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Clinical Teaching Resource
Alternate routes of administration.
A stepwise approach for comfort and symptom management — and a route-by-route reference for 58 common hospice medications.
When a patient can no longer take medication by mouth, the goal stays the same: effective symptom relief by the least invasive route possible.
The decision pathway
Choose the route, step by step.
Start at the top. Tap any route to expand the full clinical detail — administration technique, advantages, limitations, and when to avoid it.
Can the patient safely take oral medications?
Standard oral administration. Reassess swallowing, absorption, and nausea at every visit — many hospice patients lose this route over time.
- Widely used and well-studied
- Easy to administer
- Predictable absorption
- Often most cost-effective
- Medications may undergo first-pass metabolism
- Many patients lose the ability to use it safely
Use orally disintegrating tablets, crushed tablets mixed with a small amount of water, or a liquid formulation. Place under the tongue (sublingual) or between the gum and cheek (buccal).
- Avoids first-pass metabolism (bypasses the GI tract)
- Rapid absorption given good mucosal blood supply
- Drug stability maintained
- Economical — tablets can often be crushed
- Can be unpalatable due to bitter taste
- Can irritate the mucosal lining
- Only limited volumes can be given effectively
Empty the rectum first to ensure proper absorption, then insert the medication about two inches, using a lubricant if needed (e.g., KY Jelly or petrolatum).
- Useful with nausea, vomiting, and unconsciousness
- Bypasses hepatic metabolism
- Potential for rapid absorption
- Useful in the pediatric population
- Erratic absorption (delayed, prolonged, unpredictable)
- Incomplete absorption
- Dose may need adjustment vs. oral; not always well accepted
Subcutaneous (SQ) delivers medication into the tissue beneath the skin — less invasive and easier to maintain than IV access. Reserve IV for when rapid, reliable delivery is essential.
- Ease of administration
- Decreased cost compared to IV
- Least painful of the parenteral routes
- Low systemic infection risk
- Volume limitations (≤ 2 mL)
- Irritation at the injection site
- Delayed absorption
Bring any route question to your Wise clinical pharmacist — on call through shift changes, weekends, and after hours.
Confirm the route with your hospice's qualified clinical contact. If on-demand pharmacist support is hard to reach, that's the gap we close.
Explore on-demand clinical supportProvide effective symptom relief using the least invasive route possible, while maintaining comfort and quality of life.
- Choose medications appropriate for each route
- Dose conversions may be necessary
- Monitor effectiveness and side effects
- Reassess frequently and adjust as needed
Medication reference
58 medications, every viable route.
Search by name or filter by route to see which medications can be crushed, given sublingually, subcutaneously, rectally, or via a Macy Catheter.
Don't see a medication? For any medication not on this list, consult your Wise Hospice Options clinical pharmacist.
Not partnered with Wise? Reach out to your own organization's clinical resource team to confirm route appropriateness.
