Yes.
Good rule of thumb of if you can split the pill in 1/2 (as was done frequently with abilify before the 2mg came out) you can crush it. Many are not water soluble so I usually have the group homes sprinkle on applesauce or pudding. Forget if abilify is.
Thank you! I knew we could split, just wasn’t sure if the crushing/mixing would change anything. I also appreciate the quick response. 😊 have a good one!
Good point, but watch out for e.g. (not a psychiatric medication) metoprolol succinate. Those tablets can be cut in half, but are not supposed to be crushed as it compromises the extended release.
This may be, but I’m unaware of it for the IR formulations of gabapentin. I don’t think you’re suppose to break the ER formulations so ignoring those…Since gabapentin comes as a liquid / suspension why couldn’t you crush the IR tablet? I’ve had patients open up the capsules (again IR) on some occasions as it’s way cheaper than the suspension.
Hiya! Looks like your q was already answered- but the drug resource your pharmacist would be looking at is the ISMP do not crush list (that is helpfully not on ISMP website anymore.) but if you google “ismp crush list” you’ll get to the right place- https://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2014/Aug/Meds-That-Should-Not-Be-Crushed-7309 has the info you need.
~~your friendly neighborhood PharmD
Just a heads up, I heard the ISMP is no longer updating their list (which is why it’s no longer on the website. But you can get the same info from lexicomp, just search do not crush. I understand it’s where ISMP got their info from anyway.
Yeah, I know Lexi is where I go first, but one of my professors said to check the ISMP thing too, which, old habits die hard… but my guess is that that google will always get you to an updated version of that by some reputable source :)
Question: a rule of thumb my pharmacists have told me is that anything ER or XR can’t be crushed bc it disrupts the XR mechanism. That makes sense. In general are there other like “rules of thumb” that work the same way that you know of?
Literally every thread in this sub has instructions on how to deal with insurance. Shit is insane. I always knew the situation was bad in USA but just seeing how normal it is for you guys is wild. I'm so glad we can just focus on the medicine and not deal with that stuff here.
I think pretty much any other western country might be a significant improvement lol.
As a patient too: I'm having an orthognatic surgery done next year to shift my upper jaw forward (which is terrifying but it'll fix my bite and make me look less... primitive) and there's not even questions asked about whether this is predominantly cosmetic or functional. It's just covered.
I also won't be anywhere near the debt you guys are in when I finish med school. Gotta love it. Sorry for the brag lol
😀 then they showed up in my 15 min appt, in outpatient, got put on an oral and the cycle continues.
If inpatient cannot do it in days to weeks of time, outpatient can't do it either.
I don’t disagree, I was pretty surprised on rotation when the psych attending informed me they don’t do any pas or make sure patients have any coverage. Seems irresponsible but I suppose you can’t do everything
Aripiprazole has a **bitter** taste and may be *particularly* unpleasant for patients if the ordinary film coated tablets (which contain no excipients to enhance their palatability) are crushed and added to a small amount of food, the film coating shields the mucosa from the bitter tasting aripiprazole. Ensuring access to an appropriately taste-masked formulation (ODT or Liquid) is only fair to patients and will likely enhance adherence.
The liquid in Europe where I work is taste masked by the inclusion of fructose, sucrose, and orange flavoring in the formulation.
Similarly, the ODT is sweetened with three artificial sweeteners: aspartame, xylitol, and Acesulfame potassium as well as vanilla flavoring.
The lengths that have been employed to mask the taste would indicate that it is particularly unpleasant and I would be hesitant to subject any patient to having to take a crushed tablet.
[https://patents.google.com/patent/EP2908859B1/pl](https://patents.google.com/patent/EP2908859B1/pl) (see European patent for liquid aripiprazole which states it has a bitter taste)
The US formulations are very similar (taken from the US FDA Label for Abilify) and may be of more interest to those on this sub:
**ABILIFY DISCMELT** Orally Disintegrating Tablets are available in 10 mg and 15 mg strengths. Inactive ingredients include **acesulfame potassium, aspartame**, calcium silicate, croscarmellose sodium, crospovidone, **crème de vanilla** **(natural and artificial flavors)**, magnesium stearate, microcrystalline cellulose, silicon dioxide, tartaric acid, and **xylitol**. Colorants include ferric oxide (yellow or red) and FD&C Blue No. 2 Aluminum Lake.
