Oral Dosage Forms
Full update July 2021
There’s a wide variety of oral dosage forms available. Capsules, tablets, and liquids are likely to come to mind immediately. However, these categories can be broken down further. There are different kinds of tablets, such as immediate-release, extended-release (including controlled- and sustained-release), chewable, orally disintegrating, effervescent, buccal, and sublingual. For capsules, there are immediate-release, extended-release, and sprinkle. Oral liquids include solutions, syrups, suspensions, and elixirs. And then there are a number of other oral dosage forms, such as lozenges and troches, powders, sprays, and films (or strips). Adding to the possible confusion, there are even tablets and capsules that should NOT be taken orally.
Any of the dosage forms mentioned can require special considerations when they’re prescribed and dispensed to patients, or when they’re purchased over-the-counter (OTC).
You are processing an e-Rx for a 3-year-old patient, Claire Morris. The prescription is for montelukast 4 mg tablets to be taken by mouth once daily. You first confirm the demographic information you have on file for Claire matches what is on the e-Rx. Next you review Claire’s prescription history and notice that her last prescription for this drug was for montelukast 4 mg oral granules. You wonder if the prescriber may have accidentally selected the chewable tablets instead of the granules. You bring this to the pharmacist for help.
How do oral dosage forms work?
Most oral dosage forms are meant for absorption into the bloodstream. Oral dosage forms, such as tablets, capsules, and liquids, are usually swallowed. They then travel down through the gastrointestinal (GI) tract and are absorbed into the blood through the lining of the stomach or small intestine. Once in the bloodstream, they are transported throughout the body where they can act on receptors and have their effect.
It’s important to understand the difference between immediate-release and extended-release tablets or capsules. Immediate-release medications are formulated to release the drug immediately after oral administration. In contrast, extended-release formulations have a special coating or other mechanism to help release the drug more slowly. Often, this can reduce the number of times a day that a patient needs to take a drug. For example, immediate-release diltiazem (Cardizem [U.S.], AA-Diltiaz [Canada], etc) is given three or four times a day. However, extended-release formulations of diltiazem (Cardizem CD [U.S.], Diltiazem CD [Canada], etc) can be given just once a day.
Some drugs, such as proton pump inhibitors (e.g., omeprazole, lansoprazole), are formulated to delay the release of the drug. Delayed-release tablets or capsules help ensure that the drug is released in a specific part of the GI tract so acid exposure, which could destroy the drug, is reduced.
Keep in mind that you can’t depend on suffixes (ER, XL, SR, etc) to have uniform meanings. We have more information on drug names with suffixes in our technician tutorial, What Drug Names Really Mean.
Oral dosage forms that are available in sprinkle capsules, such as divalproex (Depakote Sprinkle Capsules [U.S.]) or topiramate (Topamax Sprinkle Capsules), can either be swallowed whole or opened, and the pellets sprinkled over soft food or into a feeding tube. Patients usually should not chew or crush the pellets, to prevent the med from being released all at once. And don’t assume all sprinkle capsules can be swallowed whole. For example, AcipHex Sprinkle (rabeprazole [U.S.]) should NOT be swallowed whole; the capsule must be opened and the pellets sprinkled on food. Swallowing the capsule whole could cause this drug to not work as well.
Some OTC or Rx products come in a “softgel,” “liquid gel,” or “gel cap” formulation. These terms are used to refer to a liquid-filled capsule that has a gelatin-based shell, or “gel” for short. This smooth, tasteless gelatin shell may make it easier for some patients to swallow the med. It’s also possible that some of these meds may work faster than a tablet dosage form. Since they are already in liquid form, the stomach doesn’t have to do as much work to break them down.
Most oral liquids can be thought of as similar to immediate-release tablets or capsules. Many oral meds come in both solid and liquid dosage forms, such as azithromycin, lisinopril (Qbrelis [U.S.]), andrisperidone.
Chewable tablets are a convenient dosage form for children and adults who have a hard time swallowing pills. These are intended to be chewed first and then swallowed. Examples of medications available as chewable tablets include antacids, low-dose aspirin, amoxicillin, lanthanum carbonate (Fosrenol), montelukast (Singulair), and children’s versions of acetaminophen (Tylenol), ibuprofen (Advil, etc), and diphenhydramine (Benadryl). Chewable tablets are most useful for their ease of administration.
