Guide to administration of medicines to patients with swallowing difficulties or feeding tubes (NG/PEG)

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1 Guide to administration of medicines to patients with swallowing difficulties or feeding tubes (NG/PEG) This document is intended to guide pharmacists in advising nursing staff on the administration of medicines to patients with swallowing difficulties or feeding tubes (NG/PEG). The information cannot necessarily be extrapolated to Jejunal feeding tubes as these bypass the stomach and duodenum and hence drug absorption may differ. Much of the information is not supported by published data and most recommendations are therefore theoretical or based on local experience. Drug Abacavir Acebutolol Aceclofenac Acetazolamide Acetylcysteine Aciclovir Acitretin Alendronate Alfacalcidol Alfuzosin Allopurinol Alverine Amantadine Amiloride Presentation/Method of administration/clinical Guidance A 20mg/ml oral solution. 100mg, 200mg caps Open caps and disperse contents in water. Change to alternative NSAID (e.g. diclofenac, ibuprofen). 250mg tabs disperse tab (fine sediment). 500mg injection has been used orally. 250mg SR caps change formulation. 200mg sachet. 600mg effervescent tab. Injection can be used orally; contact Medicines Information for further details (NEWT). 200mg, 400mg, 800mg dispersible tabs. 200mg/5ml, 400mg/5ml suspension. 10mg, 25mg caps contents poorly soluble; not suitable for administration via feeding tubes, can be sprinkled onto soft food. 5mg, 10mg, 70mg tab DO NOT CRUSH. Crushed fragments could get stuck in the oesophagus. Patients with feeding tubes may get reflux into oesophagus. Oesophageal reactions have been reported with this drug. Change to Didronel PMO. 2mcg/ml oral drops (1 drop contains 100nanogram) hold bottle vertically upside down without shaking drops should flow automatically. For patients with feeding tubes please contact Medicines Information for further details (NEWT). 2.5mg tabs crush and disperse in water. 10mg XL tabs change to plain tabs, dose equiv. 2.5mg tds. 100mg, 300mg tabs cut tab in half and disperse in water (or tab will disperse in 10 minutes). 60mg, 120mg caps open caps and disperse contents in water, contents have a local anaesthetic effect. 50mg/5ml syrup. 100mg caps open caps and disperse contents in water or sprinkle onto food. 5mg/5ml oral solution. 1

2 Drug Presentation/Method of administration/clinical Guidance Aminophylline 225mg MR tab DO NOT CRUSH, change to Slo-Phyllin capsules see theophylline information (225mg aminophylline is approximately equal to 180mg theophylline). Monitor response to treatment and check levels after 3 days. Aminophylline injection can be used orally. Seek further advice from Medicines Information. Amiodarone 100mg, 200mg tabs disperse or crush and disperse in water. Tastes bitter better mixed with fruit juice for patients with swallowing difficulties. Amisulpride 100mg/ml solution. Amitriptyline 25mg/5ml and 50mg/5ml oral solution. If on continuous enteral feed, stop and flush well either side of aministration. Amlodipine 5mg, 10mg tabs disperse tab. Amoxicillin 125mg/5ml and 250mg/5ml suspension. Anastrozole 1mg tab crush and mix with water (crush under water to avoid exposure). Antacids Not recommended via feeding tubes as may interact with feed. Consider ranitidine or PPI. Aripiprazole 5mg, 10mg, 15mg, 20mg tabs crush and mix with water. Arthrotec Do not crush. Change to diclofenac dispersible tabs plus PPI (lansoprazole FasTab) OR misoprostol. Asasantin Retard Capsules can be opened and contents (pellets plus a small aspirin tab) mixed with soft food for patients with swallowing difficulties, DO NOT CRUSH CONTENTS. Some patients may still have problems swallowing the tablet, in which case change to aspirin 75mg od and dipyridamole 200mg bd (see dipyridamole entry). Otherwise, for patients with feeding tubes change to aspirin dispersible 75mg each morning and dipyridamole 100mg qds. Ascorbic acid Effervescent 1g tablets (for doses of 250mg, 500mg and 1g) Aspirin 75mg and 300mg dispersible tabs. 150mg and 300mg suppository. Atazanavir 100mg, 150mg, 200mg cap open and disperse contents in water or mix with soft food (quite insoluble). Atenolol 25mg/5ml liquid. Atomoxetine 10mg, 18mg, 25mg, 40mg, 60mg caps open caps and disperse contents in grape juice (not grapefruit!) or into soft food. Atorvastatin 10mg, 20mg, 40mg, 80mg tabs crush and disperse in water (a residue may be left flush well). 2

3 Drug Azathioprine Azithromycin Baclofen Balsalazide Bendroflumethiazide Benzhexol Betahistine Betamethasone Bezafibrate Bicalutamide Biotin Bisacodyl Bisoprolol Brewers yeast Bromocriptine Budesonide Bumetanide Bupropion Cabergoline Calcium Presentation/Method of administration/clinical Guidance 25mg, 50mg tab CYTOTOXIC DO NOT CRUSH disperse tab within syringe may take 5 mins (Method: remove plunger from syringe, place tablet in barrel, replace plunger without crushing tablet, draw up water into syringe and shake until dispersed) 200mg/5ml suspension. B 5mg/5ml liquid not recommended for feeding tubes as very thick and difficult to flush. 10mg tablet disperse tab or crush and disperse in water. 750mg cap open caps and disperse contents in water. Contents are bright yellow and can stain. 2.5mg tab disperse tab or crush and disperse in water. See Trihexyphenidyl. 8mg, 16mg tab disperse tab. 500mcg soluble tab. 200mg tab disperse tab (1-2 mins). 400mg MR DO NOT CRUSH, change to 600mg of conventional tablets (prescribed as 200mg tds). 50mg, 150mg tab crush well and disperse in water. Tabs crush and mix with water, can also be added to drinks 5mg EC tab DO NOT CRUSH, use suppository, OR change to senna syrup. 1.25mg, 2.5mg, 3.75mg, 5mg, 7.5mg, 10mg tab crush well and disperse in water. Tab crush finely and mix with water. 1mg, 2.5mg tab crush and disperse in water use immediately. 3mg CR caps (Entocort) may be opened and pellets mixed with orange juice or other acidic solution. DO NOT CRUSH CONTENTS. For patients with feeding tubes please contact Medicines Information for further information (see NEWT guidelines). 1mg/5ml liquid. 1mg, 5mg tab will disperse in water in 5-10 minutes, give immediately. Do NOT crush as modified release. C 0.5mg, 1mg, 2mg, 4mg tab crush and disperse in water. Most formulations are chewable so should be suitable for patients with swallowing difficulties. Otherwise, or for feeding tubes, formulation may need to be changed to Cacit effervescent tabs providing 500mg calcium OR Cacit D3 sachets if vitamin D is also required. Calcium-Sandoz syrup also available (108.3mg calcium/5ml). 3

