How does the enteral feed affect medication delivery?

Types of Drug Formulations:

• Liquid solutions• Solid immediate release tablets & capsules• Enteric coated tablets• Sustained release tablets & capsules• Hard gelatin capsules• Others

Liquid Preparations

• All liquid formulation will be suitable ?.

• Elixirs or suspensions or syrup(clumping)?

• Advantages:

• allows accurate dosing, ready to use

• Easily measured.

Disadvantages, Co-solvents like sorbitol, large amount(child formulations), higher osmolarity (not written on bottle),viscosity

Medications That Have an Osmolality of ≥ 3000

mOsm/kg

Liquid Medications That Contain Considerable

Amounts of Sorbitol With Typical Daily Dosing

Medications Physically Incompatible With Most

Enteral Nutrition

Solid Dosage Forms

Solid Dosage Forms

Medication Delivery Systems(1)

• Began as simple extract of plants made into powders

• Present day: complex delivery systems

Solid Dosage Forms

To Crush or Not to Crush?

• Extended release products- suffixes for sustained-release, controlled-release, or controlled-delivery products include: 12-hour, 24-hour, CC, CD, CR, ER, LA, Retard, SA, Slo-, SR, XL, XR, or XT.

• Enteric coated tablets

To Crush or Not to Crush?Extended-Release formulations

• Capsules- opened, sprinkled,…• Lansoprazole• Diltiazem• Duloxetine

• Tablets-• K-Dur• Tegretol CR

To Crush or Not to Crush?Enteric Coated tablets

• No• Enteric coating will

not dissolve• Switch to regular

tablet

To Crush or Not to Crush?Taste

• Altered texture of medication• Local anesthetic effect• Stain teeth• Irritate mouth, esophageal mucosa or stomach

lining• Coating on tablets or capsules to mask bitter

or unpleasant taste

To Crush or Not to Crush?Risk to Nurse

• Crushing some potential teratogenic/carcinogenic/allergenic medications can put nurse at risk.

• Drugs: • Bosentan• Methotrexate• Dutasteride• Mycophenolate• Raloxifene• Finasteride

Types of Drug Formulations:

• Solid immediate release tablets & capsules• Enteric coated tablets• Sustained release tablets & capsules• Liquid solutions• Buccal or sublingual preparations • carcinogenic, teratogenic, or cytotoxic

properties should also not be crushed.

Best Practice Guidelines from ASPEN:Methods of Administering Medications via Enteral Feed Tubes (1)

• Do not add medication directly to an enteral feeding formula.• Administer each medication separately through an appropriate

access site.• Liquid dosage forms should be used when available and if

appropriate.• Only immediate-release solid dosage forms may be substituted.

• Grind simple compressed tablets to a fine powder and mix with sterile water.• Open hard gelatin capsules and mix the powder with sterile water.

• Avoid mixing together medication intended for administration through an enteral feeding tube, given the risks of physical and chemical incompatibilities, tube obstruction, and altered drug responses.

Best Practice Guidelines from ASPEN:Methods of Administering Medications via Enteral Feed Tubes (1

• Before administering medicatoin, stop feeding and flush the tube with at least 15ml of sterile water.

• Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe that’s 30ml or larger.

• Flush the tube again with at least 15ml of sterile water, taking into account the patient’s volume status.

• Repeat the previous three steps before administering the next medication.

• After all the medications have been administerd , flush the tube one final time with at least 15ml of sterile water.

• Restart feeding in a timely manner to avoid compromising the patient’s nutritional status. Feeding may be delayed for 30minutes or longer, when appropriate, to avoid altering the bioavailability of the drug.

• Consult with a pharmacist as needed.

Methods to Unclog Feeding Tubes:

• Flushes before and after medication administration

• Use a syringe of greater than 30mls to avoid rupture of tube

• Warm Water flushes, CB or Cra. JUICE• Sodium Bicarbonate 325mg tab and

Pancreatic Enzyme capsule• mechanical declogging device

Specific Medications:

• Phenytoin (70% less abs.)

• Carbamazepine

• Fluoroquinolones

• Warfarin

• Proton Pump Inhibitors

Methods of crushing:

•Mortar and pestle

•Silent knight

•Crushing syringe

Interdisciplinary Team

• Communication• Physician• Nurse• Pharmacist• Dietician

• Medication Administration Record

• Links to resources

Conclusions

• Reduce drug therapy to the minimum necessary.

• Transfer QD formulations with a long half-life where possible (not modified- slow-release formulations).

• Determine alt. formulations and routes available where possible.

• Effectively monitored with each change.