TYPE 2 DIABETES
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?
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 lifethreatening 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 sugarcoated 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.
MORPHINE Brand names such as Morphgesic or Zomorph GENERALLY given as a extendedrelease 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 name 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.
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