion, Coal tar 4% shampoo or Coal tar extract 2% shampoo (LICENSED) 2. Prescribe as Coal tar solution 5% in Betamethasone valerate 0.025% ointment (UNLICENSED, HIGH COST) 1. Co-amoxiclav suspension 125mg/31mg/5mL, 250mg/62mg/5mL or 400mg/57mg/5mL (LICENSED). Shelf life is 7 days once reconstituted. Do not open modified release (MR) or immediate release (IR) capsules. 1. Co-beneldopa 12.5mg/50mg or 25mg/100mg dispersible tablets (LICENSED) Note: dispersible tablets have a faster onset of action and shorter duration of action than MR capsules and a direct substitution cannot occur. Seek advice from specialist. If changing from IR capsules to dispersible tablets a direct changeover is acceptable, but the patient should be monitored for any change in effect as there may be an altered bioavailability. It may be appropriate to prescribe a small when-required dose to cover any unexpected on-off effects. (NEWT, July 2017) The modified release tablets should not be crushed - seek advice from specialist for conversion to immediate release. 1. Immediate release tablets can be crushed and dispersed in water (UNLICENSED*). If swallowing difficulty/feeding tube is long-term, consider switching to co-beneldopa dispersible tablet as per the dosing guidance in table 1 (NEWT May 2014). Table 1: Conversion table Sinemet (co-careldopa) Madopar (co-beneldopa) Sinemet 62.5mg tablet Sinemet 110mg tablet Sinemet Plus 125mg tablet Sinemet 275mg tablet Half Sinemet CR 125mg tablet Sinemet CR 250mg tablet Madopar 62.5mg disp. tablet Madopar 125mg disp. tablet Madopar 125mg disp. tablet 2 x Madopar 125mg disp. tablet Seek advice from Pharmacy Seek advice from Pharmacy 2. Co-careldopa 25mg/100mg/5mL oral suspension (UNLICENSED, HIGH COST MOST COST EFFECTIVE STRENGTH). Shelf life is 30 days once Codeine Phosphate 1. Codeine 15mg/5mL linctus sugar free or Codeine 25mg/5ml oral solution (LICENSED) Co-Dydramol (Dihydrocodeine/Paracetamol) Colecalciferol 1. Change to individual products, dihydrocodeine and paracetamol (see separate entries). Maintenance/prophylaxis dose Do not prescribe. HMMC guidance: 1. Treatment dose 10,000 units/ml oral drops (prescribe as Thorens, one drop contains 200 units 3 P a g e

4 Cyanocobalamin Cyclizine Hydrochloride Dabigatran Dexamethasone Diazepam Diclofenac Sodium Digoxin Dihydrocodeine Tartrate Diltiazem (topical) Diltiazem Hydrochloride (oral) colecalciferol) (LICENSED) 2. If malabsorption/compliance issues with oral treatment in adults - ergocalciferol 300,000 units/ml give via intramuscular injection (LICENSED) 1. Consider increasing dietary intake of vitamin B12 2. Consider hydroxocobalamin intramuscularly 1. Consider switching to an alternative anti-emetic e.g. Domperidone 5mg/5ml oral suspension sugar free (LICENSED) or ondansetron oral solution/orodispersible tablets (LICENSED, HIGH COST) 2. Crush and disperse tablets in water. May have a bitter taste (UNLICENSED*, LOW COST) (NEWT, May 2014) 3. Cyclizine 50mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 30 days once Do not open the capsules as this may greatly affect the oral bioavailability of the drug, with a risk of increased side effects (i.e. bleeding). 1. Consider switch to alternative NOAC edoxaban, apixaban or rivaroxaban. See separate entries. 1. Crush and disperse the 2mg tablets in water (UNLICENSED*, LOW COST). They should be crushed with care to avoid inhalation of dust by the carer. (NEWT, April 2018) 2. Dexamethasone soluble tablets sugar free 2mg, 4mg or 8mg (LICENSED, HIGH COST) 3. Dexamethasone 2mg/5mL oral solution sugar free (LICENSED, HIGH COST) 1. Diazepam 2mg/5ml oral solution. Dilute solution if being administered via a feeding tube (LICENSED, HIGH COST) 2. Diazepam 2.5mg, 5mg or 10mg rectal tubes (LICENSED, LOW COST) Diclofenac treatment should only be initiated after careful consideration for patients with significant risk factors for cardiovascular events ( - MHRA, June 2013) 1. If NSAID is required, consider ibuprofen or naproxen (see individual entries) 2. Diclofenac suppositories (LICENSED, LOW COST) 3. Diclofenac 50mg/5ml oral suspension (UNLICENSED, HIGH COST) 1. Crush tablets and mix with water (UNLICENSED*, LOW COST) (NEWT, Feb 2014) 2. Digoxin 50micrograms/mL oral solution. Note: one 62.5microgram tablet is equivalent to 50mcg/mL, prescribe as Lanoxin PG Elixir (LICENSED, LESS COST-EFFECTIVE) (NEWT, Feb 2014) Do not crush the modified release tablets (NEWT, March 2016) 1. Dihydrocodeine 10mg/5mL oral solution (LICENSED) 1. Consider if Glyceryl Trinitrate (GTN) 0.4% ointment is clinically appropriate (LICENSED) 2. Diltiazem 2% ointment (UNLICENSED). Ointment is more cost-effective than cream. Diltiazem capsules/tablets should be prescribed by brand as bioavailability differs between preparations. 