| Medication | Crush | SL / Buccal | SubQ | Rectal | Macy Cath | Notes |
|---|---|---|---|---|---|---|
Acetaminophen Report | Yes | Not recommended | Not recommended | Yes | Yes | Oral solution; commercially available suppositories. |
Alprazolam Review | IR | Yes | Not recommended | Yes | IR | ODT and oral solution available. |
Amlodipine Review | Yes | Not recommended | Not recommended | Unknown | Unknown | |
Antidepressants (SSRI) Review | IR | Not recommended | Not recommended | Not recommended | Not recommended | Immediate-release tablets only. |
Aripiprazole Package insert | Yes | Not recommended | Not recommended | Not recommended | Not recommended | Oral solution available. |
Aspirin Review | Yes (non-EC) | Not recommended | Not recommended | Yes | Yes | Non-enteric-coated only. |
Baclofen Case report | Yes | Not recommended | Yes | Not recommended | Not recommended | Case report supporting subcutaneous use. |
Benadryl Anecdotal | Yes | Not recommended | Not recommended | Yes | Yes | Rectal use anecdotal only. |
Bumetanide Review | Yes | Not recommended | Not recommended | Yes | Yes | Rectal administration reviewed. |
Buspirone Case report | Yes | Not recommended | Not recommended | Yes | Yes | |
Carbamazepine Review | IR | Not recommended | Not recommended | Yes | Yes | Compounded suppositories; crushed tabs dissolved in water. |
Carbidopa-Levodopa Case report | IR | Yes | Not recommended | Not recommended | Not recommended | Sublingual supported by case report. |
Carvedilol Package insert | IR | Not recommended | Not recommended | Unknown | Unknown | Compounded oral solution; potential with solubility enhancer. |
Chlorpromazine Clinical trial | Yes | Yes | Not recommended | Yes | Yes | |
Clonazepam Review | Yes | ODT | Not recommended | Yes | Yes | ODT available; dissolved tablets administered. |
Dexamethasone Review | Yes | Yes | Not recommended | Yes | Yes | Sublingual anecdotal; oral solution available. |
Diazepam Review | Yes | Yes | Not recommended | Yes | Yes | Oral solution and rectal gel available. |
Donepezil Package insert | Yes | Not recommended | Not recommended | Unknown | Unknown | |
Doxepin Case series | Yes | Not recommended | Not recommended | Yes | Yes | Oral solution available. |
Esomeprazole Package insert | Not recommended | Not recommended | Not recommended | Not recommended | Not recommended | Capsules can be opened and sprinkled. |
Famotidine Review | Yes | Not recommended | Not recommended | Not recommended | Not recommended | Oral suspension available; chewable OTC tablets. |
Furosemide Review | Yes | Not recommended | Yes | Yes | Yes | Supported by review and package insert. |
Gabapentin Review | IR | Not recommended | Not recommended | Not recommended | Not recommended | Immediate-release only. |
Glycopyrrolate Review | Yes | Yes | Yes | Not recommended | Not recommended | Oral solution available. |
Haloperidol Anecdotal | Yes | Yes | Yes | Yes | Yes | Anecdotal reports; per package insert. |
Hydromorphone RCT | IR | Yes | Yes | Yes | Yes | Commercially available suppository (3 mg). |
Hydroxyzine Package insert | Yes | Not recommended | Not recommended | Unknown | Unknown | No studies on rectal administration. |
Hyoscyamine Package insert | Yes | Yes | Yes | Not recommended | Not recommended | Supported by review. |
Ibuprofen RCT | Yes | Not recommended | Not recommended | Yes | Yes | Oral suspension available. |
Lamotrigine RCT | IR | ODT | Not recommended | Yes | Yes | Crushed tabs in water; ODT ($$$). |
Levetiracetam Review | IR | Not recommended | Not recommended | Yes | Yes | Oral solution available; crushed tabs in water. |
Lisinopril Package insert | Yes | Not recommended | Not recommended | Not recommended | Not recommended | No data on rectal administration. |
Lorazepam Review | Yes | Yes | Yes | Yes | Yes | Well supported across routes. |
Losartan Package insert | Yes | Not recommended | Not recommended | Not recommended | Not recommended | Compounded solution 2.5 mg/mL. |
Methadone Review | Yes | Yes | Yes | Yes | Yes | Oral solution available. |
Metoclopramide Review | Yes | Not recommended | Yes | Yes | Yes | Supported by review and package insert. |
Metoprolol Comparative | IR | Not recommended | Not recommended | Yes | Yes | Immediate-release only. |
Midazolam Review | Liquid | Yes | Yes | Yes | Yes | Injectable solution administered by alternate routes. |
Mirtazapine RCT | Yes | ODT | Not recommended | Unknown | Unknown | ODT available. |