4 Drug Calcium folinate Calcium resonium Candesartan Capecitabine Presentation/Method of administration/clinical Guidance 15mg tab crush and disperse in water. Flush well for feeding tube administration as excipients not completely soluble. Rectal route advised for patients with feeding tubes, usual dose 30g OD. Enema preparation available from pharmacy. 2mg, 4mg, 8mg, 16mg, 32mg tab crush and disperse in water. 150mg, 500mg tabs CYTOTOXIC DO NOT CRUSH Could try to disperse tab within syringe may take 15 mins (Method: remove plunger from syringe, place tablet in barrel, replace plunger without crushing tablet, draw up luke warm water into syringe and shake until dispersed) Solution may need to be flavoured (e.g. with raspberry) to improve palatability. Captopril 2mg, 12.5mg, 25mg and 50mg tab will disperse in water in 5-10 minutes. Use immediately. For further information please contact Medicines Information (see NEWT guidelines). Carbamazepine Carbimazole Carbocisteine Carvedilol Cefalexin Celecoxib Celiprolol Cetirizine Chlordiazepoxide Chloroquine Chlorphenamine Chlorpromazine Ciclosporin 100mg/5ml liquid MUST dilute with equal volume of water for administration via feeding tubes as it gets adsorbed onto tubing. Enteral feeds should be stopped for at least two hours before and two hours after dose to maximise drug absorption. 200mg, 400mg Retard tab DO NOT CRUSH, change to liquid, daily dose should be in 2-3 divided doses. 125mg, 250mg suppositories 100mg PO = 125mg PR. Give daily dose in four divided doses (max dose 250mg QDS for 7 days) seek further advice. 100mg, 200mg chewtabs may be suitable for some patients who are able to chew tablets. 5mg, 20mg tab crush and disperse in water. 125mg/5ml, 250mg/5ml liquid mg, 6.25mg, 12.5mg, 25mg tab crush and disperse in water (or tab will slowly disperse in water). 125mg/5ml, 250mg/5ml suspension. 100mg, 200mg caps Open caps and sprinkle contents onto semi-solid food. Do not mix with water. Consider alternative drug for patients with feeding tubes. 200mg, 400mg tab crush well and disperse in water. 5mg/5ml oral solution. 5mg, 10mg caps Open caps and disperse contents in water. 5mg, 10mg tab crush and disperse in water. 50mg (base)/5ml syrup. 2mg/5ml syrup. Personnel should avoid direct contact with chlorpromazine as contact sensitisation may occur. 25mg/5ml syrup, 100mg/5ml suspension. 100mg/5ml oral solution may adhere to feeding tubes flush with orange juice instead of water. Monitor serum levels closely if changing from capsules. 4

5 Drug Cimetidine Cinnarizine Ciprofibrate Ciprofloxacin Citalopram Clarithromycin Clindamycin Clobazam Clomethiazole (chlormethiazole) Clomipramine Clonazepam Clonidine Clopidogrel Clozapine Co-amilofruse Co-amilozide Co-amoxiclav Co-beneldopa Presentation/Method of administration/clinical Guidance 200mg/5ml syrup/suspension. Injection could be used orally if necessary. 15mg tab suck/chew or crush and disperse in water. 100mg tab crush and disperse in water. 250mg/5ml suspension NOT via feeding tubes (may degrade tube). Instead use 250mg tab and disperse in water for injection. Feeds containing calcium, magnesium or iron may reduce absorption; consider stopping feed for an hour either side of dose or for very severe infection use the intravenous route. 10mg, 20mg, 40mg tab crush and disperse in water (may taste unpleasant). 40mg/ml oral drops NOT RECOMMENDED as dropper bottle doesn t consistently deliver medication. Not bioequivalent to tabs [10mg tab = 8mg oral drops (4 drops). Invert bottle drops should flow automatically, DO NOT SHAKE. Mix drops with water, orange juice or apple juice before giving] 125mg/5ml, 250mg/5ml suspension mix with equal volume of water immediately prior to administration via feeding tubes. 75mg, 150mg cap open caps and disperse contents in water (capsule gives off an offensive smell when opened). May be unpalatable for patients with swallowing difficulties due to foul taste. Try mixing with grape juice or maple syrup. 10mg tab crush and disperse in water. Could chew (may be unpleasant). 250mg/5ml syrup not via feeding tubes as it is absorbed by PVC. Consider alternative. 10mg, 25mg, 50mg cap open cap and disperse contents in water. 75mg SR tab DO NOT CRUSH, change to plain caps. 0.5mg, 2mg tab crush and disperse in water (OR tab will disperse in 5 mins). Use at least 30ml water if giving via feeding tubes as it may bind to tube. 100mcg, 300mcg tab crush and disperse in water. Injection can be administered orally, used either neat or diluted in water prior to administration. 75mg tab crush and disperse in water. 25mg, 100mg tab crush and put onto soft food, not soluble in water. Change to furosemide and amiloride prescribed separately (both available in liquid form) 2.5/25mg, 5/50mg tab crush and disperse in water. 375mg dose use 375mg dispersible tab. 625mg dose use 10ml of 250/62mg per 5ml suspension. Dilute with equal quantity of water prior to feeding tube administration. See Madopar. 5

6 Drug Co-careldopa Co-codamol Co-danthramer Codeine Co-dydramol Colchicine Colestyramine (cholestyramine) Combivir (lamivudine + zidovudine) Co-phenotrope Co-proxamol Co-tenidone Co-trimoxazole Cyanocobalamin Cyclizine Cyclophosphamide Cyproterone Danazol Dantrolene Dapsone Demeclocycline Presentation/Method of administration/clinical Guidance See Sinemet. 8/500mg, 30/500mg effervescent tabs. 25/200mg or 75/1000mg per 5ml suspension. 15mg/5ml linctus, 25mg/5ml syrup dilute with water for feeding tube administration. Change to alternative analgesic (e.g. co-codamol). 0.5mg tab disperse or crush and disperse in water. 4g sachet mix with water, fruit juice, skimmed milk or thin soup before administration. Give one hour after other meds and wait 4-6 hours before giving any other meds (absorption may be affected). Ideally use the constituent drugs separately in liquid form. Tab DO NOT CRUSH, place in 50ml tepid (not hot) water and allow to dissolve. It has a bitter taste which could be disguised with juice. Tabs ideally change to alternative (e.g. loperamide) otherwise can crush and mix with water but has a very bitter taste and forms a sediment. Change to alternative analgesic (e.g. co-codamol). 50/12.5mg, 100/25mg tab crush and disperse in water. 240mg/5ml, 480mg/5ml suspension. 50mcg tabs crush and mix with water. Liquid 35micrograms/5ml available. 50mg tab disperse (takes a few minutes) or crush and disperse in water. 50mg tab CYTOTOXIC DO NOT CRUSH disperse tab within syringe (Method: remove plunger from syringe, place tablet in barrel, replace plunger without crushing tablet, draw up water into syringe and shake until dispersed) 50mg, 100mg tab crush and disperse in water. D 100mg, 200mg caps open capsule and disperse contents in water or in soft food. 25mg, 100mg caps open cap and disperse contents (which are bright orange) in water or acidic fruit juice (such as orange juice rather than Ribena type squash). 50mg, 100mg tab crush and disperse in plenty of water. 150mg caps contents do NOT disperse well in water except in large volumes ( ml) which is not useful as the patient is usually fluid restricted. PEGs have been blocked by trying to give in a smaller volume. Consider alternative. 6