1. Switch modified preparation (MR) preparation to Tildiem 60mg total daily dose to be divided to three times daily. Crush and disperse tablets in water (UNLICENSED*) 2. Open MR capsules and mix contents with soft food for administration. Do not crush the capsule contents. May block tubes (UNLICENSED*) Docusate Sodium 1. Docusate 12.5mg/5mL or 50mg/5mL oral solution sugar free (LICENSED) Donepezil Hydrochloride Doxazosin Mesilate Doxycycline Hyclate Edoxaban Enalapril Maleate Esomeprazole Ezetimibe Felodipine 1. Crush and disperse tablets in water. Strong, bitter taste (UNLICENSED*, LOW COST) (NEWT, Dec 2015) 2. Donepezil 5mg or 10mg orodispersible tablets (LICENSED, HIGH COST) 3. Donepezil 1mg/mL oral solution (LICENSED, HIGH COST). Shelf life is 2 months once 1. Assess ongoing clinical need and switch to alternative Hypertension see HMMC guidance: Benign prostatic hyperplasia consider finasteride or tamsulosin (see individual entries for administration information). 2. Doxazosin 1mg/5mL or 4mg/5mL oral solution (UNLICENSED, HIGH COST). Shelf life is 28 days once Do not open the capsules as the contents are an irritant. 1. Doxycycline 100mg dispersible tablets (LICENSED). Note: when given via enteral tubes, doxycycline binds to calcium ions reducing absorption, so prescribe at the higher end of the standard dosage range (NEWT, Oct 2013) 1. Crush and disperse tablets in water for nasogastric administration, or crush and mix with apple puree for swallowing difficulties (Duchin et al., 2017) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST). 2. Enalapril 5mg/5mL oral solution (UNLICENSED, HIGH COST - MOST COST-EFFECTIVE PREPARATION). Shelf life is 28 days once 1. Consider switching to lansoprazole orodispersible tablets. See individual entry 2. Disperse the gastro-resistant tablets in water and the micro-granules will remain for administration. Do not crush the micro-granules. (NEWT, May 2018) (LICENSED, LOW COST) 3. Esomeprazole 10mg gastro-resistant granules sachets for oral suspension (LICENSED, HIGH COST) 1. Consider alternative. Refer to Lipid Modification HMMC guidance: - Treatment Guidelines for Lipid Modification: - Evolocumab: - Alirocumab: Do not crush modified-release (MR) tablets (NEWT Aug 2015). 1. Review indication. Consider switching to amlodipine (see individual entry) Ferrous Fumarate 1. Ferrous fumarate 140mg/5mL oral solution (LICENSED) Ferrous Sulfate 1. Convert to appropriate dose of ferrous fumarate oral solution. Note: ferrous sulfate 200mg tablets three times a day, is equivalent to 10mL twice daily of ferrous fumarate 140mg/5mL oral solution (LICENSED) Fexofenadine Hydrochloride 1. Consider switching to alternative antihistamine in liquid form e.g Loratadine 5mg/5ml oral solution (LICENSED), which can be purchased over-the-counter (OTC) as per OTC guidance: 2. Crush and disperse tablets in water (UNLICENSED*) (NEWT, June 2014) 4 P a g e

5 Finasteride 1. Crush and disperse tablets in water (UNLICENSED*). Note: women who are, or who may become pregnant should not handle crushed, broken, or dissolved tablets. (NEWT, May 2010) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, July 2015) Folic Acid 2. Folic acid 2.5mg/5mL oral solution sugar free (LICENSED, HIGH COST) 1. Furosemide oral solution 20mg/5mL, 40mg/5mL or 50mg/5mL, prescribe as Frusol (LICENSED) (NEWT, April Furosemide 2016) 1. Open capsules and disperse capsule contents in water, and give immediately. Contents can be sprinkled on Gabapentin food or given in fruit juice to mask their unpleasant taste (UNLICENSED*, LOW COST) (NEWT, Jan 2015) 2. Gabapentin 50mg/mL oral solution sugar free (LICENSED, HIGH COST). Shelf life is 28 days once Do not crush the modified-release (MR) tablets; convert dose to immediate-release (IR). Note: 30mg MR is equivalent to 80mg IR Gliclazide 