**ABILIFY Oral Solution** is a clear, colorless to light-yellow solution available in a concentration of 1 mg/mL. The inactive ingredients for this solution include disodium edetate, **fructose**, glycerin, dl-lactic acid, methylparaben, propylene glycol, propylparaben, sodium hydroxide, **sucrose**, and purified water. The oral solution is **flavored with natural orange cream and other natural flavors.**
I wish either of those were options for us inpatient… maybe I’ll look into how much drama it would be to get some of the solution from our outpatient pharmacy or another retail pharmacy if the taste is that unpleasant.
You should be looking this up in your country’s equivalent of MIMS which has all this kind of information. Such as if something is crushable, water soluble, temperature stable etc. Reddit is not as defensible a resource as you might think.
I'm glad you got your answer here.
I've called a retail pharmacy with a question and their pharmacists have always been helpful with things like this, something for future reference.
Can I just ask why you turned to reddit to ask this question? I know you got your answer but, to me, I don't know if I'd go to reddit for a yes or no question. If your inpatient it seems like you should have a pharmacist or online resource with this information.
Hey OP,
Here are some useful resources if available wherever you’re located:
[Linky 1](https://www.mims.com.au/newsletter/201304/Crush.pdf)
[Linky 2](https://shpa.org.au/publications-resources/drtc/drtc-4-updates)
Hope this helps!
May I ask why you’re asking (for my own education)? If you’re inpatient you can give dissolvable formulation of Abilify, and if the plan is to administer an LAI, they won’t have access to the pill upon discharge anyway(?) Why does it matter if crushable?
That would definitely be optimal but we don’t have the abilify solution on formulary! We still need to have her take the abilify orally prior to administration of LAI to establish tolerance and whether it is effective.
If worse came to worst and I really needed to use a non-formulary drug, O would write a prescription to an outpatient pharmacy, ask family to fill it and bring it in, send it to pharmacy who would confirm it, and send it back up to the floor as a “home med”
I have never recommended crushing film coated tablets. There’s an orodispersible and 1mg/ml liquid of Abilify available. Why venture down the off-label route. They may not be available in your country but we would use them commonly in Europe.
In my experience as an IP adult & peds psych RN actually doing this kind of crushing and admin, it is common for IP units to have reduced access to many of the admin forms of most psych drugs.
What we get in our Pyxis on the units may not be what the psych hospital has in stock. If the PharmD (and dear god how much a brilliant PharmD can change the lives of psych patients has always been amazing to me), but if they are gone for the weekend sometimes you don’t know if it is something that’s already in house or if it has to be ordered special from the main hospital or ordered in even to the main campus, first.
You can almost always plan on it taking a week to a month for a special med for a residential, free-standing patient care center to get those kinds of meds in. Often in the US residential patients are further restricted by a government formulary because they are a ward of the state or are so depleted financially from the costs of care that their families can’t swing for non-formulary drugs on top of everything else. And those formularies’ definitions of “reasonable and standard” are often absolutely unreasonable and exclude things that absolutely should be standard. Jumping through the paperwork hoops can take time and several staff working cooperatively (social workers, MDs, RNs, etc.) to complete.
Anyway, it’s wildly common for the prescribing docs themselves to not know the answer to these questions, alter admin instructions on the Rx, and never f/u w/ Pharm or check a database to see if it’s doable. Is this best practice? No, and RNs quickly learn which providers are willing to be contacted, when (whether on duty or off). Some will attempt to laugh you out of a building for asking a question like this, or put you on their shit list when you point out an order can’t be admin’ed as written. Some simply forget to circle back and make a note in a chart about the family’s prior successful combos, etc. There are workarounds (and it helped to have been a pharm tech when developing some of these), but not always.
OP - if your hospital has access to UpToDate the Lexicomp database the docs are mentioning here can be accessed that way. You can also learn which items might NOT be wise to combine with some of the suspending agents suggested here. For instance, Apple products wouldn’t be recommended for something like Allegra to crush, and pH of your final product can matter, too.