7 Drug Desmopressin Dexamethasone Diazepam Diclofenac Didanosine Digoxin Dihydrocodeine Diltiazem Dipyridamole Disopyramide Presentation/Method of administration/clinical Guidance Tabs can be crushed (crush under water to reduce exposure), chewed, dispersed in water. Can be absorbed into plastics, not suitable for feeding tubes. DDAVP melt available suitable if patient can swallow saliva. Dose alteration required, seek further information from Medicines Information. 2mg/5ml syrup. 2mg/5ml, 5mg/5ml syrup mix well with water before administration via feeding tubes to reduce viscosity and prevent binding to the tube. Rectal administration may be a suitable alternative route of administration, available as 2.5mg, 5mg, 10mg rectal tubes. 50mg dispersible tabs. 50mg, 100mg suppositories. 50mg EC tab DO NOT CRUSH, change to dispersible tabs. 75mg, 100mg MR tab/cap DO NOT CRUSH, change to 50mg tds dispersible tabs. 25mg, 200mg tab can be chewed, crushed or dispersed in water, clear apple juice may be added for flavouring. Videx EC cap DO NOT OPEN, must be swallowed whole. 250mcg/5ml elixir give the same dose as the tablet (difference in bioavailability not considered significant) 62.5mcg, 125mcg, 250mcg tab crush and disperse in water (bioavailability may be increased considered insignificant). 10mg/5ml suspension. DHC Continus DO NOT CRUSH. When converting from MR preparation to liquid, daily dose should be in 4 divided doses. For patients with swallowing difficulties MR caps may be opened and contents mixed with soft food (DO NOT CRUSH CONTENTS). For patients with feeding tubes Viazem or Adizem MR caps may be opened and contents flushed down wide bore feeding tubes. 60mg MR tabs may also be crushed. Amlodipine may be a suitable alternative (BUT not for all patients depending on indication for use of diltiazem). 200mg Retard caps (Persantin) mix contents with soft food for patients with swallowing difficulties (DO NOT CRUSH CONTENTS). 100mg sugar coated tab crush and disperse in water. 100mg plain tab disperse in water. Dose is 100mg QDS if changing from 200mg Retard BD. Suspension is expensive. 100mg, 150mg caps open cap and disperse contents in water. 7

8 Drug Disulfiram Docusate Domperidone Donepezil Dosulepin (dothiepin) Doxazosin Doxycycline Duloxetine (Cymbalta) Dutasteride Efavirenz Emtricitabine Enalapril Presentation/Method of administration/clinical Guidance Tabs company cannot recommend crushing. 50mg/5ml solution. 5mg/5ml suspension. 30mg suppositories available dose different to oral (60mg bd). 5mg, 10mg orodispersible tablet available. 5mg, 10mg tab crush and disperse in water. 75mg tab too hard to crush. 25mg caps open and disperse powder contents in water, may have a local anaesthetic effect. 1mg, 2mg, 4mg tab crush and disperse in water for injection (drug will precipitate in presence of chloride) OR tab will disperse in a few mins. May be sludgy so alfuzosin may be a better choice for patients being treated for prostatic hyperplasia. 4mg, 8mg XL tab change to plain tab. There is no consensus whether to use the same dose or half dose. 100mg dispersible tab may bind to calcium in feed. Consider stopping feed for an hour either side of dose. 30mg, 60mg caps DO NOT CRUSH capsule contents are gastro-resistant and can be mixed with ONLY apple juice/sauce as they are acidic. Caps must be swallowed whole. Consider changing to finasteride. E 30mg/ml oral solution dose change required: 720mg of solution is equivalent to a 600mg tablet. For feeding tubes mix with water before administration. 10mg/ml oral solution. (240mg solution = 200mg capsule) 200mg caps open capsule and dissolve contents in water (very soluble). 2.5mg, 5mg, 10mg, 20mg tab disperse or crush and disperse in water. Entacapone 200mg tab DO NOT CRUSH as this produces red dust disperse in water, flush well as it is not fully soluble. It will also stain skin/clothing orange. Has a bitter taste mix with orange juice for patients taking orally. Eprosartan Erythromycin Escitalopram 300mg, 400mg, 600mg tabs crush and disperse in water. 125mg/5ml, 250mg/5ml, 500mg/5ml suspension. 5mg, 10mg, 20mg tab can crush and mix with cold food. Unpleasant taste. Not very soluble in water for patients with feeding tubes consider changing to citalopram (10mg escitalopram = 20mg citalopram) 8

9 Drug Presentation/Method of administration/clinical Guidance Esomeprazole 20mg, 40mg tab will disperse (for feeding tubes use 20mg tabs only: put into a syringe and add 25ml water, suitable for tubes size 8Fr or larger; 40mg tabs are only suitable for tubes size 14Fr or larger). OR change to lansoprazole FasTabs (dose change required) Etamsylate 500mg tab crush and mix with water. Ethambutol 100mg, 400mg tab crush and mix with water. Etidronate 200mg tab crush and disperse in water. For enteral feeding flush with 50ml water. Stop enteral feed for 2 hours either side of administration. Etoricoxib 60mg, 90mg, 120mg tab may taste unpleasant when crushed and no information on bioavailability change to NSAID + PPI in dispersible/syrup form. Exemestane 25mg tab crush and disperse in water (crush under water to avoid exposure). Ezetimibe 10mg tab tablets are insoluble in water change to alternative. F Famciclovir 125mg, 250mg, 500mg, 750mg tab crush and mix with water. Felodipine 2.5mg, 5mg, 10mg MR tabs DO NOT CRUSH change to amlodipine. Fenofibrate 67mg, 200mg, 267mg cap open caps and disperse contents in water. 160mg MR tab DO NOT CRUSH change to 200mg cap which is the equivalent dose. Ferrous Sulphate 200mg tab change to ferrous fumarate liquid (7.2ml will give the same amount of elemental iron as one tab) For 200mg TDS, prescribe 10ml BD. Fexofenadine 30mg, 120mg, 180mg tab crush and mix with water. OR consider changing to loratadine syrup 5mg/5ml (usual adult dose 10mg od) if likely to be long term. Finasteride 5mg tab put tab into syringe, add 10ml water and shake well (this method minimises person contact). NB Women who are or may become pregnant should not handle crushed, broken or dissolved tablets. Flavoxate 200mg tab crush and mix with water. Tastes bitter. Flush enteral feeding tubes well. Flecainide 50mg, 100mg tab crush and mix with water (OR tab will disperse in 5 mins). Has a local anaesthetic effect so not suitable for patients with swallowing difficulties. 25mg/5ml mixture (unlicensed, made by Penn) Flucloxacillin 125mg/5ml, 250mg/5ml syrup. Should be given on an empty stomach, consider stopping enteral feed for an hour either side of dose or for very severe infection use the intravenous route. 9

