Crushed Tablet Order for a Patient Who Cannot Swallow
A prescriber sends an order for 'metformin 500 mg PO, crush and mix with applesauce' for a 78-year-old patient with dysphagia. The pharmacy stocks only immediate-release metformin 500 mg tablets and extended-release (ER) 500 mg tablets. The patient's blood glucose log shows fasting readings of 160-190 mg/dL. The nurse asks you to prepare the dose now. The ER tablets are film-coated and labeled 'do not crush.' You also notice the patient is on a thickened-liquid diet.
1. Can you prepare the order as written with the stock you have? Explain your reasoning.
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No, not exactly as written. The order specifies crushing, but the ER product is explicitly labeled do not crush; crushing an ER formulation destroys the release mechanism and can cause dose dumping and hypoglycemia. The immediate-release tablet could be crushed, but the order does not specify which formulation, and substituting IR for ER changes the dosing interval. The safe action is to clarify with the prescriber which formulation is intended and whether an alternative dosage form (e.g., an oral solution or a different agent) is appropriate for dysphagia. You should not silently crush the ER tablet.
2. The patient is on thickened liquids. How does that affect your choice of mixing vehicle, and what do you tell the nurse?
Read the worked answer
Applesauce is a semisolid and is generally acceptable for dysphagia, but thin liquids like water or juice used to mix or chase a crushed dose may be contraindicated. If the crushed IR tablet must be given, mix it in a small amount of applesauce (not a thin liquid) and confirm the speech-language pathologist's texture recommendations. Tell the nurse the formulation must be confirmed first, and that any mixing vehicle must match the patient's prescribed diet texture.