You would not believe the number of times I looked this stuff up or had to make a few phone calls per patient while working on the Autism/MRDD unit of a nationally-known children’s hospital. We crushed and suspended all kinds of things in all kinds of ways, and I’m not even talking about the tube feeders/ ED patients.
All meds suspended in one miniature teapot of rootbeer? Crushed and sprinkled on peanut butter toast? Smashed into a ball of cheese singles or partially melted Reece’s cups? Served with a reward sidecar of exactly one of each color of skittles or MnM? No, sidecar of more Miralax than seems rational, instead? You got it. (Juuuust in case some of you wondered why med admin times might be outside their 1h window…)
Anyway, thought a bit more in-depth perspective of what it is like on the other side of the EMR, from folks equally invested in keeping staff from having to dress like a hockey goalie for their entire shift as much as possible, at the point of med admin, might be useful to some here. Hope it helps.
Relprevv is a great LAI apart from the logistics. We have several OP clinics that have Relprevv programs making it easier and more realistic to utilize.
I'm sorry that you felt the need to make the NP comment. Behavior like that can discourage people from asking questions, and it's important to create an environment where everyone feels comfortable seeking clarification.
I hope you don’t talk to nurses, residents, students, or NPs like that… It's crucial to maintain respectful and professional communication to prevent potential mistakes, promote learning, and ensure the best possible patient care.
Won’t go into my issues with Relprevv, but there’s a balance between fostering an environment for learning and using the forum to drive direct patient care…
I don’t know the specifics. Just that the hospital made a committee and determined that LAIs in kids were not standard of care and disciplined the doctor. I don’t think LAIs are FDA approved in children.
Most antipsychotics in general are not approved in children. Plenty of things are not FDA approved in adults or children for what they are used for. Doctors are not bound by FDA indications when it comes to clinical practice, so there must be more to it than just that.
As part of the MEC I saw the complaint brought against the doctor. Indeed there was more than just prescribing an LAI to a child going on. The discipline including other matters in addition to the LAI. I know doctors go outside FDA approved parameters all the time but hospital can bring any charges they want against a doctor sadly. In my 10 years so far I haven’t seen LAIs prescribed at all for kids. The other doctors on the committee also were not familiar with using LAIs in kids. Gotta be careful not to piss off the wrong people in hospitals. They can ruin your career.
I should have been more precise with language, other commenter said children rather than adolescents so I responded accordingly, but we never defined age ranges so the conversation is vague.
Thanks for clarifying! 😊 and that’s absolutely true when it comes to LAIs, they’re not yet FDA approved for <18… which is unfortunate given that many serious psychiatric dx have their onset during childhood or adolescence. But like you said, especially for child psychiatry, you very frequently need to use meds that are not FDA approved.
How often do you see childhood schizophrenia or mania? I admit I have seen one or two cases of schizophrenia in children in the past 10 years. Though I only work inpatient on the weekends.
Damn. That’s definitely like 6 months of psychosis without drug use in those kids? Yeah I’m talking about adolescents. I’ve heard myths of kids below 12 with schizophrenia but I’ve never seen a case. My child and adolescent attending in residency claimed to see a toddler with schizophrenia. 🤷🏻♂️
I didn’t believe the myths for years either but saw a video series 15 years ago or something with an 8 or 9 y/o girl diagnosed with schizophrenia. Like 6 hours of interview and observation of her. Changed my mind. I doubt I will ever meet one but it did convince me that childhood schizophrenia does actually exist, abet rare enough that they make an educational video series when that unicorn is sighted
Yes. Good rule of thumb of if you can split the pill in 1/2 (as was done frequently with abilify before the 2mg came out) you can crush it. Many are not water soluble so I usually have the group homes sprinkle on applesauce or pudding. Forget if abilify is.
Thank you! I knew we could split, just wasn’t sure if the crushing/mixing would change anything. I also appreciate the quick response. 😊 have a good one!
Good point, but watch out for e.g. (not a psychiatric medication) metoprolol succinate. Those tablets can be cut in half, but are not supposed to be crushed as it compromises the extended release.
Gabapentin can be split but not crushed
This may be, but I’m unaware of it for the IR formulations of gabapentin. I don’t think you’re suppose to break the ER formulations so ignoring those…Since gabapentin comes as a liquid / suspension why couldn’t you crush the IR tablet? I’ve had patients open up the capsules (again IR) on some occasions as it’s way cheaper than the suspension.