10 Drug Fluconazole Fludrocortisone Fluoxetine Flupentixol Fluphenazine Fluvastatin Fluvoxamine Folic acid Forceval Fosinopril Furosemide Fybogel Gabapentin Galantamine Glibenclamide Gliclazide Glimepiride Glipizide Glyceryl Trinitrate Glycopyrronium Granisetron Presentation/Method of administration/clinical Guidance 50mg/5ml, 200mg/5ml suspension. Stop enteral feeds for one hour before and after administration. 100mcg tab disperse in water. 20mg/5ml liquid for feeding tubes dilute with equal volume of water. 20mg caps open and dissolve contents in 120ml water, leave for 5 minutes to dissolve. 0.5mg, 1mg (Fluanxol) crush and disperse in water. 3mg tab crush and mix with water or fruit juice (poorly soluble flush feeding tube well). 1mg, 2.5mg, tab crush and disperse in water. 20mg, 40mg cap open caps and disperse contents in water 80mg XL tab DO NOT CRUSH, change to 40mg cap BD. 50mg, 100mg tab crush and mix with water. 2.5mg/5ml syrup. Capsule contents are oily and do not mix with water. Change preparation (seek further advice). 10mg, 20mg tab crush and mix with water. 20mg/5ml, 40mg/5ml, 50mg/5ml syrup. Sachet NOT for administration via feeding tubes as it may block them. Consider using an enteral feed with a high fibre content if patient is having enteral feeds. G 100mg, 300mg, 400mg cap open caps, disperse contents in water and give immediately (limited stability). Bitter taste. Could try mixing with orange juice or Ribena. 600mg, 800mg tabs change to same dose of caps. 4mg/ml oral solution. 2.5mg, 5mg tab crush and mix with water (OR tab will disperse in 10 mins). Give before enteral feed begins each day. 80mg tab crush and mix with water or orange juice. Give before enteral feed begins each day. 30mg MR tab DO NOT CRUSH change to 80mg tab (equivalent to 30mg MR) 1mg, 2mg, 3mg, 4mg tab crushing may affect bioavailability. Consider alternative (seek further advice) 2.5mg, 5mg tab crush and mix with water (OR tab will disperse in 5 mins). Give before enteral feed begins each day. Sublingual, Buccal and Transdermal routes not applicable. Sustac MR tab change formulation (seek further advice). 200mcg/ml injection has been used orally and via feeding tubes. 1mg/5ml liquid H 10

11 Drug Presentation/Method of administration/clinical Guidance Haloperidol 1mg/ml, 2mg/ml oral liquid for feeding tubes dilute with equal volume of water first. HRT DO NOT CRUSH. Consider using patches. SEEK FURTHER ADVICE. Hydralazine 20mg injection made up with WFI can be given orally/via feeding tubes. 25mg/50mg tab can be crushed but may block feeding tubes. Hydrocortisone 10mg, 20mg tab crush well and mix with water (although it is insoluble) (OR tab will disperse in 5 mins). Hydroxycarbamide 500mg caps CYTOTOXIC SEEK FURTHER ADVICE (hydroxyurea) Caps should be swallowed whole with plenty of fluid. Hydroxyzine 10mg/5ml syrup. Hyoscine 10mg tab do not crush for oral use (unpleasant taste), may be butylbromide crushed for feeding tube administration. 20mg/ml injection can be used orally/via feeding tubes I Ibuprofen 100mg/5ml syrup. Indapamide 2.5mg tab crush and mix with water. 1.5mg MR tab DO NOT CRUSH. Change to 2.5mg tablet which is the equivalent dose. Indometacin Change to alternative NSAID (e.g. diclofenac, ibuprofen) (indomethacin) OR change to suppositories (dose amendment required: usually 100mg ON or BD). Indoramin 20mg tab crush and mix with water (OR tab will disperse in 5 mins). Inositol nicotinate 500mg tab will not dissolve. Can crush and mix with soft food for patients with swallowing difficulties. Irbesartan 75mg, 150mg, 300mg tab crush and mix with water. Iron See ferrous sulphate. Isoniazid 50mg/5ml elixir. Isosorbide dinitrate 10mg, 20mg tab disperse tab. 20mg, 40mg MR tab DO NOT CRUSH. Change to equivalent dose of plain tabs. Seek further advice. 11

12 Drug Isosorbide mononitrate Itraconazole Ivabradine Presentation/Method of administration/clinical Guidance 10mg, 20mg, 40mg tab crush and mix with water. 25mg, 40mg, 50mg MR cap Not suitable for feeding tube administration, change to plain tabs (see below). For patients with swallowing difficulties the caps may be opened and contents mixed with soft food (DO NOT CRUSH CONTENTS). 25mg, 40mg, 50mg, 60mg MR tab DO NOT CRUSH. Change to plain tabs. When converting from MR preparation to plain tabs, daily dose should be in 2 divided doses given morning and lunchtime suggested dose amendments: 25mg MR 10mg BD 40mg MR 20mg BD 50mg MR 20mg BD 60mg MR 20mg BD GTN patches may be a suitable alternative. 10mg/ml liquid Should be given on an empty stomach, consider stopping enteral feed for an hour either side of dose. Tabs crush and mix with water, monitor for desired effects. K Ketoconazole 200mg tab crush and mix with water (OR tab will disperse in 5 mins) L Labetalol 50mg, 100mg, 200mg, 400mg tab DO NOT CRUSH or disperse (powder sensitive to oxidation) 100mg/20ml injection can be used via feeding tubes. If given to patients with swallowing difficulties, mix with orange juice to disguise bitter taste. Lacidipine 2mg, 4mg tab crush (may be difficult!) and disperse in water. Lactulose Solution for administration via feeding tubes dilute each 10ml with 30ml water. Lamivudine 50mg/5ml oral solution Epivir for HIV only. 25mg/5ml oral solution Zeffix for Hep B only. Lamotrigine Lansoprazole Leflunomide Lercanidipine Letrozole 2mg, 5mg, 25mg, 100mg dispersible tabs. 15mg, 30mg FasTabs disperse in water. Ensure all beads are administered as these contain the drug. 30mg suspension sachet too viscous for feeding tubes but may be suitable for patients with swallowing difficulties. 10mg, 20mg, 100mg tab crush and mix with water. 10mg tab crush and mix with water. 2.5mg tab crush and disperse in water (crush under water to reduce exposure), rinse container well as active ingredient insoluble in water. 12

