Although aimed mainly at pharmacists, other healthcare professionals or care staff may also find this article helpful. It is intended to be used in conjunction with the article: Covert administration of medicines in adults: legal issues.

Seek pharmacist advice

National Institute for Health and Care Excellence (NICE) guidance on covert administration of medicines to adults receiving social care in the community recommends seeking advice from a pharmacist to plan how medicines will be given.

To provide advice, the pharmacist will need to consider the pharmaceutical issues with covert administration, particularly the risks and patient factors.

These are summarised in this article and we also provide links to useful reference sources for further detail.

Risks and factors to consider

Very often, there is no information available on the stability of medicines when mixed with food or drink. However, it is useful to consider the risks of the medicine degrading in food or drink versus the risks of not giving the medicine at all.

When adding a medicine to food, try and add it to the first mouthful of food, so that the full dose is received.

At all times healthcare professionals should ensure that any increased risk of harm from manipulating a medicine is minimised, and that the action is justifiable in terms of the potential clinical benefits to the patient.

Acceptability

You will need to consider the taste and other possible effects of the medicine, particularly if tablets are to be crushed or contents removed from capsules.

For example, crushed sertraline tablets can be mixed with soft food or drink for administration (off-label), but they have a bitter taste. They may also have a slight anaesthetic (numbing) effect on the tongue.

This means you will need to consider the best way to hide the taste, such as using something more strongly-flavoured like juice, yoghurt or jam. Check individual likes and dislikes with family or carers to decide what might be suitable.

Because of the possible numbing effect, take care with giving the patient hot food or drinks with, or immediately after, giving crushed sertraline tablets.

If problematic, you may need to consider alternatives as outlined in our article: Selective serotonin reuptake inhibitor (SSRI) formulations suggested for adults with swallowing difficulties.

Absorption with food

Food can affect the absorption of medicines in different ways. It can affect the rate (speeding up or slowing down) of absorption of medicines, as well as the amount  (increasing or reducing) of medicine absorbed.

To help with deciding whether or not to give medicines covertly you should consider the effects of food on medicines.

You will often find information about this in the relevant Summary of Product Characteristics (usually available on the emc or MHRA Products website). Alternatively, the Patient Information Leaflet (PIL) may give instructions about taking the medicine with food or on an empty stomach.

Individual monographs in the BNF advise on any cautionary labels that need to be applied to dispensed medicines with respect to administration with food or on an empty stomach (before food).

For example, for the antibiotic flucloxacillin, the BNF recommends applying cautionary label 23: “Take this medicine when your stomach is empty. This means an hour before food or 2 hours after food”. This is because food reduces absorption of flucloxacillin. Mixing it with food to give to a patient covertly may result in the antibiotic not working. Other options will need to be discussed with the prescriber.

Incompatibility with foods or drinks

Some medicines may be pharmaceutically incompatible with certain minerals (or salts) in food or drinks, such as calcium, iron, magnesium, aluminium and zinc. Similarly to the absorption issues discussed above, this may help in deciding whether or not to give a medicine covertly.

For example, the antibiotic ciprofloxacin reacts with these minerals. It binds with the minerals to form an insoluble complex known as a “chelate”. This results in reduced absorption of ciprofloxacin, so it would not be suitable for mixing with foods or drinks containing these minerals.

Safety

For some medicines, crushing tablets or opening capsules may be a potential health risk to the person giving them (the carer) if they are exposed to the powder or dust created, either by contact with their skin, mouth or eyes, or by breathing it in.

Examples of tablets or capsules that may not be safe to crush or open include medicines that are:

• irritant
• cytotoxic
• immune-suppressing
• teratogenic
• hormonal
• steroids

Enteric coating or extended-release formulations

Crushing or chewing tablets or opening capsules with enteric coating or extended-release (also known as modified-release or prolonged-release) properties can affect their release characteristics. The medicine may be released earlier than usual, or in larger amounts, or in a different part of the digestive system (e.g. in the stomach instead of the intestine).

This puts the patient at risk of harm, either from side effects or toxicity of the medicine, or from the medicine not working as it should do.

There are some exceptions, but usually manipulation of enteric coated or extended-release medicines is not recommended.

Reference sources and how to use them

A variety of reference sources are available to help pharmacists and other healthcare professionals consider the pharmaceutical issues and patient factors when making a best interests decision to give medicines covertly.

Most of these don’t specifically consider covert administration of medicines. Instead they tend to focus on options for giving medicines to people with swallowing difficulties, including those who need medicines to be given via an enteral feeding tube, or to children.

Nonetheless this information can be extrapolated to the scenario of covert administration to decide whether it is safe to manipulate medicines (crush tablets or open capsules, and/or hiding medicines in food or drink), or whether there may be preferable alternatives.

• Royal Pharmaceutical Society. Pharmaceutical Issues when Crushing, Opening or Splitting Oral Dosage Forms; June 2011.
• emc website. Occasionally a Summary of Product Characteristics (SmPC) for a medicine will give the manufacturer’s advice about crushing tablets or opening capsules. You may also find information about how the medicine is affected by food in the SmPC. Alternatively you could try contacting the manufacturer for advice. Contact details are usually on the emc website.
• BNF and BNF for Children. Individual medicine monographs sometimes contain useful advice in a section entitled ‘Directions for administration’. These references are also useful to check what other medicinal forms may be available, or to consider possible alternative medicines.
• Specialist Pharmacy Service: swallowing difficulties. This suite of advice on using medicines safely and effectively in patients with swallowing difficulties may also be useful in the covert administration scenario. In particular, giving medicines safely with food or thickened fluid, choosing formulations of medicines for adults with swallowing difficulties and manipulating medicines for administration to adults with swallowing difficulties.
• The NEWT Guidelines (J Smyth, Betsi Cadwaladr University Local Health Board). Subscription required. Provides guidance on administering medicines to patients with swallowing problems or via enteral feeding tubes in the form of monographs for individual medicines.
• Drug Administration via Enteral Feeding Tubes (Rebecca White, Pharmaceutical Press). Subscription required. Royal Pharmaceutical Society members may be able to access via the e-library service.
• Colchester Hospital University NHS Foundation Trust. MOC Guidelines for Tablet Crushing in Patients with Swallowing Difficulties. Hospital guideline describing the suitability of tablets for crushing or capsules for opening to mix in water, other drinks or food for patients with swallowing problems; last updated in 2018.
• Medicines for Children website. The leaflets on this website may provide useful information on administration of medicines in food or drink, or on crushing tablets or opening capsules. Although intended for children, this information can often be extrapolated to adults receiving medicines by covert administration.

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