1. Crush and disperse the IR tablets in water or orange juice (UNLICENSED*, LOW COST) (NEWT, Feb 2015) 2. Gliclazide 80mg/5mL oral suspension (UNLICENSED, HIGH COST - MOST COST-EFFECTIVE STRENGTH). Shelf life is 30 days once Griseofulvin 1. Review indication and switch to alternative antifungal e.g. terbinafine (see separate entry) Haloperidol Hydrocortisone Hydroxychloroquine Sulfate Hyoscine Butylbromide Ibuprofen 1. Haloperidol 10mg/5ml oral solution sugar free (LICENSED, MORE COST-EFFECTIVE) 2. Haloperidol 5mg/5ml oral solution sugar free (LICENSED, LESS COST-EFFECTIVE) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, Jan 2014) 2. Hydrocortisone 10mg/5mL oral suspension (UNLICENSED, HIGH COST, MOST COST-EFFECTIVE STRENGTH). Shelf life is 28 days once 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT Nov 2012) 2. Hydroxychloroquine 200mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 30 days once 1. Use 20mg/1ml solution for injection ampoules orally (UNLICENSED*, LOW COST) 2. Hyoscine butylbromide 10mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 30 days once 1. Ibuprofen 100mg/5ml oral suspension sugar free (LICENSED) Do not crush the modified-release (MR) tablets; convert dose to immediate-release (IR). Note: 1.5mg MR is Indapamide equivalent to 2.5mg IR 1. Crush and disperse IR tablets in water (UNLICENSED*) Irbesartan 1. Crush tablets and disperse in water (UNLICENSED*) (NEWT, Feb 2012) Do not open capsule contents and do not crush the modified release (MR) tablets (note: if scored, they can be halved) (NEWT, Dec 2016). MR preparations can be converted to twice daily immediate release (IR) preparations (morning and lunchtime see below). Most patients can be changed initially on a milligram per milligram substitution of their total daily dose where available preparations allow. (PresQIPP Bulletin 85 Isosorbide Mononitrate Prescribing 2.0 Nov 2015) Isosorbide Mononitrate Lamotrigine Lansoprazole Levetiracetam Levomepromazine Levothyroxine Sodium Dose of isosorbide mononitrate MR 25mg once daily 40mg once daily 60mg once daily 60mg once daily 100mg once daily Dose of isosorbide mononitrate IR 10mg twice daily 20mg twice daily 30mg twice daily 40mg twice daily (monitor for symptom control and adjust dose as required) 50mg twice daily 120mg once daily 60mg twice daily 1. The IR tablets can be crushed and dispersed in water (UNLICENSED*, LOW COST). They may have an increased rate of absorption and therefore increased side effects. Consider reducing the dose and giving doses more frequently if this occurs. 2. Isosorbide mononitrate 20mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 30 days once 3. Consider use of glyceryl trinitrate transdermal patches (LICENSED, HIGH COST). If used as epilepsy treatment, a product change may pose a risk of fits: 1. Lamotrigine dispersible tablets (LICENSED, LOW COST) (NEWT, Aug 2015) 1. Lansoprazole 15mg or 30mg orodispersible tablets (LICENSED) (NEWT, May 2018). For dosing in paediatrics refer to guidance: If used as epilepsy treatment, a product change may pose a risk of fits: 1. Levetiracetam 100mg/mL oral solution sugar free (LICENSED) 1. Consider switching to alternative antipsychotic if appropriate (e.g. haloperidol, chlorpromazine, sulpiride available as LICENSED liquids). Contact specialist for advice/review. For nausea and vomiting Use one quarter of a 25mg tablet for 6.25mg dose (scored). Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, Jan 2015) 1. Crush and disperse tablets in water (UNLICENSED*) (NEWT, Jan 2018). Patients taking capsules (UNLICENSED, HIGH COST) due to lactose or galactose intolerance - Switch to levothyroxine sodium tablets and add to the directions TEVA GENERIC ONLY (as these are lactose free tablets) (LICENSED, LOW COST) 2. Levothyroxine oral solution 50micrograms/5mL or 100micrograms/5mL (LICENSED, HIGH COST). Shelf life is 5 P a g e

