From simple white paracetamol to blue diamond-shaped Viagra, our pills come in all shapes, sizes and colours.
But why are there such huge differences in how they look – and the ease with which they can be swallowed?
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The simple answer is that drug manufacturers have total control over these factors. There are no specific rules guiding the shape and size of pills, and some manufacturers appear to give little consideration to how hard a pill is to swallow.
The average adult gullet is 2cm in diameter. However, ‘some medications can be longer than 1cm or half a centimetre wide, which makes them very difficult to swallow,’ explains Dr Simon Gaisford, head of the department of pharmaceutics at University College London.
‘Manufacturers may not consider how difficult it may be to swallow a medicine when making it, because they don’t need to.’
The size of a pill is partly dictated by the amount of drug and other ingredients needed to make a stable dose, adds David Erskine, director of the Medicines Information Centre for London and the South-East.
Some drugs, such as contraceptive pills, including ethinylestradiol, are ‘high potency’, meaning a tiny amount is needed for the effect, so these tablets are often very small.
Conversely, drugs such as ibuprofen are low potency, meaning a lot more is required to elicit the desired effects; this means tablets can get very large.
Most active drugs also need to be mixed with various ingredients to help them compress into an acceptable shape.
‘Other substances are then used to make them behave as they need to, such as chemicals known as “disintegrants” to help the pill actually dissolve when it gets to its destination,’ adds Dr Gaisford.
Indeed, he says, when you see a pill listed as 300mg, for instance, that’s just how much active drug there is and the pill itself may be much larger because of all of the added ingredients.
But it is dangerous to assume you can break up big pills to make them easier to swallow – or more palatable mixed with food. Most pills have a coloured sugar coating partly to make them more recognisable and more pleasant to taste. But sometimes coatings are needed for the drug to function properly. This is what determines whether a tablet or capsule is safe to crush, cut or dissolve.
Pills such as paracetamol are just compressed powder, so would be fine to cut, as long as patients are still taking their entire dose, adds Dr Gaisford. But others are coated to protect the oesophagus from irritation as the pill is swallowed and should never be crushed.
Other medications, such as those for angina, are coated so the active drug is released slowly and constantly as it moves through the body, so cutting a pill into smaller pieces means the drug is released before it’s meant to be.
This could lead to an overdose or mean the drug doesn’t have the desired effects.
Other pills are coated to protect the drug as it goes through the acidic stomach because it needs to be released lower in the digestive system.
‘Some capsules are fine to open up and empty into a liquid which is easier to drink,’ says David Erskine. ‘It’s also possible to empty them into yoghurt if you prefer to eat something. But make sure you drink or eat the entire thing to get the whole dose.’
A doctor, nurse or pharmacist dealing with a patient who can’t swallow pills may be able to find an alternative drug that works the same way but which is available as a liquid or a soluble tablet, or even a patch or suppository, he adds.
Sometimes specialist pharmacies may make a liquid form of the medication. But this is more expensive and may require more frequent prescriptions as the medicine can have a shorter shelf-life.
Look on the packaging and if you see the letters MR (modified release), ER (extended release) and/or EC (enteric coated), ‘you should not cut that pill in any way as this means it has a special coating to delay or control the medicine’s release,’ explains Dr Gaisford. And always check first with your pharmacist or doctor.
Here we look at some of the most common prescription drugs and explain what you can – and can’t – do to make the medicine go down more easily.
PAIN
Tramadol Brand names include Tradorec, Maxitram or Zamadol
Available as round orange tablet or in an extended-release green, yellow or blue capsule. All forms should not be opened, crushed or dissolved in water, but swallowed whole.
Using tramadol in any other way, or potentially inhaling it while crushing or opening the capsule, can cause life-threatening side-effects because you’re exposed to the high dose too quickly, which can slow or stop breathing.
Dihydrocodeine Brand name DHC continus
These white, capsule-shaped tablets are sugar-coated to hold the ingredients together and make them taste acceptable. Standard tablets are relatively small, and may be crushed or split for easier swallowing. But the tablets also come in extended-released form, which means they’re designed to release the drug slowly, typically over 24 hours; you must not crush or split these.