13 Levetiracetam Levofloxacin Levomepromazine (methotrimeprazine) Levothyroxine Linezolid Liothyronine Lisinopril Lithium carbonate Lofepramine Lomustine Loperamide Loratadine Lorazepam Losartan Lumiracoxib Madopar (co-beneldopa) Magnesium glycerophosphate 100mg/ml oral solution. 250mg, 500mg, 750mg,1g tab crush and mix with water (drug is very soluble although excipients not so soluble) 250mg, 500mg tab crush well and disperse in water (Theoretically should not crush, but anecdotally, this has been done). Consider IV route or changing to a suitable alternative antibiotic. Enteral feeds should be stopped 1 hour pre and 2 hours post dose. 6mg, 25mg tab crush and mix with water. Consider using injection by SC route if palliative. 25mcg, 50mcg, 100mcg tab crush and mix with water. 100mg/5ml suspension may be too thick for feeding tubes. 600mg tab can crush and disperse in water. 20mcg tab can crush and mixed with water or food. 2.5mg, 5mg, 10mg, 20mg tab disperse tab or crush and disperse in water. Tabs DO NOT CRUSH. For each 200mg lithium carbonate tab (Priadel MR, Camcolit), prescribe 2.5ml bd of lithium citrate 5.4mmol/5ml liquid (Priadel 520mg/5ml, Li-Liquid 509mg/5ml). Preparations vary widely in bioavailability monitor serum levels as advised for initiation of treatment (see BNF). 70mg/5ml suspension. 40mg caps CYTOTOXIC if absolutely essential to use this drug can mix capsule contents with yoghurt and give immediately. Nurse should wear apron, mask and gloves. 1mg/5ml syrup. 2mg cap contents will not disperse well in water so unsuitable for use via feeding tubes. 5mg/5ml syrup. 1mg, 2.5mg tab crush and mix with water (OR tab will disperse in 5 mins). Can also be given sublingually if mouth is moist enough. 25mg, 50mg,100mg tab crush and mix with water to at least 10mg/ml. 100mg tabs crush and mix with water. Use immediately. M 62.5mg, 125mg dispersible tab. 62.5mg, 125mg, 250mg cap change to dispersible tab. 125mg CR cap Must be swallowed whole to be effective. Direct conversion from CR to dispersible tabs not possible (dose may need to be reduced by 33%). Seek further advice. Monitor patient for altered efficacy. 2mmol caps open cap and disperse contents in water. 4mmol tab can be crushed, chewed or dispersed in water. NB Capsules disperse more easily than tablets. 13

14 Mebendazole 100mg chewable tabs. 100mg/5ml suspension. Mebeverine 135mg tab crush and disperse in water bitter taste. 200mg MR cap may be opened and contents sprinkled onto soft food, do not crush pellets. Contents may be able to be flushed down feeding tubes. Medroxyprogesterone All strength tabs disperse or crush with water (to minimise dust). Mefenamic acid 50mg/5ml paediatric suspension large volumes required for adult doses consider alternative. Megestrol Acetate 40mg, 160mg tab crush with water (to minimise dust). Melatonin Caps (including slow release) open and mix contents with soft cold food (e.g. yoghurt). Contents not very soluble in water. Meloxicam 7.5mg, 15mg tab crush and disperse in water OR change to suppository (use for shortest time possible) OR change to alternative NSAID (e.g. diclofenac, ibuprofen). Melphalan 2mg tab CYTOTOXIC DO NOT CRUSH. Tablets do not fully disperse, leaving fragments which may block feeding tubes. No suspension is available. Discuss with prescriber. Memantine 10mg tab crush and disperse in water, not fully soluble so will need to flush feeding tubes well. Oral drops available 10 drops = 5mg. Menadiol 10mg tab crush and disperse in water or mix with food. Mesalazine 1g granules not suitable for patients with feeding tubes but useful for patients with swallowing difficulties if they can swallow them with water or orange juice without chewing. 400mg EC tab (Asacol, Ipocol, Mesren MR) DO NOT CRUSH. Consider granules or changing to Pentasa. 500mg MR tab (Pentasa) DO NOT CRUSH. Will disperse in water releasing microgranules (smaller than granules) may be suitable for wide bore feeding tubes. Do not crush or chew microgranules. Suppositories, foam or liquid enemas are also available but may not be appropriate depending on location of disease seek advice from patient s doctor. Metformin 500mg, 850mg tab crush and disperse in water. An licensed liquid preparation 500mg/5ml is available. 500mg MR tabs DO NOT CRUSH change to plain tabs at the same total daily dose, but given in divided doses. Methotrexate 2.5mg, 10mg tabs CYTOTOXIC DO NOT CRUSH disperse tab within syringe. (Method: remove plunger from syringe, place tablet in barrel, replace plunger without crushing tablet, draw up water into syringe and shake until dispersed) A suspension is available from Nova Labs (but not immediately). Methyldopa 125mg, 250mg, 500mg tabs crush and disperse in water. Metoclopramide 5mg/5ml oral solution. 14

15 Metolazone Metoprolol Metronidazole Metyrapone Mexiletine Mianserin Midodrine Mifepristone Minocycline Minoxidil Mirtazapine Misoprostol Moclobemide Montelukast 5mg tab crush and mix with water (although this may increase bioavailability watch for enhanced effects). (NB tabs should not be halved to give a 2.5mg dose) 50mg, 100mg tab will disperse very slowly in water or crush and mix with water. Atenolol liquid may be a suitable alternative for some patients. 200mg/5ml suspension. OR use IV route. 500mg, 1g suppositories may be suitable for maintenance treatment (1g tds for 3/7 then 1g bd thereafter). Not for initiating treatment due to slower absorption and lower plasma levels. 400mg tabs (Alpharma & Ranbaxy brand) crushing not recommended very unpleasant taste disguise with jam no information on administration via feeding tubes. 250mg cap (fluid filled) can be chewed by patient OR pierce capsule with needle and squeeze out contents into water, use needle and syringe to instil water into capsule to rinse and squeeze out, repeat until water is clear. The contents are too viscous to be withdrawn with needle and syringe. 50mg, 200mg cap open caps and disperse contents in water. Has a local anaesthetic effect so not suitable for patients with swallowing difficulties. 10mg, 20mg, 30mg tab crush and mix with water. Crushed tabs may have local anaesthetic effect on mouth. 2.5mg, 5mg tab disperse in water ensure all sediment administered and flush well. 200mg tab will not disperse. Can crush and mix with jam. Females should limit their exposure to the dust (wear gloves, mask and gown). 50mg tabs crush and mix with water if feeding tube present. Not suitable for patients with swallowing difficulties. Seek further advice from Medicines Information (NEWT). 100mg MR caps change to 50mg tabs (50mg BD). 2.5mg, 5mg, 10mg tab crush and mix with water. 15mg, 30mg, 45mg SolTab disperse on tongue or in water. 15mg/ml oral solution also available. 200mcg tab disperse in 20ml water. Not to be handled by pregnant women theoretical risk. Consider changing to lansoprazole FasTab. 150mg, 300mg tab crush and mix with water. 4mg granules may be swallowed or mixed with cold food (but not fluid) and taken immediately. NOT suitable for feeding tubes. 4mg, 5mg chewable tab disperse in water. 10mg tab crush and disperse in water. 15