In most cases, swallowing tablets meant to be chewed shouldn’t cause any issues. The stomach will just have to do more work to break them up. However, there can be exceptions. For example, lanthanum carbonate, which is used to treat high potassium in patients with advanced kidney disease, MUST be chewed before swallowing because it can cause severe GI problems if swallowed whole (blockage of the intestines, formation of holes in the GI tract, etc).
On the other hand, get the pharmacist involved if a patient asks if they can chew a med not meant to be chewed. In some cases, this can be dangerous, such as with extended-release meds which can release large amounts of medicine all at once if chewed.
Orally disintegrating tablets (e.g., rizatriptan [Maxalt-MLT (U.S.), Maxalt RPD (Canada), etc], olanzapine [Zyprexa Zydis, etc], ondansetron [Zofran ODT, etc], amphetamine [Evekeo ODT (U.S.)]), or orally soluble/disintegrating films (e.g., ondansetron [Zuplenz (U.S.)], Ondissolve ODF [Canada]) are kind of tricky. As the name implies, these dissolve in the mouth and should be placed on top of the tongue. However, they still need to be swallowed so that the drug can be absorbed through the GI tract. Because of this, they may not be a good choice for patients who can’t swallow, such as those with breathing tubes. The advantage of orally disintegrating tablets and films is that they fall apart in the saliva and can then be easily swallowed with or without taking a drink of liquid. This can keep patients from holding them in their cheeks, pretending to swallow them and then later spitting them out. So, it makes sense that some medications for psychiatric conditions, such as olanzapine, are formulated as orally disintegrating tablets. It also makes sense that anti-nausea medications, like ondansetron, and triptans for migraines, like rizatriptan, are formulated in this manner. These oral dosage forms provide an option for patients who are too nauseous to drink liquid or swallow a tablet or capsule.
Effervescent tablets (e.g., Airborne [vitamin supplement (U.S.)], Alka-Seltzer Original [antacid/aspirin], Binosto [alendronate (U.S.)], Effer-K [potassium citrate/potassium bicarbonate (U.S.)], etc) are typically placed in water to dissolve completely, then swallowed. One important consideration with effervescent tablets is that they can contain a lot of sodium since sodium bicarbonate is the ingredient that typically gives them their “fizz.” (Effervescent potassium supplements have potassium bicarbonate instead of sodium bicarbonate.) Consider that most people should limit their total sodium intake per day to about as much found in one teaspoon of table salt (about 2,300 mg). One Alka-Seltzer Original tab alone has over 500 mg of sodium and one Airborne effervescent tab has over 200 mg.
Oral powders are another dosage form that requires swallowing for absorption in the GI tract. These can usually be mixed with a liquid and swallowed or placed on the tongue and washed down with a drink. Some examples of oral powders are Goody’s Powders (U.S.) and BC Powders (U.S.), both OTC pain relievers. Oral granules, which are similar to a powder but grainier, are also an available dosage form for drugs like montelukast and ivacaftor (Kalydeco).
Buccal and sublingual tablets or films are actually absorbed into the blood through the lining of the mouth, instead of the lining of the stomach or small intestine as with most other oral meds. So, these don’t need to be swallowed to be absorbed. In fact, if they are swallowed, they may take longer to work and/or be less effective.
Buccal tablets, such as Fentora, a formulation of fentanyl, are placed between the teeth and the cheek. Sublingual tablets, such as nitroglycerin (Nitrostat), go under the tongue. With both dosage forms, the medication is left to be absorbed where it is placed. An advantage with these dosage forms is that they act quickly, since they skip steps, such as moving down through the esophagus and into the stomach. So, it makes sense that some pain meds, like fentanyl, and meds for chest pain related to heart issues, like nitroglycerin, are formulated in this way.
Do ALL oral dosage forms work by getting absorbed into the blood?
No, not all oral dosage forms work by getting absorbed into the blood. There are some medications that are swallowed, but work by having local effects in the GI tract. Examples of this include bismuth (Pepto-Bismol, etc) and sucralfate (Carafate [U.S.], Sulcrate [Canada], etc). These drugs are used to coat the lining of the stomach to protect it from acid injury.