Buprenorphine Brand names such as Subutex, Gabup or Prefibin
Due to their tiny size, these aren’t usually difficult to take (they are placed under the tongue where they are absorbed) and crushing them may lose some of the small dose. But you can do this provided you swallow all the crushed tablet.
Oxycodone Brand names such as Longtec, Reltebon, Oxeltra or Lynlor
Depending on the brand, this sugar-coated tablet can be grey, red, brown or purple.
There are extended-release versions in light blue, pink, yellow or green. All are biggish, from 6mm. The standard pill can be split, but don’t tamper with an extended-release pill as this can cause overdose and may even stop you breathing.
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Morphine Brand names such as Morphgesic or Zomorph
Generally given as a extended-release tablet, although sugar-coated versions are sometimes available. Do not break, crush, chew, dissolve, or split morphine extended-release tablets as too much medicine can be released into the bloodstream, which could be fatal.
HIGH BLOOD PRESSURE
Ramipril Brand names include Altace or Tritace
The tablet form can be crushed and put in water. The 7mm-long capsule version has a hard gelatine cover and should be swallowed whole to ensure you get the entire dose, but you can open it up and mix the contents in water.
Doxazosin Brand names Cardura, Raporsin or Doxadura
This round tablet is available in two forms: the lower dose 1mg or 2mg tablets can be cut and crushed, but make sure you have the whole dose. The higher 4mg dose is an extended-release form, meaning it’s designed to release the drug over 24 hours, so do not cut or crush it.
Valsartan Brand name Diovan
This comes as a large orange or brown oval tablet (19mm by 8.2mm) or in capsule form. Tablets can be split and crushed in water. The capsule is made of gelatine and as there’s no evidence it’s safe to open, do not do so.
Propranolol Brand name Inderal
THis comes as an off-white tablet (up to 11 mm-wide depending on the dose) or extended-release clear blue capsule. The tablets can be split or crushed; but capsules cannot be tampered with.
Metoprolol Brand names Lopresor
A round peach or sky-blue tablet, around 8mm wide. Normal tablets can be crushed but the extended-release version with the letters ER or LA (long-acting) cannot as it would be released too quickly, and cause harmful side-effects.
TYPE 2 DIABETES
Metformin Brand names Diagemet, Glucient or Glucophage
Metformin pills can be up to 13.5mm long and 6.6mm wide, and come in both standard and extended-release forms. The standard tablets can be split, but never split the extended-release forms. If you can’t swallow the dose prescribed, a liquid version is available.
Saxagliptin Brand name Onglyza
These tablets are either pale yellow or bright pink and 8mm wide, and have a special film coating to make sure it reaches the intestine, where it is designed to be absorbed. For this reason, the pills must not be split or crushed.
Dapagliflozin Brand name Forxiga
This yellow tablet, either round or diamond shaped, can be up 1cm wide. It’s relatively new so regarded as a ‘black triangle’ drug by the NHS – meaning it requires additional monitoring to check for potential side-effects. Even though it’s a normal-release drug, it shouldn’t be cut because little is known about the consequences.
Glimepiride Brand name Amaryl
These oblong 8mm-wide tablets, which can be yellow, green or pink depending on the dose, are usually scored so they can be split into smaller pieces by doctors to adjust the doses, but also to make them easier to swallow – it’s fine to do this if you take the whole dose.
Repalinide Brand name Prandin
Available in various doses and coloured accordingly, this tablet is generally only 6mm wide but can be split and crushed with water if you want.
ACID REFLUX AND GUT PROBLEMS
Omeprazole Brand names Losec or Zanprol
A treatment for gastric ulcers and acid reflux, this is an extended-release drug that comes in tablet and capsule form. Capsules should be swallowed whole to ensure the drug is only released once they reach the stomach to stop it producing acid. However, they can be opened and the contents mixed with half a glass of water or a slightly acidic fluid such as fruit juice, which helps protect the drug’s potency intact until swallowed – but swallow quickly.
