Can You Crush Paxlovid Tablets?

Answer

Thanks so much for reaching out to us! The answer to this question is going to be a little long-winded because I want to give some context to the official answer, which is that Paxlovid tablets should not be crushed, split, cut or otherwise altered. They are recommended to be swallowed whole.

This recommendation comes directly from Pfizer, the manufacturer of Paxlovid:

PAXLOVID (both nirmatrelvir and ritonavir tablets) can be taken with or without food. The tablets should be swallowed whole and not chewed, broken, or crushed.

Why Can't Paxlovid Be Crushed?

Here is where we get into some ambiguity. The 'fact sheet' for Paxlovid, provided by Pfizer and authorized by the FDA (Food and Drug Administration) does not give a reason why the tablets cannot be crushed.

Generally, when we think of medications that should not be crushed, we think of drugs that are modified-release dosage forms, such as extended or delayed-release tablets. This is not the case for Paxlovid tablets, however.

Does Paxlovid Use Special Dispersion Technology?

There are some drugs in tablet form that use a variety of new 'dispersion delivery' technologies, which can improve how drugs are delivered into our system and absorbed when taken orally.

Two of the more common dispersion technologies are 'amorphous solid dispersions' and 'nanocrystal' technologies. One area where these technologies really shine is in increasing the solubility of poorly water-solubility drugs (which allows for better absorption).

These types of dispersion technologies are relatively new, and there is a lot of misinformation on whether or not drugs in tablet form that use this type of technology can be crushed.

In general, tablets and capsules that use new dispersion technologies are very similar in appearance to your usual tablets and capsules, and many times, are not technically extended or modified-release (at least not in the drug name). Nevertheless, tablets that use these technologies should not be crushed as doing so can ruin the dispersion technology and make the drug less effective.

I mention all this since I have seen some resources online stating that it's likely Paxlovid can't be crushed since the tablets use a dispersion technology like amorphous solid dispersions and nanocrystals, but this appears to be just speculation. I could find no resources or data whatsoever confirming Paxlovid tablets use any type of new dispersion technology.

What Pfizer Says

Since Paxlovid (which actually contains two different drug tablets, nirmatrelvir and ritonavir) isn't modified-release and doesn't have confirmation of using any sort of new dispersion technology in the tablets, some individuals/organizations have contacted Pfizer directly asking why Paxlovid can't be crushed.

One such organization that contacted Pfizer is 'The British Columbia COVID-19 Therapeutics Committee'. They have released a 'therapeutic brief' regarding crushing Paxlovid tablets, and in that brief, they state the following:

Two drug information requests submitted to the manufacturer [Pfizer] and the responses quoted lack of data to characterize pharmacokinetics and pharmacodynamics of nirmatrelvir and ritonavir as the rationale for the statement for administration.

So, it appears that the recommendation from Pfizer not to crush Paxlovid tablets simply comes from the lack of data surrounding how crushed tablets compare to whole tablets. There was nothing said about specific drug delivery technologies that would be compromised by crushing the tablets.

Recommendations From Other Organizations

The 'therapeutic brief' provided by The British Columbia COVID-19 Therapeutics Committee does go on to recommend crushing Paxlovid tablets to avoid a delay if the drug is medically necessary for certain individuals. They state:

Both ritonavir and nirmatrelvir (components of Paxlovid) can be split or crushed and mixed with apple sauce, pudding or any common food or liquid including dairy-containing products based on Phase I studies demonstrating that suspensions achieve similar pharmacokinetics to whole tablets.

They base their recommendation on knowing how the drug is formulated, the ingredients used, and several clinical studies that support the safety of crushing nirmatrelvir and ritonavir (the two drugs in Paxlovid).

The British Columbia COVID-19 Therapeutics Committee does go on to state that crushing tablets should only be done on a dose-by-dose basis, and they should not be stored for later use. They also state that their recommendations should not replace the clinical judgment of your provider team (i.e., doctors and other healthcare professionals) since you may have more scientifically-backed therapy options available to you.

I have embedded the full document from the British Columbia COVID-19 Therapeutics Committee below.

What To Do?

So, we're in a situation where Pfizer (who makes Paxlovid) states that the tablets need to be swallowed whole, but that recommendation appears to be grounded simply in the lack of information available about how crushed tablets compare to whole ones (which, of course is a perfectly valid reason to not recommend crushing).

As written in the section above though, there seems to be some support showing that crushed Paxlovid (specifically, crushing nirmatrelvir and ritonavir tablets) appears to be safe and effective on a dose-by-dose basis (i.e., not storing crushed powder for later use).

With this conflict, I highly recommend speaking with your doctor about what is best for your medical situation.

If Paxlovid is a medically necessary drug to treat your condition and there are no other viable or reasonable alternatives for you, they may recommend crushing the tablets and administrating them that way.

This isn't ideal since we don't know for sure that crushed tablets will work the same way as intact ones, but again, if there aren't better options for you, it may be worth doing.

Again, please speak to your doctor so you can be given guidance about what the best options are for your health.

Final Words

I apologize for the long answer but I felt it was important to give context around the simple answer of Paxlovid not being recommended to be crushed.

Thanks again for reaching out and please do so again anytime.