6 Linagliptin Liothyronine Liquid paraffin 50%/ Emulsifying ointment 50% 28 days once Diabetes type 2 guidance: 1. No information available. Review indication and consider alternative options. See individual entries. 1. New patients Do not prescribe in primary care. Interim HMMC position see guidance: 2. Existing patients who are already receiving liothyronine from the GP Switch to liothyronine 20mcg tablets - these can be dissolved/dispersed in 20 ml of water for 10 minutes, in a small measuring cup. For part dosing, use a suitable oral syringe to withdraw the amount of liquid corresponding to the dose prescribed (5mL for a 5mcg dose; 10 ml for a 10mcg dose) (LICENSED, HIGH COST) (Summary of Product Characteristics, May 2018) or these can be halved or quartered for part-dosing (UNLICENSED*, HIGH COST) (Common practice advised by local specialists) Emollients guidance: 1. Switch to alternative emollient e.g. White soft paraffin 50% / Liquid paraffin 50% ointment (LICENSED). 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT Sept 2015) 2. Lisinopril 20mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 30 days once Lisinopril 3. Lisinopril 5mg/5mL oral solution (LICENSED, VERY HIGH COST). Shelf life is 28 days once The solution is absorbed to a lesser extent than tablets (NEWT, Sept 2015) Seek advice from specialist. Lithium shared care 1. Loperamide 1mg/5mL oral solution sugar free (LICENSED, MORE COST-EFFECTIVE) 2. Loperamide 2mg orodispersible tablets (LICENSED, LESS COST-EFFECTIVE) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT Feb 2015) Lorazepam 2. Give tablets sublingually but the patient must have a sufficiently moist mouth for absorption to occur (UNLICENSED*) (NEWT, Sept 2018) 3. Lorazepam 1mg/5mL or 500micrograms/5mL oral solution (UNLICENSED, HIGH COST) Shelf life is 28 days once 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, April 2011) 2. Losartan 2.5mg/mL oral suspension sugar free (LICENSED, HIGH COST). Shelf life is 28 days once reconstituted. 3. Losartan 50mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 28 days once Lymecycline 1. Consider switching to doxycycline (LICENSED) (see separate entry) Lithium Carbonate Loperamide Hydrochloride Losartan Potassium Magnesium Mebeverine Hydrochloride Mercaptopurine Mesalazine Metformin Methotrexate Metolazone Metoprolol Midazolam Mirtazapine Calculate mmol of magnesium and switch to alternative magnesium salt 1. Magnesium asparatate 243mg (10mmol magnesium) oral powder sachets (LICENSED) or Magnesium glycerophosphate Chewable Tablets 97.2mg (4mmol) (LICENSED) 2. Magnesium glycerophosphate (magnesium mg/5ml (5mmol/5ml)) oral solution (LICENSED, HIGH COST) Contact specialist for advice on modified-release capsules. Mebeverine 135mg tablet is equivalent to mebeverine 150mg liquid (NEWT May 2010) 1. Mebeverine 50mg/5mL oral suspension sugar free (LICENSED, VERY HIGH COST) Cancer indication RED drug: Do not prescribe in primary care. Non-cancer indications - shared care: CYTOTOXIC DO NOT CRUSH TABLETS 1. Mercaptopurine 20mg/ml oral suspension (LICENSED, HIGH COST) 1. Mesalazine MR granules sachets sugar free (LICENSED) can be used for patients with swallowing difficulties but not for enteral feeding. Prescribe as Pentasa or Salofalk 2. Pentasa tablets will disperse in water, leaving small beads which must be administered in tact (therefore suitable only for large-bore tubes) (UNLICENSED*). Do not crush. 3. Consider rectal route (enemas or suppositories) if appropriate to the location of the condition. (NEWT, May 2010) Convert modified release to immediate release tablets. Total daily modified release dose (usually once or twice daily) to be converted to equivalent immediate release dose and given up to three times daily. Monitor blood glucose levels. 1. Crush and disperse immediate release tablets in water (UNLICENSED*, LOW COST) 2. Metformin 500mg/5ml oral solution sugar free (LICENSED, HIGH COST, MOST COST-EFFECTIVE STRENGTH) CYTOTOXIC DO NOT CRUSH TABLETS 1. Methotrexate 2mg/mL oral solution (LICENSED, HIGH COST). Shelf life is 28 days once 2. Consider subcutaneous routes of administration. Shared care guidance: Initiation by specialist only (UNLICENSED) 1. Consider switching to equivalent dose of bendroflumethiazide (LICENSED) 2. Crush and disperse tablets in water (UNLICENSED*) Do not crush modified release (MR) tablets 1. Consider switching to atenolol (See individual entry) 2. Refer to indications and dosing in the BNF to convert to immediate release tablets. Immediate release tablets can be crushed and dispersed in water (UNLICENSED*) HMMC guidance specialist initiation only. Prescribe by brand. See guidance: 1. Mirtazepine orodispersible tablets (LICENSED, LOW COST) 2. Crush and disperse tablets in water (UNLICENSED*, LOW COST). The tablets have a bitter taste and an anaesthetic effect on the mouth. (NEWT May 2012) 3. Mirtazepine 15mg/mL oral solution (LICENSED, HIGH COST). Shelf life is 42 days once 6 P a g e