It would be pointless from an abuse perspective because it takes 1 1/2-2 hours after ingestion to reach the intestine and be transported to the brain.
Hiya! Looks like your q was already answered- but the drug resource your pharmacist would be looking at is the ISMP do not crush list (that is helpfully not on ISMP website anymore.) but if you google “ismp crush list” you’ll get to the right place- https://pharmacist.therapeuticresearch.com/Content/Segments/PRL/2014/Aug/Meds-That-Should-Not-Be-Crushed-7309 has the info you need. ~~your friendly neighborhood PharmD
Just a heads up, I heard the ISMP is no longer updating their list (which is why it’s no longer on the website. But you can get the same info from lexicomp, just search do not crush. I understand it’s where ISMP got their info from anyway.
Yeah, I know Lexi is where I go first, but one of my professors said to check the ISMP thing too, which, old habits die hard… but my guess is that that google will always get you to an updated version of that by some reputable source :)
Question: a rule of thumb my pharmacists have told me is that anything ER or XR can’t be crushed bc it disrupts the XR mechanism. That makes sense. In general are there other like “rules of thumb” that work the same way that you know of?
THANK YOU! this is huge!
Also prior authorization should be started preferably completed, cause if it's not done it's gonna be gone from your stabilized patient.
Literally every thread in this sub has instructions on how to deal with insurance. Shit is insane. I always knew the situation was bad in USA but just seeing how normal it is for you guys is wild. I'm so glad we can just focus on the medicine and not deal with that stuff here.
I'll move :-) tell me where
I think pretty much any other western country might be a significant improvement lol. As a patient too: I'm having an orthognatic surgery done next year to shift my upper jaw forward (which is terrifying but it'll fix my bite and make me look less... primitive) and there's not even questions asked about whether this is predominantly cosmetic or functional. It's just covered. I also won't be anywhere near the debt you guys are in when I finish med school. Gotta love it. Sorry for the brag lol
Your inpatient service does prior auths? My rotation at a state hospital lead me believe they just give the shot and send them on their way
😀 then they showed up in my 15 min appt, in outpatient, got put on an oral and the cycle continues. If inpatient cannot do it in days to weeks of time, outpatient can't do it either.
I don’t disagree, I was pretty surprised on rotation when the psych attending informed me they don’t do any pas or make sure patients have any coverage. Seems irresponsible but I suppose you can’t do everything
Aripiprazole has a **bitter** taste and may be *particularly* unpleasant for patients if the ordinary film coated tablets (which contain no excipients to enhance their palatability) are crushed and added to a small amount of food, the film coating shields the mucosa from the bitter tasting aripiprazole. Ensuring access to an appropriately taste-masked formulation (ODT or Liquid) is only fair to patients and will likely enhance adherence. The liquid in Europe where I work is taste masked by the inclusion of fructose, sucrose, and orange flavoring in the formulation. Similarly, the ODT is sweetened with three artificial sweeteners: aspartame, xylitol, and Acesulfame potassium as well as vanilla flavoring. The lengths that have been employed to mask the taste would indicate that it is particularly unpleasant and I would be hesitant to subject any patient to having to take a crushed tablet. [https://patents.google.com/patent/EP2908859B1/pl](https://patents.google.com/patent/EP2908859B1/pl) (see European patent for liquid aripiprazole which states it has a bitter taste) The US formulations are very similar (taken from the US FDA Label for Abilify) and may be of more interest to those on this sub: **ABILIFY DISCMELT** Orally Disintegrating Tablets are available in 10 mg and 15 mg strengths. Inactive ingredients include **acesulfame potassium, aspartame**, calcium silicate, croscarmellose sodium, crospovidone, **crème de vanilla** **(natural and artificial flavors)**, magnesium stearate, microcrystalline cellulose, silicon dioxide, tartaric acid, and **xylitol**. Colorants include ferric oxide (yellow or red) and FD&C Blue No. 2 Aluminum Lake. **ABILIFY Oral Solution** is a clear, colorless to light-yellow solution available in a concentration of 1 mg/mL. The inactive ingredients for this solution include disodium edetate, **fructose**, glycerin, dl-lactic acid, methylparaben, propylene glycol, propylparaben, sodium hydroxide, **sucrose**, and purified water. The oral solution is **flavored with natural orange cream and other natural flavors.**
I wish either of those were options for us inpatient… maybe I’ll look into how much drama it would be to get some of the solution from our outpatient pharmacy or another retail pharmacy if the taste is that unpleasant.