Most oral lozenges, sprays, troches, and some liquids act locally in the mouth or throat. Think about OTC Chloraseptic lozenges or spray for numbing a sore throat. Or nystatin suspension and clotrimazole lozenge, or troche (U.S.), which treat fungal infections in the mouth and throat.
Are there capsules or tablets which are not to be placed in the mouth at all?
Watch for capsules whose contents are meant to be inhaled with the use of an inhaler device to act in the lungs, such as Arcapta Neohaler (indacaterol [U.S.]), Ultibro Breezhaler (indacaterol/glycopyrronium [Canada]), or Spiriva HandiHaler (tiotropium) for chronic obstructive pulmonary disease (COPD). And watch for tablets that are meant for vaginal use where they act locally, such as Vagifem (estradiol). These will require special attention to make sure patients understand how to use them. Since these may be referred to as “capsules” and “tablets,” and look like oral capsules and tablets, they can be especially tricky.
If patients swallow capsules or tablets that are not meant to be taken orally, they won’t have the desired effect. This can be dangerous in some cases. For example, patients with COPD who swallow a capsule meant for inhalation could end up with severe breathing problems requiring medical attention.
How can I help prevent errors with oral dosage forms?
Take care to select the right product. Many oral meds come in a variety of oral dosage forms, such as with medications used to treat attention-deficit/hyperactivity disorder (ADHD). For example, amphetamine is available in several different salts and dosage forms. To illustrate, Evekeo (U.S.) is a regular tablet, while Evekeo ODT is an orally disintegrating tablet. And immediate-release methylphenidate comes as a tablet, chewable tablet (U.S.), and oral solution (U.S.). Because ADHD meds are often used in children, it’s important to make sure you’re selecting the right product, since younger children may have difficulty chewing or swallowing pills. For a list of the different ADHD med dosage forms, see our chart, Comparison of ADHD Medications (U.S. subscribers; Canadian subscribers).
To help prevent mix-ups when selecting product from the shelf, separate different oral dosage forms of the same med using tags, bins, or dividers. Many packages may look similar, so be sure to confirm NDC (or DIN) numbers on the product match what is on the prescription label.
Don’t automatically substitute between oral dosage forms. They usually require pharmacist or prescriber approval to switch. Even in cases where the prescriber orders a tablet, but all you have in stock is a capsule, you should get the pharmacist involved. For example, if you get a prescription for fluoxetine tablet (U.S.), but all you have in stock are the capsules, you should check with the pharmacist before substituting.
Make sure the directions for use are clear. You’ll want to make sure the directions on the label specify exactly how to take the med, to avoid potential problems. For example, the directions on a label for nystatin suspension should clearly state to swish in the mouth before swallowing or spitting it out. Otherwise, the drug may not be effective in clearing a yeast infection from the mouth. It’s also important for patients to know if these types of meds should be “swished and spit” or “swished and swallowed.”
Review some more examples of specific instructions required for different dosage forms:
- Chewable tablets – directions should tell the patient to “Chew and swallow.”
- Orally disintegrating tablets – directions should be typed as “Place on the tongue” or “Dissolve on the tongue,” instead of “Take by mouth.”
- Effervescent tablets – patients need to know the amount of water these tabs should be dissolved in, and that the tabs must be fully dissolved in water prior to taking. Swallowing effervescent tabs whole can lead to choking or irritation of the stomach and esophagus. Check with the pharmacist about how they prefer to share this information with patients, if it isn’t clear from the instructions provided by the prescriber. For example, your pharmacy may have auxiliary labels that include instructions for how to take effervescent tabs.
- Sublingual tablets or films – directions should state to place the dose under the tongue.
- Buccal tablets or films – directions should state to place the dose in-between the cheek and molar.
- Sprinkle capsules – directions may need to say “Sprinkle…” instead of “Take…”
Additionally, to avoid confusion with oral dosage forms, inhaled capsules and vaginal tablets should also have explicit directions for use. Don’t assume that the patient knows what to do with different dosage forms. There are endless stories of patients who have used drugs incorrectly because they did not have proper information describing how to take them.
