Crushing Tablets & Drug Administration via Enteral Feeding Tubes

KEY POINTS

• Always follow local guidelines when crushing tablets and/or administering drugs via enteral feeding tubes
• Potential clinical resources that may be consulted to check whether a drug is suitable for crushing include local guidelines, the drug’s data sheet/Summary of Product Characteristics (SmPC), a reputable clinical textbook on tablet crushing or checking with a hospital’s medicines information department.
• Before considering whether a drug can be crushed, explore if an alternative formulation can be given to the patient such as transdermal patches, sublingual tablets, buccal tablets, injections, nasal spray, oral liquids, immediate-release tablets, pessaries or suppositories. If the patient’s medicine is switched from one formulation to another, it is crucial to consider the dose equivalence between the two formulations.
• If an alternative formulation cannot be given to the patient, consider prescribing a suitable alternative medicine
• The following should not be crushed: EC (enteric-coated)/gastro-resistant medicines, MR (modified-release) medicines, CR (controlled release) medicines, XL (extended-release) medicines, LA (long-acting) medicines, SA (sustained action) medicines, SR (sustained release) medicines, buccal medicines and sublingual medicines.
• Furthermore, the following medicines belonging to these drug classes should not be crushed either: hormone antagonists, cytotoxics, teratogenic medications, steroids and antibiotics
• Please be aware that there are some situations where it might be required to crush a tablet or open a capsule from these drug classes. In these situations, it is important to follow health and safety protocols to protect healthcare workers from accidental exposure to potentially harmful drug particles that have teratogenic, carcinogenic, or irritating effects.
• Here is a list of 50+ medications that should not be crushed

Guidelines for Tablet Crushing in Patients With Swallowing Difficulties
Colchester Hospital University NHS Foundation Trust

• Source: stch.org.uk
• Clinical Resource: Guidelines
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Swallowing Difficulties
Prescriber Information

This section is designed to help you prescribe appropriately for patients with dysphagia and those with enteral feed tubes. In both instances basic guidance on what should be considered is provided.

Additionally for those patients where you have decided that crushing is the only option available for you to recommend we have provided information on different types of tablet, different coatings and modified formulations so that you can determine whether crushing may be appropriate or not.

Information on the effect of crushing in both clinical and legal terms is provided as well as information on other formulations which you may choose to prescribe instead.

• Source: swallowingdifficulties.com
• Clinical Resource: Various
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Swallowing Difficulties – Specialist Pharmacy Service

All our advice on using medicines safely and effectively in patients with swallowing difficulties

• Source: sps.nhs.uk
• Clinical Resource: Clinical Various
• Register to Access Content: No

Optimising Medicines Administration for Patients with Dysphagia in Hospital: Medical or Nursing Responsibility?

This article considers the clinical and legal issues surrounding administration of medicines to people with dysphagia from a UK perspective and debates whether medicines optimisation should be the primary responsibility of the prescriber when initiating therapy on the ward or the nurse who administers the medicine.

• Source: nih.gov
• Clinical Resource: Journal Article
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”Primary Care Guidance: Prescribing medicines for adults who are unable to swallow oral solid dosage forms
Betsi Cadwaladr University Health Board

Some adults have difficulty swallowing oral solid dosage forms such as tablets and capsules; therefore prescribers must work with the patient and/or carer(s) to address their needs. This guideline provides a framework for healthcare professionals to support their prescribing decisions in response to the increased demand, complexity and cost of some “specials”. This guidance was developed by Betsi Cadwaladr University Health Board and endorsed by AWMSG as an example of good practice.

• Source: awttc.nhs.wales
• Clinical Resource: Guidance
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Dispersing/Tablets Or Opening Capsules for Commonly Prescribed Medicines Guidelines
Derby and Derbyshire Integrated Care Board

This guideline contains a list of commonly prescribed medicines and alternative methods of administration for patients with swallowing difficulties, feeding tubes or for patients prescribed unlicensed ‘specials’ medication.

• Source: derbyshiremedicinesmanagement.nhs.uk
• Clinical Resource: Advice
• Register to Access Content: No

Considerations when switching between solid doses and liquids

Bioavailability, release profile and licensed uses are some of the considerations needed when changing between solid dose and liquid formulations.

• Source: sps.nhs.uk
• Clinical Resource: Advice
• Register to Access Content: No

Guide for Crushing Oral Medication for Residents with Swallowing Difficulties in Residential Aged Care

• Source: saferx.co.nz
• Clinical Resource: List
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Medicine Leaflets – Medicines for Children

Search their A to Z list of medicines. Find instructions on how to give a particular medicine in a tablet or capsule form to a child.

• Source: medicinesforchildren.org.uk
• Clinical Resource: Database
• Register to Access Content: No

Which injections can be given orally or via enteral feeding tubes?

This updated Medicines Q&A is a quick reference summary to different types of enteral feeding tubes, in relation to medication issues.