7 1. Disperse montelukast 4mg or 5mg chewable tablets sugar free in water (LICENSED) (NEWT, Oct 2013) 2. Montelukast 4mg sugar free oral granules (LICENSED) can be administered either directly in the mouth, or mixed with a spoonful of soft food (SPC Montelukast sodium 4mg oral granules, April 2016) 1. Consider switching to Ibuprofen 100mg/5ml oral suspension sugar free (LICENSED, LOW COST) Naproxen 2. Crush and disperse tablets in water (UNLICENSED*, LOW COST). Do not crush the enteric coated tablets. (NEWT Sept 2015) 3. Naproxen 250mg effervescent tablets sugar free (LICENSED, HIGH COST) 4. Naproxen 250mg/5ml oral suspension (LICENSED, HIGH COST MOST COST EFFECTIVE STRENGTH) Nicorandil 1. Crush and mix tablets with water (UNLICENSED*) (NEWT, May 2010) Montelukast Nifedipine Nitrofurantoin Paroxetine Hydrochloride Use of immediate release (IR) nifedipine capsules for blood pressure control is no longer recommended due to the risk of rebound hypertension and tachycardia. For blood pressure control 1. Consider alternative methods of blood pressure control, e.g. switching to amlodipine. See separate entry (NEWT, May 2017) 2. Modified release (MR) capsules (e.g. Coracten ) can be opened and contents given, do not crush contents (UNLICENSED*) (Dosing is brand specific BNF, 2018) For other indications 1. IR capsules can be bitten and the contents administered sublingually (UNLICENSED*) 2. Nifedipine 10mg/5mL oral suspension (UNLICENSED, MOST COST-EFFECTIVE STRENGTH). Shelf life is 30 days once Do not open modified release (MR) capsules. 1. Open 50mg or 100mg immediate release (IR) capsules and disperse contents in water (UNLICENSED*, LOW COST). Crush and disperse IR tablets in water for enteral feeds only (UNLICENSED*) (NEWT, Jan 2018) 2. Nitrofurantoin 25mg/5mL oral suspension sugar free (LICENSED, VERY HIGH COST) 1. Olanzapine orodispersible tablets (LICENSED, HIGH COST). The tablet can be placed on the tongue or dispersed in water, orange juice, apple juice, milk, or coffee. Olanzapine may be irritant to the skin and eyes, Olanzapine so take precautions to avoid contact (e.g. wear gloves) (NEWT, April 2012) 2. Olanzapine 2.5mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 14 days once Omeprazole 1. Consider switching to lansoprazole which is licensed for enteral tube administration (see individual entry). 2. Omeprazole dispersible gastro-resistant tablets (LICENSED), prescribe as Losec MUPS. Disperse tablet in water. Can mix this with orange / apple / pineapple juice, apple sauce, or yogurt. Oxybutynin Do not crush the modified release (MR) tablets (NEWT, Jan 2013). Refer to HMMC urinary incontinence guidelines (2018) for alternatives: 1. Crush and disperse immediate release (IR) tablets in water (UNLICENSED*, LOW COST). 2. Oxybutynin 3.9mg/24hours transdermal patches (LICENSED, HIGH COST) 1. Consider switching to another proton pump inhibitor which is available in a suspension or dispersible form, Pantoprazole e.g. lansoprazole orodispersible tablets or omeprazole (Losec MUPS). See separate entries (NEWT, Jan 2015) Paracetamol 1. Paracetamol 250mg/5ml oral suspension sugar free (LICENSED) 1. Crush tablets and mix with water (UNLICENSED*, LOW COST). The crushed tablets are bitter and have a slight local anaesthetic effect. (NEWT, May 2010) 2. Paroxetine 10mg/5mL oral suspension (LICENSED, HIGH COST). Shelf life is 28 days once Switch perindopril arginine to perindopril erbumine. Perindopril arginine 2.5mg is equivalent to 2mg perindopril erbumine. See separate entry. 