16 Morphine Moxonidine Multivitamins Mycophenolate mofetil Mycophenolic acid Naftidrofuryl Naproxen Nebivolol Nicardipine Nicorandil Nifedipine Nimodipine Nitrazepam Nitrofurantoin Norethisterone Oramorph oral solution (immediate release) Sevredol immediate release tab change to Oramorph. Zomorph cap (slow release, given 12 hourly) can be opened and contents sprinkled on soft food or flushed down feeding tubes greater than 16Fr (do not crush). For smaller bore feeding tubes try MST Continus Suspension, use immediately, do not allow to stand. MST tab change to Zomorph cap/mst Continus Suspension. MXL cap change to Zomorph cap/mst Continus Suspension: daily dose will need to be divided into 2 doses, 12 hours apart. MST Continus Suspension can be mixed with soft foods eg yoghurt. 200mcg, 300mcg, 400mcg tab crush finely, mix with 50ml water, leave for 2 minutes before administering (not very soluble). Dialyvit tabs crush and mix well with water, or yoghurt. 1g/5ml oral suspension use mask and gloves when reconstituting to limit exposure to powder. 180mg, 360mg EC tab DO NOT CRUSH change to mycophenolate mofetil suspension (720mg mycophenolic acid = 1g mycophenolate mofetil) N 100mg caps open caps and disperse contents in water if patient has a feeding tube. If patient has swallowing difficulties please contact Medicines Information for further information (see NEWT guidelines). Change to alternative NSAID (e.g. diclofenac, ibuprofen). 5mg tabs crush and mix with water. 20mg, 30mg cap open caps and disperse contents in water. 30mg, 45mg MR cap DO NOT OPEN, change to plain caps, daily dose will need to be in 3 divided doses. 10mg, 20mg tab disperse in water. Some excipients are insoluble so flush feeding tubes well. Adalat LA tab, Adalat Retard, Adipine MR (many others available see BNF) DO NOT CRUSH. 5mg, 10mg liquid filled caps opening is not advised as when administered may cause a profound drop in blood pressure. Amlodipine may be a suitable alternative. 30mg tab At patient s bedside, crush tab to fine powder (may be very hard use pestle and mortar if possible), mix with water and flush immediately (will degrade once crushed and is light sensitive). 2.5mg/5ml suspension. 25mg/5ml suspension. 5mg tab crush in water to limit exposure to powder. 16

17 Norfloxacin Ofloxacin Olanzapine Olmesartan Olsalazine Omeprazole Ondansetron Orlistat Orphenadrine Oxcarbazepine Oxprenolol Oxybutynin Oxycodone Pantoprazole Paracetamol Paroxetine 400mg tab crush and mix with water, not very soluble, light sensitive and unpleasant taste. Use immediately. Consider changing to ciprofloxacin. O 200mg, 400mg tab crush and mix with water. 5mg, 10mg, 15mg Velotabs place on tongue and allow to dissolve OR disperse in water, orange juice, apple juice, milk or coffee. 2.5mg tab can be crushed if dose can t be made with Velotabs. 10mg, 20mg, 40mg tabs change to alternative as drug very insoluble in water and has a bitter taste. 250mg cap open and disperse contents in water. 500mg tab crush and disperse in water. 10mg, 20mg, 40mg MUPS tabs disperse in water. Suitable for patients with swallowing difficulties, but for patients with feeding tubes change to lansoprazole FasTabs. 10mg, 20mg, 40mg EC tabs change to lansoprazole FasTab. 10mg, 20mg, 40mg caps containing EC pellets change to lansoprazole FasTab. 4mg, 8mg Melt tab place on tongue to disperse. 4mg/5ml syrup. 120mg cap open cap and disperse contents in water. 25mg/5ml elixir. 50mg/5ml oral solution. 300mg/5ml suspension. 20mg, 40mg, 80mg, 160mg tab crush and mix with water. 160mg MR tab DO NOT CRUSH. Change to 80mg plain tabs bd. 2.5mg/5ml elixir. 5mg, 10mg XL tab DO NOT CRUSH. Daily dose will need to be in 2-3 divided doses if changing to elixir. Patch also available. OxyNorm 5mg/5ml liquid, 10mg/ml concentrate. OxyNorm 5mg, 10mg, 20mg cap use liquid. OxyContin MR tab DO NOT CRUSH. Change to OxyNorm liquid. Total daily dose should be in 4-6 divided doses. P 20mg, 40mg EC tab DO NOT CRUSH. Change to lansoprazole FasTab (dose amendment needed). 500mg soluble tabs. 120mg/5ml and 250mg/5ml suspension. Suppositories also available. 10mg/5ml liquid dilute with equal volume of water if going down a feeding tube as quite viscous. 20mg, 30mg tabs when liquid not available can be crushed and mixed with food/drink. 17

18 Penicillin V Pentoxifylline Pergolide Pericyazine Perindopril Phenelzine Phenobarbital Phenytoin Phytomenadione Pimozide Pioglitazone Piracetam Piroxicam Pizotifen Potassium Pramipexole Pravastatin Prazosin 125mg/5ml, 250mg/5ml suspension. Should be given on an empty stomach; consider using amoxicillin for patients on continuous enteral feeds. 400mg MR tab these can be crushed despite MR coating as this is only to provide protection from dyspepsia. DO NOT CRUSH if patient is at risk of dyspepsia. 50mcg, 250mcg, 1mg tab will slowly disperse in water. 10mg/5ml syrup. 2.5mg, 10mg tab crush and disperse in water. 2mg, 4mg, 8mg tab crush and mix with water (OR tab will disperse in 5 mins). Tabs crush and mix with water, give immediately. 15mg/5ml elixir contains 38% alcohol 30mg/5ml suspension mix with equal volume of water before flushing down feeding tubes. 90mg/5ml suspension available where large volumes of 30mg/5ml would be required. 100mg cap/tab is equivalent to 90mg suspension. Enteral feeds will reduce absorption of phenytoin hence they must be stopped for 2 hours either side of giving phenytoin (i.e. give the phenytoin in the middle of a four hour break). 10mg tab can chew or allow to dissolve slowly in mouth. OR use Konakion MM injection (10mg/ml or 2mg/0.2ml) orally or via feeding tube and flush well (due to small volume involved). 4mg tab crush and mix with water. 15mg, 30mg, 45mg tab crush and mix with water mg/ml solution follow with a glass of water/soft drink to reduce bitter taste. 10mg, 20mg dispersible tabs disperse in water. 250mcg/5ml elixir. Sando K effervescent tabs (12mmol K per tab) disperse in water. Slow K 600mg tab (8mmol K per tab) DO NOT CRUSH must be swallowed whole with fluid whilst patient is upright. Change to Sando K or liquid. Kay-Cee-L liquid (1mmol K per ml) dilute with water before administration via feeding tubes. 88mcg, 180mcg, 700mcg tab crush and mix with water. 10mg, 20mg, 40mg tab crush and mix with water. 0.5mg, 1mg, 2mg, 5mg tab disperse or crush and mix with water. Lots of sludge flush well. Alfuzosin may be a better option for patients being treated for prostatic hyperplasia. Prednisolone 5mg soluble tabs (Predsol) Pregabalin 25mg, 50mg, 75mg, 100mg, 150mg, 200mg, 300mg caps open capsule and disperse contents (fairly soluble). May taste unpleasant. Primidone 250mg tab disperse in water. 18