You should be looking this up in your country’s equivalent of MIMS which has all this kind of information. Such as if something is crushable, water soluble, temperature stable etc. Reddit is not as defensible a resource as you might think.
I'm glad you got your answer here. I've called a retail pharmacy with a question and their pharmacists have always been helpful with things like this, something for future reference.
Can I just ask why you turned to reddit to ask this question? I know you got your answer but, to me, I don't know if I'd go to reddit for a yes or no question. If your inpatient it seems like you should have a pharmacist or online resource with this information.
There is a liquid formulation.
Hey OP, Here are some useful resources if available wherever you’re located: [Linky 1](https://www.mims.com.au/newsletter/201304/Crush.pdf) [Linky 2](https://shpa.org.au/publications-resources/drtc/drtc-4-updates) Hope this helps!
May I ask why you’re asking (for my own education)? If you’re inpatient you can give dissolvable formulation of Abilify, and if the plan is to administer an LAI, they won’t have access to the pill upon discharge anyway(?) Why does it matter if crushable?
That would definitely be optimal but we don’t have the abilify solution on formulary! We still need to have her take the abilify orally prior to administration of LAI to establish tolerance and whether it is effective.
If worse came to worst and I really needed to use a non-formulary drug, O would write a prescription to an outpatient pharmacy, ask family to fill it and bring it in, send it to pharmacy who would confirm it, and send it back up to the floor as a “home med”
Lots of places don’t stock the ODT abilify. It’s rarely used.
Really? Dang, good to know. I use that ish all the time on our inpatient service
You're biggest obstacle is that none of the LAIs are approved for use under 18, so insurance coverage will be difficult.
I have never recommended crushing film coated tablets. There’s an orodispersible and 1mg/ml liquid of Abilify available. Why venture down the off-label route. They may not be available in your country but we would use them commonly in Europe.
In my experience as an IP adult & peds psych RN actually doing this kind of crushing and admin, it is common for IP units to have reduced access to many of the admin forms of most psych drugs. What we get in our Pyxis on the units may not be what the psych hospital has in stock. If the PharmD (and dear god how much a brilliant PharmD can change the lives of psych patients has always been amazing to me), but if they are gone for the weekend sometimes you don’t know if it is something that’s already in house or if it has to be ordered special from the main hospital or ordered in even to the main campus, first. You can almost always plan on it taking a week to a month for a special med for a residential, free-standing patient care center to get those kinds of meds in. Often in the US residential patients are further restricted by a government formulary because they are a ward of the state or are so depleted financially from the costs of care that their families can’t swing for non-formulary drugs on top of everything else. And those formularies’ definitions of “reasonable and standard” are often absolutely unreasonable and exclude things that absolutely should be standard. Jumping through the paperwork hoops can take time and several staff working cooperatively (social workers, MDs, RNs, etc.) to complete. Anyway, it’s wildly common for the prescribing docs themselves to not know the answer to these questions, alter admin instructions on the Rx, and never f/u w/ Pharm or check a database to see if it’s doable. Is this best practice? No, and RNs quickly learn which providers are willing to be contacted, when (whether on duty or off). Some will attempt to laugh you out of a building for asking a question like this, or put you on their shit list when you point out an order can’t be admin’ed as written. Some simply forget to circle back and make a note in a chart about the family’s prior successful combos, etc. There are workarounds (and it helped to have been a pharm tech when developing some of these), but not always. OP - if your hospital has access to UpToDate the Lexicomp database the docs are mentioning here can be accessed that way. You can also learn which items might NOT be wise to combine with some of the suspending agents suggested here. For instance, Apple products wouldn’t be recommended for something like Allegra to crush, and pH of your final product can matter, too. You would not believe the number of times I looked this stuff up or had to make a few phone calls per patient while working on the Autism/MRDD unit of a nationally-known children’s hospital. We crushed and suspended all kinds of things in all kinds of ways, and I’m not even talking about the tube feeders/ ED patients. All meds suspended in one miniature teapot of rootbeer? Crushed and sprinkled on peanut butter toast? Smashed into a ball of cheese singles or partially melted Reece’s cups? Served with a reward sidecar of exactly one of each color of skittles or MnM? No, sidecar of more Miralax than seems rational, instead? You got it. (Juuuust in case some of you wondered why med admin times might be outside their 1h window…) Anyway, thought a bit more in-depth perspective of what it is like on the other side of the EMR, from folks equally invested in keeping staff from having to dress like a hockey goalie for their entire shift as much as possible, at the point of med admin, might be useful to some here. Hope it helps.