1. Crush and disperse tablets in water (UNLICENSED*) (NEWT, Nov 2013) 2. Perindopril 4mg/5mL oral solution (UNLICENSED). Shelf life is 28 days once If used as epilepsy treatment, a product change poses a risk of fits: Phenobarbital update/antiepileptic-drugs-new-advice-on-switching-between-different-manufacturers-products-for-a- particular-drug. Seek secondary care advice. Restricted as per Herts Glaucoma Pathway: 1. For preservative free prescribe as Minims Pilocarpine Nitrate 2% w/v, Eye drops solution (LICENSED) Pioglitazone 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) Perindopril Arginine Perindopril Erbumine Pilocarpine (eye) Pizotifen 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) 2. Pizotifen 250micrograms/5ml oral suspension (UNLICENSED, HIGH COST) Potassium Chloride 1. Sando-K (12mmol) effervescent tablets or Kay-Cee- L syrup 5mmol/5ml (LICENSED) Potassium Permanganate 1. Dissolve one potassium permanganate 400mg tablets for cutaneous solution (Permitabs ) (LICENSED) in four litres of water to provide a 0.01% (1 in ) solution. See guidance link: Pravastatin Sodium 1. Crush and disperse tablets in water. Give immediately (UNLICENSED*) (NEWT, May 2010) Prednisolone Pregabalin Prochlorperazine Maleate See link to local guidance: 1. Crush tablets and disperse in water (UNLICENSED*, LOW COST). Do not crush the enteric-coated tablets due to the risk of tube blockage. Consider using rectal preparations e.g. Prednisolone 20mg/100ml enema standard tube (if appropriate to the location of the condition) (NEWT, Feb 2016) 2. Prednisolone 5mg soluble tablets (LICENSED, HIGH COST) If used as epilepsy treatment, a product change poses a risk of fits: 1. Dissolve capsule contents in water (UNLICENSED* LOW COST). The capsule contents may have an unpleasant taste (NEWT, April 2013) 2. Pregabalin 20mg/mL oral solution sugar free (LICENSED, HIGH COST) 1. Prochlorperazine 5mg/5mL oral solution (LICENSED, LOW COST) 2. Prochlorperazine 3mg buccal tablets (LICENSED, HIGH COST) 7 P a g e

8 Procyclidine Hydrochloride 1. Procyclidine 5mg/5mL oral solution (LICENSED, MOST COST-EFFECTIVE STRENGTH) Promethazine Hydrochloride Propranolol Hydrochloride Quetiapine Quinine Sulfate Ramipril Ranitidine Risperidone Rivaroxaban Ropinirole Hydrochloride 1. Promethazine 5mg/5mL oral solution sugar free (LICENSED). Shelf life is 28 days once Do not crush/open modified release (MR) preparations, switch to immediate release (IR) and give total daily dose as solution in two to three divided doses (NEWT, July 2016) 1. Propranolol 10mg/5mL, 40mg/5mL or 50mg/5mL oral solution (LICENSED) Do not crush modified release (MR) preparations convert to immediate release (IR). Switch from IR to MR tablets at the equivalent daily dose; to maintain clinical response, dose titration may be required (BNF, 2018). 1. Crush and disperse IR tablets in water or add to soft food (UNLICENSED*). Crushed tablets taste bitter (NEWT May 2012). 2. Quetiapine 25mg/5mL oral suspension (UNLICENSED, HIGH COST - MOST COST-EFFECTIVE STRENGTH). Shelf life is 28 days once 3. Quetiapine 20mg/ml oral suspension sugar free (LICENSED, VERY HIGH COST) 1. Crush and disperse tablets well in a large volume (e.g. 200mL) of water (UNLICENSED*). The crushed tablets have a bitter taste which may be masked by mixing with syrup. (NEWT, Feb 2013) 2. Quinine sulfate oral suspension 200mg/5mL and 300mg/5mL (UNLICENSED, HIGH COST). Shelf life is 28 days once 1. Open capsule and disperse contents in water (UNLICENSED*). The contents can be placed onto bread or mixed with apple juice/apple sauce or can be placed directly into the mouth, though taste unpleasant. (NEWT, April 2016) 2. Crush and disperse tablets in water (UNLICENSED*) 3. Ramipril 2.5mg/5mL oral solution sugar free (LICENSED, HIGH COST). Shelf life is 28 days once 1. Ranitidine 75mg/5ml sugar free oral solution (not for PEJ use) (LICENSED) 2. Ranitidine 150mg or 300mg effervescent tablets, dissolved in at least 75mL of water (LICENSED, HIGH COST) 1. Risperidone 1mg/mL oral solution sugar free (LICENSED). 2. Risperidone orodispersible tablets sugar free. Dissolve on tongue or disperse in water (LICENSED, HIGH COST) 1. Crush and disperse tablets. Not suitable for administration via enteral feeding tubes terminating beyond the stomach (i.e. in the duodenum or jejunum) (LICENSED) Do not crush the modified release (MR) tablets. Switch MR tablets to immediate release (IR) tablets (SPC Ropinirole MR various) Ropinirole MR tablets Total daily dose 2mg 4mg 6mg 8mg 12mg 16mg 20mg 24mg Ropinirole IR tablets Total daily dose mg 3-4.5mg 6mg 7.5-9mg 12mg 15-18mg 1. Crush and disperse the IR tablets in water (UNLICENSED*). Crushed tablets may also be mixed with soft food (NEWT, Sept 2015). Rosuvastatin Calcium 1. Crush