19 Procarbazine Prochlorperazine Procyclidine Proguanil Promazine Propantheline Propranolol Propylthiouracil Pseudoephedrine Pyrazinamide Pyridostigmine Pyridoxine Quetiapine Quinine Sulphate Rabeprazole Raloxifene Ramipril Ranitidine Rasagiline Reboxetine Repaglinide Rifampicin Riluzole 50mg caps CYTOTOXIC if absolutely essential to use this drug can mix capsule contents with any liquid and give immediately. Nurse should wear apron, mask and gloves. 5mg/5ml syrup. 5mg, 25mg suppositories and 3mg buccal tabs available seek further advice about doses. 2.5mg/5ml, 5mg/5ml syrup. 100mg tab crush and mix with water, milk or jam 25mg/5ml, 50mg/5ml oral solution. 15mg tab crush and mix with water, may taste bitter. 5mg/5ml, 10mg/5ml, 50mg/5ml oral solution. 80mg, 160mg MR cap DO NOT CRUSH. Daily dose will need to be in 2 divided doses if changing to syrup. 50mg tab crush and mix with water. 30mg/5ml elixir. 500mg tab crush and mix with water, take within 20 minutes, do not flavour with anything that may alter ph (e.g. acidic juice). 60mg tab crush and mix with water. 10mg cap not suitable to open. 50mg tab can be crushed (could make suspension with Keltrol for patients on 10mg od). Q 25mg, 100mg, 150mg, 200mg, 300mg tab moderately soluble in water crush well and disperse in water for feeding tube administration. For patients with swallowing difficulties, it is possible to crush the tablets, mix with yoghurt and administer immediately. 200mg, 300mg tab crush well and mix with large volume of water (200ml). Consider need for treatment. R 10mg, 20mg EC tab DO NOT CRUSH. Change to lansoprazole FasTab (dose amendment needed, found in Pharmacist Substitution Policy). 60mg tab DO NOT CRUSH (not very well absorbed). 1.25mg, 2.5mg, 5mg, 10mg cap open caps and disperse contents in water (may taste unpleasant). 1.25mg, 2.5mg, 5mg, 10mg tab crush and mix with water. 150mg/10ml syrup. 150mg, 300mg effervescent tabs. 1mg tabs crush and mix with water. 4mg tab crush and mix with water. 0.5mg, 1mg, 2mg crush and mix with water. 100mg/5ml syrup dilute with equal volume of water for administration via feeding tubes. 50mg tab crush and mix with soft food or puree. If dispersing in water, it sediments quickly flush well. May have a local anaesthetic effect in the mouth. 19

20 Risedronate Risperidone Ritonavir Rivastigmine Ropinirole Rosiglitazone Rosuvastatin Salbutamol Saquinavir (Fortovase) Selegeline Senna Sertraline Simvastatin Sinemet (Co-careldopa) Sodium bicarbonate 5mg, 30mg, 35mg tab DO NOT CRUSH. Crushed fragments could get stuck in the oesophagus. Patients with feeding tubes may get reflux into oesophagus. Oesophageal reactions have been reported with this drug. Change to Didronel PMO. 1mg/ml liquid may be diluted with water, orange juice or black coffee. 0.5mg, 1mg, 2mg orodispersible tab (Quicklet ) place on tongue and allow to dissolve. 400mg/5ml oral solution. Contains 43% alcohol! Do not mix with water; chocolate milk may mask bitter taste. 2mg/ml solution. 1.5mg, 3mg, 4.5mg, 6mg caps open caps and disperse contents in water/drink if solution not available. 0.25mg, 0.5mg, 1mg, 2mg, 5mg tab crush and mix with water. 4mg, 8mg tab crush and mix with water. 10mg, 20mg, 40mg tabs dissolve in 5-10ml water give immediately as light sensitive, film coat may not dissolve well. S 2mg/5ml oral solution. 4mg, 8mg MR tab (Volmax) DO NOT CRUSH, change to liquid, daily dose needs to be in 3-4 divided doses. Consider nebulising drug instead. 200mg gel-filled cap open and disperse contents in water. Drug has a bitter taste. 10mg/5ml liquid. 5mg, 10mg tab use liquid. 1.25mg freeze-dried tab (Zelapar ) dissolve on tongue (NOTE this is equivalent to the 10mg conventional tablet). 7.5mg/5ml syrup (= 1 tablet). 50mg, 100mg tab crush and mix with water. May taste bitter and have an anaesthetic effect in the mouth. If likely to be a long term problem, consider changing to fluoxetine/paroxetine syrup. Seek further advice. 10mg, 20mg, 40mg, 80mg tab crush and mix with water. 62.5mg, 110mg, 125mg, 275mg tab crush and mix with water (OR tab will disperse in 5 mins). Sinemet CR, Half Sinemet CR change to same dose in conventional tablets, but give divided into 3-4 doses. Consider changing to Madopar dispersible. Seek further advice from Medicines Information (see NEWT guidelines). 500mg caps open capsule and mix contents with soft food but will not disperse in water. 8.4% polyfusor infusion can be used orally (contains 1mmol/ml) 7 day expiry at room temp once decanted. 1g sodium bicarbonate = 12mmol. 20