Check that the product can be taken as directed. For example, if you know that a patient cannot swallow a capsule or tablet, these might be inappropriate dosage forms unless they can be crushed (tablet) or opened (capsule). This is especially true in the hospital setting, where patients are more likely to have medications given through a feeding tube. Use our chart, Meds That Should Not Be Crushed, to find this information.
If a dose is ordered that would necessitate the patient taking a fraction, such as half, of a tablet, it’s important to make sure that dividing the tablet is okay. Often, extended-release tablets should NOT be split. And most orally disintegrating tablets cannot be split, or if they are split, one-half of the tablet may need to be discarded. We have a technician tutorial, Considerations for Splitting, Crushing, or Opening Tablets or Capsules, dedicated to this topic. If you notice that there are problems with the way a tablet or capsule is supposed to be given, alert the pharmacist.
Make sure the patient has a good way to measure the appropriate dose. Dispense a measuring device with oral liquids (i.e., calibrated dosing cup, dropper, spoon, oral syringe) that don’t already come with one. Using a household teaspoon for measuring oral liquids should be avoided because the amount of liquid they hold can vary. Also, make sure that the dosing units on the prescription label match the dosing units on the measuring device to avoid confusion for the patient.
In the hospital setting, you’re likely to be packaging individualized doses of oral liquids for patients. NEVER send oral meds in intravenous (IV) syringes. This could lead to administration of the oral med through an IV line, which is a potentially serious error. Always package oral liquids in ORAL syringes that can’t be connected to IV lines. Use “For oral use only” auxiliary labels over the caps of these syringes as an extra precaution.
Suggest a pill splitter for patients who require a fraction of a tablet. For patients with poor coordination or eyesight, an easy-to-use pill splitter might help. Or the pharmacist might prefer that the tablets be split BEFORE they are dispensed to the patient. In the hospital setting, you will usually dispense tabs that are already split, instead of whole tabs for the nurse to split. Double-check with the pharmacist if you’re not sure what to do. It’s important to help ensure that patients get the most accurate dose possible. Plus, there may be policies with special precautions for splitting tablets if a med is hazardous.
Follow the right technique when handling oral suspensions. Many oral suspensions, such as antibiotic suspensions for pediatrics, need to be reconstituted. When reconstituting suspensions, make sure to tap and invert the bottle a few times first. This will help loosen the powder that may have settled. Then add the quantity of water indicated on the package labeling in two steps. First, add about one-half of the total amount of water for reconstitution. Shake the bottle vigorously to uniformly suspend the powder. Then add the remaining quantity of water, shaking vigorously again to make sure the powder is distributed evenly. Some oral suspensions come pre-made, such as sulfamethoxazole/trimethoprim (U.S.), nystatin, and hydrocodone polistirex/chlorpheniramine polistirex (Tussionex, etc [U.S.]). Shake these pre-made suspensions well before pouring to distribute the medication and ensure the patient will get enough drug in each dose.
The pharmacist reaches out to the prescriber and confirms that the Rx should be for montelukast 4 mg oral granules, not the chewable tablets. The pharmacist also confirms that the directions should now say, “Place the entire contents of 1 packet directly in the mouth or with a spoonful of applesauce once a day,” instead of the original, “Take 1 tablet once a day.”
Do any of these dosage forms require special labeling?
Auxiliary labels should be used to communicate important details about the medication, such as proper administration, storage, etc. Any of the usual auxiliary labels should be used for oral dosage forms as appropriate (e.g., “do not split, chew, or crush,” “may cause drowsiness,” “avoid exposure to the sun”). And liquid suspensions will require a “shake before using” label. Other auxiliary labels to be aware of are discussed in more detail below.
Labels should be used to communicate if an oral med should be taken with food or on an empty stomach. The contents of the stomach and changes in acidity caused by meals can cause more or less of some drugs to be absorbed into the blood. For example, levothyroxine should usually be taken first thing in the morning on an empty stomach, because calcium, fiber, iron, etc, found in food can reduce its absorption. On the other hand, the cholesterol-lowering drug lovastatin should be taken with food, so that it is absorbed to the fullest extent. Other drugs, such as some antibiotics or ibuprofen, may be recommended to be given with food to prevent stomach upset from the drug.