and disperse tablets in water (UNLICENSED*) (NEWT, May 2010) Salicylic Acid Ointment (topical) Sertraline Hydrochloride Simvastatin Sitagliptin Sodium Bicarbonate Sodium Chloride (eye) Sodium Valproate 21mg 24mg Initiation by specialist for hyperkeratotic conditions only. Review ongoing clinical need. 1. Alternatives include: Urea 10%/Lactic acid 5% cream (Calmurid ), Salicylic acid 16.7% / Lactic acid 16.7% paint (Salactol ), Salicylic acid 50% ointment (Verrugon ) (ALL LICENSED, LOW COST) 2. Salicylic acid 5%, 10% and 20% ointment (UNLICENSED, HIGH COST) 1. Consider switching to SSRI with suitable formulations e.g citalopram or fluoxetine (LICENSED) 2. Crush tablets and disperse in water, or mix with food. They have a bitter taste and an anaesthetic effect on the tongue take care with hot foods after administration (UNLICENSED*, LOW COST) (NEWT, Aug 2014) 3. Sertraline 50mg/5mL oral suspension (UNLICENSED, MOST COST-EFFECTIVE STRENGTH). Shelf life is 28 days once 1. Crush and disperse in water (UNLICENSED*) Give immediately (NEWT, Nov 2010) 2. Simvastatin 20mg/5mL or 40mg/5mL oral suspension sugar free (LICENSED, HIGH COST). Shelf life is 28 days once Diabetes type 2 guidance: 1. No information available. Review indication and consider alternative options. See individual entries. 1. Switch to 500mg sodium bicarbonate capsules (6mmol sodium/capsule). Open capsules and disperse contents in water (UNLICENSED*, LOW COST) 2. Sodium bicarbonate 420mg/5ml (1mmol/ml) oral solution (Prescribe as SodiBic ) (UNLICENSED, MORE COST EFFECTIVE SOLUTION) 3. Sodium bicarbonate 420mg/5ml (1mmol/ml) oral solution sugar free (Prescribe as Thamicarb ) 3 days (100ml) and 7 days (500ml) shelf life once opened (LICENSED, HIGH COST) Review ongoing clinical need 1. Sodium chloride 5% eye ointment preservative free (LICENSED) or sodium chloride 5% eye drops (LICENSED) If used as epilepsy treatment, a product change poses a risk of fits: 8 P a g e

9 Solifenacin Sotalol Hydrochloride Spironolactone Sulfasalazine Sumatriptan Succinate Tamsulosin Hydrochloride Terbinafine Thiamine Hydrochloride Tolterodine Topiramate Tramadol Hydrochloride Tranexamic Acid Trihexyphenidyl (formerly known as benzhexol) Ursodeoxycholic acid Venlafaxine Vitamin E capsules Warfarin Sodium Zolpidem Zopiclone 1. Sodium valproate 200mg/5mL oral solution (LICENSED) 2. Sodium valproate 100mg crushable tablets (LICENSED), which can be mixed with soft food e.g. yoghurt or jam to mask the bitter taste. 3. Sodium valproate modified release (MR) granules sachets (LICENSED, LESS COST-EFFECTIVE) for swallowing difficulty only (NEWT March 2014). This is the preferred option for patients stabilised on MR preparations. HMMC (2018) Urinary Incontinence - Not recommended for prescribing. See guidance link: 1. Crush and disperse tablets in water (UNLICENSED*) (NEWT, March 2013) 2. Sotalol 25mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 30 days once 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, Nov 2015) 2. Spironolactone oral suspension 100mg/5mL, 50mg/5mL or 25mg/5mL (UNLICENSED, HIGH COST). Shelf life is 28 days once 1. Sulfasalazine 250mg/5mL oral suspension sugar free (LICENSED, HIGH COST). Shelf life is 28 days once 1. Sumatriptan 10mg or 20mg nasal spray unit dose (LICENSED) 2. Sumatriptan 6mg/0.5mL solution for injection (LICENSED, HIGH COST) 1. Open the capsule contents and mix with cold water (UNLICENSED*) (NEWT, May 2010). Note: the tablets are modified release (MR) and should not be crushed. 2. Consider switching to Finasteride 5mg tablets see individual entry. 3. Tamsulosin 400micrograms/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 28 days once 1. Crush and disperse 250mg tablets in water (UNLICENSED*, LOW COST) 2. Terbinafine 250mg/5ml oral suspension (UNLICENSED, HIGH COST) 1. Crush and disperse the tablets in water (UNLICENSED*, LOW COST) (NEWT, March 2013) 2. Thiamine 100mg/5mL oral suspension (UNLICENSED, HIGH COST) 1. Disperse immediate release (IR) tablets in water (UNLICENSED*) Give immediately (NEWT, May 2012) 2. For swallowing difficulty, modified release (MR) capsules contain time-release beads which can be removed from the capsule and administered orally whole (UNLICENSED*). Note: beads are not to be chewed. 