Morphine Review | IR | Yes | Yes | Yes | IR | IR tabs, ER tabs (whole), inj. solution; commercial suppositories. |
Olanzapine Review | Yes | ODT | Not recommended | Yes | Yes | ODT in solution, crushed tabs; compounded suppository. |
Omeprazole Package insert | Not recommended | ODT | Not recommended | Not recommended | Not recommended | DR capsules can be opened; ODT available OTC. |
Ondansetron Review | Yes | ODT | Yes | Yes | Yes | Subcutaneous use is off-label. |
Oxybutynin RCT | IR | Yes | Not recommended | Yes | Yes | Transdermal patch; compounded suppository. |
Oxycodone RCT | IR | Yes | Not recommended | Yes | IR | Oral solution available. |
Pantoprazole Package insert | Not recommended | Not recommended | Not recommended | Not recommended | Not recommended | Oral packet ($$$). |
Phenobarbital RCT | IR | Yes | Not recommended | Yes | Yes | Elixir available. |
Prednisone Review | Yes | Yes | Not recommended | Unknown | Unknown | Prednisolone studied for SL and PR; oral solution available. |
Prochlorperazine Package insert | Yes | Not recommended | Not recommended | Yes | Yes | Commercially available suppository. |
Promethazine RCT | Yes | Unknown | Not recommended | Yes | Yes | Commercial suppository; solution given PR. |
Quetiapine Comparative | IR | Not recommended | Not recommended | Yes | Yes | Decrease PO dose 50% for PR administration. |
Risperidone Package insert | Yes | ODT | Yes | Unknown | Unknown | No rectal studies; ODT and oral solution available. |
Ropinirole Package insert | IR | Not recommended | Not recommended | Unknown | Unknown | No studies on rectal administration. |
Torsemide Package insert | Yes | Not recommended | Not recommended | Unknown | Unknown | Furosemide and bumetanide effective rectally. |
Tramadol Comparative | IR | Yes | Not recommended | Yes | Yes | Crushed tabs in water; oral solution available. |
Topiramate RCT | IR | Not recommended | Not recommended | IR | IR | Crushed tabs in water. |
Trazodone Case report | Yes | Not recommended | Not recommended | Yes | Yes | |
Valproic Acid Comparative | Oral Liquid | Not recommended | Not recommended | Yes | Yes | Compounded suppository; oral syrup given PR. |
Oral solution; commercially available suppositories.
ODT and oral solution available.
Immediate-release tablets only.
Oral solution available.
Non-enteric-coated only.
Case report supporting subcutaneous use.
Rectal use anecdotal only.
Rectal administration reviewed.
Compounded suppositories; crushed tabs dissolved in water.
Sublingual supported by case report.
Compounded oral solution; potential with solubility enhancer.
ODT available; dissolved tablets administered.
Sublingual anecdotal; oral solution available.
Oral solution and rectal gel available.
Oral solution available.
Capsules can be opened and sprinkled.
Oral suspension available; chewable OTC tablets.
Supported by review and package insert.
Immediate-release only.
Oral solution available.
Anecdotal reports; per package insert.
Commercially available suppository (3 mg).
No studies on rectal administration.
Supported by review.
Oral suspension available.
Crushed tabs in water; ODT ($$$).
Oral solution available; crushed tabs in water.
No data on rectal administration.
Well supported across routes.
Compounded solution 2.5 mg/mL.
Oral solution available.
Supported by review and package insert.
Immediate-release only.
Injectable solution administered by alternate routes.
ODT available.
IR tabs, ER tabs (whole), inj. solution; commercial suppositories.
ODT in solution, crushed tabs; compounded suppository.
DR capsules can be opened; ODT available OTC.
Subcutaneous use is off-label.
Transdermal patch; compounded suppository.
Oral solution available.
Oral packet ($$$).
Elixir available.
Prednisolone studied for SL and PR; oral solution available.
Commercially available suppository.
Commercial suppository; solution given PR.
Decrease PO dose 50% for PR administration.
No rectal studies; ODT and oral solution available.
No studies on rectal administration.
Furosemide and bumetanide effective rectally.
Crushed tabs in water; oral solution available.
Crushed tabs in water.
Compounded suppository; oral syrup given PR.
Full citations for this guide are available on request from the Wise clinical team.
Reach out to usThis resource supports clinical judgment and does not replace it. Always confirm medication, dose, and route appropriateness with a Wise Hospice Options clinical pharmacist.