• Source: sps.nhs.uk
• Clinical Resource: Medicines Question and Answer
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Oral Antiretroviral Administration: Information on Crushing and Liquid Drug Formulations

• Source: hivclinic.ca
• Clinical Resource: Table
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Antiretroviral Dosage Forms for Swallowing Difficulties

• Source: hiv-druginteractions.org
• Clinical Resource: Table
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When Patients Cannot Take Pills: Antiretroviral Drug Formulations for Managing Adult HIV Infection

A thorough search of several drug databases, a literature search of MEDLINE through Ovid, and a review of full prescribing information for each currently available antiretroviral drug, was performed to obtain insight into the bioavailability of antiretrovirals. Implications for the findings are discussed as they relate to adherence, resistance, alternative methods of administration, and the sometimes conflicting information on bioavailability that exists for various antiretroviral agents.

• Source: iasusa.org
• Clinical Resource: Journal Article
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Administrating medicines by enteral feeding tubes

A practical guide

• Source: bapen.org.uk
• Clinical Resource: Guide
• Register to Access Content: No

American Society for Parenteral and Enteral Nutrition Enteral Nutrition Practice Recommendations > VII. Medication Administration

• Source: nutritioncare.org
• Clinical Resource: Guideline
  
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Medication Administration Through Enteral Feeding Tubes

Drug therapy can be complicated in hospitalized patients requiring an enteral feeding tube (EFT). Some medications may be given via an EFT while others are unsuitable for this form of administration. Inappropriate drug selection for EFT administration can cause potential toxicity, reduced efficacy, and tube obstruction. Therefore, it is important to know which drugs may be altered for EFT administration as well as appropriate therapeutic alternatives that can temporarily be substituted for those that may not be given via that route.

• Source: clevelandclinicmeded.com
• Clinical Resource: Newsletter
  
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Medication Administration Through Enteral Feeding Tubes

An overview of enteral feeding tubes, drug administration techniques, considerations for dosage form selection, common drug interactions with enteral formulas, and methods to minimize tube occlusion is given.

• Source: medscape.com
• Clinical Resource: Newsletter
  
• Register to Access Content: Yes – registration is FREE

Medication administration via enteral feeding tubes

Presentation by Tom Richardson, Alfred clinical pharmacists

• Source: alfredhealth.org.au
• Clinical Resource: Presentation
  
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Advice for Health Professionals: Choosing medicines for patients unable to take solid oral dosage forms
Northern Ireland (NI) Regional Medicines and Poisons Information Service

• Source: niformulary.hscni.net
• Clinical Resource: Guideline
  
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Therapeutic options for adult patients unable to take solid oral dosage forms

• Source: niformulary.hscni.net
• Clinical Resource: Table
  
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To Hold (Enteral Feeding) or Not to Hold: That IS the Question; A Commentary and Tutorial

The purpose of this paper is to serve as a tutorial to guide clinical decision making rather than a comprehensive review of the existing literature. Clinicians are strongly encouraged to review the literature concerning drug-specific management approaches that have been published and exercise good clinical judgment to individualize the patient care plan.

• Source: virginia.edu
• Clinical Resource: Journal Article
  
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Drug-Nutrient Considerations in Patients Receiving Parenteral and Enteral Nutrition

This article will focus on basic knowledge needed for identification and appropriate management of drug-nutrient interactions in patients requiring enteral nutrition (EN) and parenteral nutrition (PN). Drug-nutrient interactions will be divided into four categories based upon their mechanisms: 1) ex vivo biopharmaceutical inactivations; 2) interactions affecting absorption; 3) interactions affecting systemic/physiologic dispositions; and 4) interactions affecting elimination/clearance. Each category will be discussed separately and examples will be given to illustrate the use of alternative methods to assure safe drug administration.

• Source: virginia.edu
• Clinical Resource: Journal Article
  
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Management of Phenytoin with Enteral Tube Feeding

Though the interaction between enteral tube feeding and phenytoin was first described 30 years ago, the mechanism of the interaction is still poorly understood.
In the discussions below, we will highlight some drug – enteral tube feeding interactions which have been found to be clinically important.

• Source: cpnp.org
• Clinical Resource: Article
  
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Enteral administration of protein supplement and valproate: A potential pharmacokinetic interaction

Valproic acid (VPA) and its derivatives are highly protein bound. Certain highly protein bound medications (eg, phenytoin) have specific administration instructions for patients on enteral nutrition supplements to optimize absorption of the medication. Pharmacokinetic interactions between VPA and enteral nutrition or protein supplements demonstrating impaired absorption have not been published to date.

• Source: cpnp.org
• Clinical Resource: Article
  
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How Does Warfarin Interact With Enteral Nutrition?

How does warfarin interact with enteral nutrition, and can this interaction be minimized?

• Source: medscape.com
• Clinical Resource: Question and Response
  
• Register to Access Content: Yes – registration is FREE

Tube feeding and Pancreatic Enzymes (Creon)

• Source: virginia.edu
• Clinical Resource: Instructions
  
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Optimizing Patient Care: Administering Psychotropic Medications via Enteral Route

Colleagues from the ESCP Special Interest Group Mental Health have prepared a very useful leaflet on Optimizing Patient Care: Administering Psychotropic Medications via Enteral Route.

• Source: escpweb.org
• Clinical Resource: Leaflet
  
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