Labels can help remind the patient about proper storage. Liquids are more likely to require refrigeration than other oral dosage forms. In fact, they will often have a shorter beyond-use date than other oral dosage forms. These shorter beyond-use dates should also be communicated with an auxiliary label. For example, prior to reconstitution, cephalexin suspension can be stored at room temperature up to the expiration date. However, once reconstituted, the suspension should be refrigerated and given a beyond-use date of 14 days.
It’s uncommon, but refrigeration may be recommended for some capsules or tablets, like some probiotics or ritonavir capsules (Norvir [U.S.]). Refrigeration is recommended for ritonavir caps if they aren’t going to be used within 30 days.
Some oral meds need to be kept in their original packaging until they are used. For example, effervescent tablets must be kept in their original packaging until they are used. This helps keep them dry. If they are exposed to moisture during storage, they might break down or start to dissolve on their own.
Other oral meds that must be stored in their original packaging include oral granules or powders, orally disintegrating tablets, and meds that are especially sensitive to light and/or moisture, such as dabigatran (Pradaxa). You can find out more with our technician tutorial, Dispensing Meds in Original Containers and our chart, Oral Meds to Keep in Original Containers.
Labels are important for pointing out when tablets and capsules should NOT be taken orally. Place an auxiliary label stating that meds such as inhaled capsules and vaginal tablets are not to be taken by mouth. If possible, also include a “for inhalation” or “for vaginal use” auxiliary label on these meds.
As you are preparing Claire’s prescription for montelukast 4 mg oral granules, you make sure to apply an auxiliary label to remind Claire’s parents to store the medication in its original packaging.
Cite this document as follows: Technician Tutorial,Oral Dosage Forms. Pharmacist’s Letter/Pharmacy Technician’s Letter. July 2021. [370780]
“Cheat Sheet” for Dispensing Oral Dosage Forms
What are the different types of oral dosage forms?
- Tablets
- Immediate-release – often dosed multiple times per day; formulated to release the drug immediately after oral administration
- Extended-release – often dosed once a day; has coating or mechanism to release the drug slowly
- Delayed-release – drug is released in a specific part of the GI tract so exposure to acid, which could destroy the drug, is reduced
- Chewable – chewed first, then swallowed
- Orally disintegrating – dissolved in mouth and swallowed
- Effervescent – dissolved in a specific amount of water, then the patient drinks the solution
- Buccal – placed between the teeth and cheek and absorbed through the mouth lining
- Sublingual – placed under the tongue and absorbed through the mouth lining
- Capsules
- Immediate-release, extended-release,ordelayed-release
- Softgel – liquid-filled capsule that has a gelatin-based shell
- Sprinkle – can be opened and the pellets sprinkled on food
- Liquids
- Solutions, syrups,suspensions,elixirs
- Powders and granules – can usually be mixed with food or placed on the tongue
- Films or strips – buccal, sublingual, or orally soluble/disintegrating
- Lozenges or troches – dissolves slowly in the mouth (takes longer to dissolve than orally disintegrating tablets); often used for local effects
- Sprays – sprayed in the mouth; often used for local effects
How can I help prevent errors with oral dosage forms?
- Select the right dosage form; the same drug can be available in multiple oral formulations.
- Don’t automatically substitute between different oral dosage forms of the same drug.
- Make sure directions for use are clear and specific.
- Confirm that the product can be taken as directed.
- Watch for patients who have difficulty swallowing.
- Watch for prescriptions instructing the patient to crush or take a fraction of a dosage form.
- Confirm altering the dosage form is okay first; check with the pharmacist if unsure.
- Ensure the patient has a good way to measure the appropriate dose.
- NEVER send oral meds in or with syringes used for injection.
- Always provide a calibrated measuring device; do NOT rely on household measuring tools.
- Make sure dosing units on Rx directions match the dosing units on the measuring device.
- Follow the right technique when handling oral suspensions.
- When reconstituting, ensure powder is uniformly distributed.
- Shake pre-made suspensions very well before pouring.
- Apply auxiliary labeling to highlight important considerations for administration and storage:
- Whether the med needs to be taken with or without food.
- If the med needs to be stored in the original container or in the refrigerator.
- When to discard the medication if it has a beyond-use date shorter than the expiration date.
- Send patients to the pharmacist for counseling on proper administration.
[July 2021; 370780]