21 Sodium clodronate Sodium fusidate Sodium Valproate Sotalol Spironolactone Stalevo (levodopa, carbidopa, entacapone) Strontium ranelate Sucralfate Sulfasalazine Sulfinpyrazone Sulpiride Tacrolimus Tamoxifen Tamsulosin Telmisartan Temazepam Temozolomide 400mg cap open cap and disperse contents in water. 800mg tab (Bonefos ) change to 400mg caps. 520mg tab (Loron ) change to 2x400mg caps (dose change needed) Stop enteral feeds for 2 hours before and after administration. 250mg/5ml suspension. NOTE 500mg tab is equivalent to 750mg suspension. Dose change required. 200mg/5ml liquid. 100mg crushable tab. 200mg, 500mg EC tab DO NOT CRUSH. Change to liquid. 200mg, 300mg, 500mg CHRONO tab DO NOT CRUSH. If changing to liquid, probably advisable to give daily dose in 3-4 divided doses. 40mg, 80mg, 160mg tab disperse in small amount of water. 5mg/5ml, 10mg/5ml, 25mg/5ml, 50mg/5ml, 100mg/5ml suspension. Tabs crush and mix with water, entacapone is orange and may stain clothing and NG tube. Doesn t dissolve fully in water so flush tube well. 2g sachet dissolve contents of sachet in water mix well and give immediately ensure all dregs are taken. Stop enteral feeds for 2 hours before and after administration. 1g/5ml suspension dilute well with water before administration via feeding tubes as it is a common cause of blockage. Stop enteral feeds for 1 hour before and after administration. 250mg/5ml suspension. 500mg EC tab DO NOT CRUSH. Suppositories and enemas are also available but may not be appropriate depending on indication and location of disease seek advice from patient s doctor. 100mg, 200mg tabs crush and disperse in water. 200mg/5ml oral solution. T 0.5mg, 1mg, 5mg cap capsule contents can be suspended in water and given via feeding tubes. It is recommended that apron, mask and gloves be worn to limit exposure to powder. 10mg/5ml oral solution. 400mcg MR cap/tab DO NOT OPEN/CRUSH. Alternative prescription required, recommend alfuzosin. Seek further advice. 20mg, 40mg, 80mg tab crush and disperse in water. 10mg/5ml oral solution. 5mg, 20mg, 100mg, 250mg caps CYTOTOXIC if absolutely essential to use this drug can mix capsule contents with 30ml apple juice and give immediately. Nurse should wear apron, mask and gloves. 21

22 Tenofovir Terazosin Terbinafine Tetrabenazine Thalidomide Theophylline Thiamine Thyroxine Tiagabine Tibolone Tinidazole Tizanidine Tolbutamide Tolterodine Topiramate Tramadol Tranexamic acid Trazodone 245mg tab can disperse in half a glass of water, grape juice or orange juice. 1mg, 2mg, 5mg, 10mg tab crush and mix with water. Excipients may not fully dissolve so care needed with feeding tubes. 250mg tab crush and mix with water. 25mg tab crush and mix with water, may be starchy, hence potential to block tubes. Manufacturer recommends very strongly that capsules are not opened under any circumstances. Contact Medicines Information for further information. Slo-Phyllin MR 60mg, 125mg, 250mg cap may be opened and contents sprinkled onto soft food (e.g. yoghurt), do not crush pellets. Contents may be able to be flushed down feeding tubes, however may block fine bore tubes. Nuelin SA 175mg, 250mg tab DO NOT CRUSH, change to nearest dose of Slo-Phyllin capsules. Monitor response to treatment and check levels after 3 days. Uniphyllin MR 200mg, 300mg, 400mg tab DO NOT CRUSH, change to nearest dose of Slo-Phyllin capsules. Monitor response to treatment and check levels after 3 days. Enteral feeds may reduce absorption of theophylline check serum levels 3 days after starting, stopping or changing enteral feed. 50mg, 100mg tab crush and mix with water. See Levothyroxine 5mg, 10mg, 15mg tab crush and mix with water. Tabs crush and mix with water 500mg tab disperse in water, very bitter taste, mix with strongly flavoured juice. 2mg, 4mg tab crush and mix with water. 500mg tab crush and mix with water. 1mg, 2mg tab crush and mix with water (may be hard to crush) 4mg XL cap can open caps and mix pellets with soft food for patients with swallowing difficulties or with water to flush down wide bore feeding tubes OR change to 2mg BD plain tab. 25mg, 50mg, 100mg, 200mg tab crush and mix with water for administration via feeding tubes. For patients with swallowing difficulties, use 15mg, 25mg, 50mg sprinkle caps open capsule and sprinkle capsule contents onto soft food. 50mg soluble tab. MR tabs/caps change to soluble tabs mg QDS. 500mg tab crush and mix with water. 500mg/5ml injection can be used orally, may need flavouring. 5% mouthwash (unlicensed preparation) can be swallowed but needs blackcurrant flavouring. 50mg/5ml liquid. 22

23 Tretinoin Trifluoperazine Trihexyphenidyl Trimethoprim Trimipramine Trospium Ursodeoxycholic acid Valsartan Vancomycin Venlafaxine Verapamil Vigabatrin Vitamin B compound strong Vitamin E Vitamin K Voriconazole Warfarin Zidovudine Caps contents not soluble in water, mix with food/yoghurt/ icecream. Can block feeding tubes. NB Women who are or may become pregnant should not handle capsule contents. 1mg/5ml syrup. 5mg/5ml oral solution. Spansules (MR caps) change to syrup/oral solution, daily dose may need to be in divided doses. 5mg/5ml syrup. 50mg/5ml suspension. 10mg, 25mg tab crush and mix with water. 50mg cap Open caps and disperse contents in water. The drug has a local anaesthetic action so care is needed in patients with swallowing difficulties. 20mg tab crush and mix with water, may taste bitter. U 250mg/5ml suspension. V 40mg, 80mg, 160mg cap Open caps and disperse contents in water, powder not very soluble flush well (will taste bitter). 500mg injection reconstitute as directed and use orally. Vial can be kept in fridge for subsequent doses for up to 24 hours. 37.5mg, 75mg tab crush and mix with water. 75mg, 150mg XL cap can be opened and contents mixed with soft food (DO NOT CRUSH CONTENTS). For patients with feeding tubes, change to plain tabs, daily dose will need to be in 2 divided doses. 40mg/5ml oral solution. MR tabs and caps (e.g. Securon, Univer) change to liquid, using a mg for mg conversion, the daily dose will then need to be given in 2-3 divided doses. 500mg sachets dissolve in water or a soft drink. Tab crush tab very well and disperse in water for feeding tube administration (tablet coating may block tube if not well crushed); mix with jam to disguise bitter taste for oral use. Vigranon B syrup also available (5ml = 1 tablet) 500mg/5ml suspension. See phytomenadione or menadiol. 50mg, 200mg tab crush and disperse in water. 200mg/5ml oral suspension available. W 1mg, 3mg, 5mg tab crush and mix with water (OR tabs will disperse in 5 mins) Enteral feeds with high vitamin K content may antagonise the effect of warfarin closely monitor INR, especially when feeds are started, stopped or changed. Z 50mg/5ml oral solution. 23

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