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Publication Type: Medical Safety Information
Single or Multiple Incident: Multiple
Date: 1/1/2020 12:00:00 AM
Country: Japan

This alert addresses the patient safety issues which can result from crushing a sustained release drug formulation. Four cases were reported in which a sustained-release preparation was ground up and administered to a patient, with the result that the active ingredient was rapidly absorbed into the patient’s bodywith adverse outcomes. Two cases are described. In the first case Nifedipine CR®, a long acting calcium channel blocker, was administered via a nasogastric tube resulting in a sudden drop in blood pressure. In the second case, a patient who had been taking Careload LA® for pulmonary hypertension required a tracheal intubation and a nasogastric feeding tube was inserted. The Careload LA® was a sustained release preparation but the formulation was unknown to the caregiver. The drug was crushed and administered via the nasogastric tube. A sudden drop in blood pressure resulted. The alert provides recommendations to prevent similar incidents.

Additional Details

nasogastric tube, enterostomy tube
calcium channel blocker, nifedipine CR prostacyclin PGI2 derivative beraprost (Careload LA®), oxycodone (Oxycontin®)
Medication/IV List:
narcotics/opiates, IV, transdermal, and oral (including liquid concentrates, immediate and sustained-release formulations)

Administration of a Sustained-Release Preparation in Ground-Up Form