Pantoprazole Brand name Pantoloc
A heartburn treatment, these bright yellow oval tablets, nearly 1cm long, are only available in gastro-resistant release form – the coating prevents breakdown as the pill passes through the stomach to ensure its release in the gut. For this reason, they must not even be chewed, let alone crushed.
Mesalazine Brand names Asacol, Pentasa or Salofalk
These are designed to be released in the bowel for treating ulcerative colitis, a type of inflammatory bowel disease. Mesalazine is also available as a suppository but both oral pill and suppository are gastro-resistant to make the drug survive the stomach and reach its destination, so you must not split or crush them, as this will cause side-effects and won’t help treat the condition.
Ranitidine hydrochloride Brand names Zantac, Ranitic
Used for heartburn and indigestion, this round tablet (8mm wide) can be crushed or dissolved in water.
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INFECTIONS (antibiotics)
Erythromycin Brand name Erymax
These orange capsules and tablets are small and have special coatings in order to protect the drug as it passes through the harsh acidic conditions of the stomach, and reach the gut where it is needed. You must swallow these whole.
Amoxicillin Brand name Amoxil
This comes as a red and white or blue and pink capsule but while it releases the drug normally, it should be swallowed whole to ensure you get the full dose from the small pill.
Trimethoprim Brand names Proloprim, Monotrim, and Triprim
These tablets are white compressed powder and can be split, cut and crushed to ease swallowing.
Flucloxacillin sodium Brand name Floxapen
These caramel-coloured hard gelatin capsules need to be swallowed whole to ensure you get the entire dose, and there is not enough evidence of the risks of emptying this capsule to do so.
Clarithromycin Brand name Klaricid
These off-white tablets are available in both normal and extended-release forms. The standard version can be split, but the higher dose extended-release forms cannot – some infections may require faster-acting drugs, whereas others need more consistent long-term release over a day or so after getting to the stomach. Crushing the extended-release tablet can cause overdose.
ANGINA
Nifedipine Brand names Adalat, Adipine or Coracten
This comes as a soft gel capsule or tablet and is an extended-release medication to ensure enough drug is delivered consistently over 24 hours, and a special coating to help it reach the gut where it is released.
Both the soft gel capsule and tablet are just under 2cm wide, and although large, cannot be split or crushed.
Diltiazem Brand names Adizem, Dilzem or Kenzem
This drug is available as a normal and extended-release tablets and capsules. The coating is designed to release the drug over approximately three hours for optimal benefits.
Although the standard pill can technically be split, avoid this as it changes the drug’s activity, meaning it is released too quickly and so does not act as it should to alleviate symptoms. Patients should try and swallow all forms of this drug whole.
Isosorbide mononitrate Brand names Imdur, Ismo
These cream-coloured tablets are scored with lines for doctors to guide the right dose for patients, but you should not assume this means you can cut them up smaller to swallow, as they are actually extended-release tablets.
Unless your doctor tells you to, do not break, crush, or even chew these before swallowing.
Verapamil hydrochloride Brand names Securon or Univer
This drug is available in standard tablet form and extended-release capsule. The small tablet is usually scored and you can break it in half, or even smaller.
But you must not open and empty the contents of the capsule as this interferes with the release of the active drug, which can be dangerous.
Lacidipine Brand name Motens
These white oval tablets are insoluble, but they can be split and crushed, then swallowed with a glass of water.
ARTHRITIS AND ANTI-INFLAMMATORIES
Diclofenac Brand names such as Voltarol
These round orange tablets are designed to pass through the stomach unaffected in order to reach the gut where they need to be released. Do not crush, chew, or break this tablet.
Colchicine Brand names Colcrys Colchicine; Allopurinol Brand name Zyloric; Hydroxychloroquine Brand name Plaquenil
These small tablets can be split and crushed and/or dissolved in water to swallow, but take the whole dose.
Etoricoxib Brand name Arcoxia
The tablets vary in size depending on their dose but are all different shades of green. It should be swallowed whole with plenty of water and not chewed, crushed or split as this will mean too much of the medication is released at the same time, potentially causing dangerous side-effects on the gut.
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Category: WHY