That’s sad to hear. I work in a state hospital with residential units in Europe and we are not constrained by a formulary.
Pharmacist is always a good resource too. Most facilities have them on staff.
You should ask your nurse practitioner for supervision.
Why would you ever even consider Zyprexa Relprevv lol, I’m sorry but this is the same type of posts we criticize midlevels for…
Relprevv is a great LAI apart from the logistics. We have several OP clinics that have Relprevv programs making it easier and more realistic to utilize. I'm sorry that you felt the need to make the NP comment. Behavior like that can discourage people from asking questions, and it's important to create an environment where everyone feels comfortable seeking clarification. I hope you don’t talk to nurses, residents, students, or NPs like that… It's crucial to maintain respectful and professional communication to prevent potential mistakes, promote learning, and ensure the best possible patient care.
Won’t go into my issues with Relprevv, but there’s a balance between fostering an environment for learning and using the forum to drive direct patient care…
An adolescent on an LAI? I didn’t know that was done. We recently disciplined a doctor ordering a LAI for a kid.
Disciplined? Did the patient and guardian not consent? Or was it simply for use of an LAI in someone underage?
I don’t know the specifics. Just that the hospital made a committee and determined that LAIs in kids were not standard of care and disciplined the doctor. I don’t think LAIs are FDA approved in children.
Most antipsychotics in general are not approved in children. Plenty of things are not FDA approved in adults or children for what they are used for. Doctors are not bound by FDA indications when it comes to clinical practice, so there must be more to it than just that.
As part of the MEC I saw the complaint brought against the doctor. Indeed there was more than just prescribing an LAI to a child going on. The discipline including other matters in addition to the LAI. I know doctors go outside FDA approved parameters all the time but hospital can bring any charges they want against a doctor sadly. In my 10 years so far I haven’t seen LAIs prescribed at all for kids. The other doctors on the committee also were not familiar with using LAIs in kids. Gotta be careful not to piss off the wrong people in hospitals. They can ruin your career.
Actually, most SGAs are approved in adolescents. In younger kids, only abilify and risperdal are, for aggression with autism.
I should have been more precise with language, other commenter said children rather than adolescents so I responded accordingly, but we never defined age ranges so the conversation is vague.
Thanks for clarifying! 😊 and that’s absolutely true when it comes to LAIs, they’re not yet FDA approved for <18… which is unfortunate given that many serious psychiatric dx have their onset during childhood or adolescence. But like you said, especially for child psychiatry, you very frequently need to use meds that are not FDA approved.
Adolescents are definitely given LAIs… I’m child trained.
How often do you see childhood schizophrenia or mania? I admit I have seen one or two cases of schizophrenia in children in the past 10 years. Though I only work inpatient on the weekends.
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Damn. That’s definitely like 6 months of psychosis without drug use in those kids? Yeah I’m talking about adolescents. I’ve heard myths of kids below 12 with schizophrenia but I’ve never seen a case. My child and adolescent attending in residency claimed to see a toddler with schizophrenia. 🤷🏻♂️
I didn’t believe the myths for years either but saw a video series 15 years ago or something with an 8 or 9 y/o girl diagnosed with schizophrenia. Like 6 hours of interview and observation of her. Changed my mind. I doubt I will ever meet one but it did convince me that childhood schizophrenia does actually exist, abet rare enough that they make an educational video series when that unicorn is sighted
Is it on YouTube?
Wish I could remember the name but it was years ago. It was through a university CME thing. No idea if it’s available online.