3. Tolterodine 2mg/5mL oral suspension (UNLICENSED, HIGH COST). Shelf life is 28 days once If used as epilepsy treatment, a product change poses a risk of fits Sprinkle capsules can be opened and contents sprinkled on food or mixed with water for administration (LICENSED) 2. Topiramate 50mg/5ml or 100mg/5ml oral suspension (UNLICENSED, HIGH COST) 1. Tramadol 50mg soluble tablets sugar free (LICENSED) 2. Tramadol 100mg/mL oral drops (LICENSED, LESS COST-EFFECTIVE). Dilute drops with water first. Note: a dose of 50mg is equivalent to 20 drops (SPC Tramadol 100mg/ml oral drops, Nov 2015) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) (NEWT, Nov 2015) 2. Tranexamic acid 500mg/5ml oral solution (UNLICENSED, HIGH COST, MOST-COST EFFECTIVE PREPARATION) 1. Crush and disperse tablets in water (UNLICENSED*, LOW COST) 2. Trihexyphenidyl 5mg/5ml oral solution (LICENSED, HIGH COST) 1. Restricted initiated on gastroenterology advice only 2. Ursodeoxycholic acid 250mg tablets can be crushed and dispersed in water (UNLICENSED*, LOW COST) 3. Ursodeoxycholic acid 250mg/5ml oral suspension sugar free (LICENSED, HIGH COST) Do not crush modified (MR) tablets, switch total daily dose to immediate (IR) tablets and give in divided doses. 1. Crush and disperse IR tablets in water (UNLICENSED*, LOW COST) 2. The MR capsules contain MR beads which can be emptied out and given in smooth food, e.g. yogurt, for patients with swallowing difficulties only (UNLICENSED*, LOW COST) (NEWT, Feb 2011) 3. Venlafaxine 75mg/5mL oral solution (UNLICENSED, HIGH COST). Shelf life is 28 days once Review indication For CF patients only: 1. Multivitamin containing vitamins A, D, E and K (DEKAs Plus). HMMC guidance: 2. Alpha tocopheryl acetate 500mg/5ml oral suspension (LICENSED, HIGH COST) Adult patients consider switch to NOAC edoxaban, apixaban or rivaroxaban where appropriate. See separate entries. 1. Crush and disperse tablets in water (UNLICENSED*). Monitor INR 2. Warfarin 1mg/mL oral suspension sugar free (LICENSED, HIGH COST) Note: some enteral feeds containing high levels of Vitamin K which can antagonise the effects of warfarin and warfarin resistance may occur. Monitor the INR closely (NEWT, October 2018) Do not prescribe long term consider clinical need for hypnotic. 1. Crush and disperse in water (UNLICENSED*) Do not prescribe long term consider clinical need for hypnotic. 1. Do not crush zopiclone tablets. Consider zolpidem tablets (see separate entry) 2. Zopiclone 3.75mg/5mL oral solution (UNLICENSED) * Manipulation of a licensed product in this way will be outside of the product s marketing authorisation. However, there is evidence and clinical experience detailed in reputable sources (e.g. NEWT) confirming that formulation manipulation of this nature can take place without compromising the effectiveness of the medicine. Some formulations should not usually be crushed and this has been taken into account in the advice outlined above. Decisions should be made on an individual basis and the specific needs and best interests of the individual patient taken into account. 9 P a g e

10 References Duchin K., Duggal A., Atiee G J., Motonori Kidokoro M., Takatani T., Shipitofsky N L., Ling He L Zhang1 G. Kakkar T (2017). An Open-Label Crossover Study of the Pharmacokinetics of the 60-mg Edoxaban Tablet Crushed and Administered Either by a Nasogastric Tube or in Apple Puree in Healthy Adults. Accessed via NEWT Guidelines for administration of medication to patients with enteral feeding tubes or swallowing difficulties. Wrexham Maelor Hospital - Pharmacy Department. Accessed via NHS Business Services Authority (NHSBSA). Drug Tariff (October 2018). Accessed via Summary of Product Characteristics (various), Electronic Medicines Compendium. Accessed via Version 4.0 Developed by Care Homes Specialist Pharmaceutical Advisor and Pharmaceutical Advisor, Pharmacy & Medicines Optimisation Team, HVCCG Date ratified v4.0 November 2018 (note title changed to Specials alternatives guidance from Guidance for swallowing difficulties and feeding tubes ); v3.0 December 2017; v2.0 October 2017; v1.0 May 2017 (Medicines Optimisation Clinical Leads group); v4.0 November 2018; v3.0 February 2018; v2.0 October 2017 (Primary Care Commissioning Committee); v1.0 May 2017 (Commissioning Executive). Review date April P a g e