Patient Case:

A 16-year-old girl with a known case of cerebral palsy presented to the ER after accidental removal of percutaneous endoscopic gastrostomy (PEG) feeding tube, which resulted in infection, skin irritation and oozing. While the patient was bleeding, the feeding tube was changed to a nasogastric tube (NGT) and the patient started on pantoprazole 40 mg intravenous twice daily. Few days later, patient therapy was changed to esomeprazole magnesium trihydrate tablet (Nexium ®) 40 mg orally twice daily via NGT. Few days later, the patient bled again! After reviewing patient’s medication regimen, it determined that esomeprazole was given after being crushed and mixed with water. Esomeprazole formulation is a film-coated tablet containing a compressed core of enteric coated micro-granules that should not be crushed. Instead, it should be mixed with water to dissolve it into little pellets for feeding tube administration.

Types of Feeding Tubes 

The type of feeding tube used will vary depending on the intended duration of feeding and the part of the GI tract the feed needs to be delivered to. Nasoenteric tubes are used for short- to medium-term feeding, whereas ostomy tubes are used for long-term feeding.

Practical Points to Consider When Administering Medication via Eternal Feeding Tube  

Route suitability

· Oral medications intended to be taken by mouth are not necessarily safe to be administered through a feeding tube

· It is important to determine the location of the distal end of the feeding tube to ensure the medication(s) will be properly dissolved and absorbed. For example, oral iron, which dissolved in the stomach and absorbed in the duodenum, will not be properly absorbed if administered via a jejunostomy tube.

Drug and dosage form suitability

· Ensure the medication and formulation are appropriate for enteral administration

· Solutions or soluble tablets are the formulations of choice

· Do not assume that liquid formulation will always be suitable

· Many immediate-release tablets can be safely crushed into a fine powder and diluted with purified water prior to administration 

· Sublingual, enteric-coated, and extended/delayed-release medications, SHOULD NOT be crushed

· Manufacturers use suffixes like [CD, CR, ER, LA, SA, SR, XR, XL] to denote extended/delayed release. However, some extended/delayed-release formulations lack the suffix designations (ex. OXYCONTIN)

Don’t mix medications

· Do not add medication(s) directly to the formula. Mixing drugs with the formula could cause drug-formula interactions, leading to tube blockages, altered bioavailability, and changes in bowel function.

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· Each medication should be administered separately through the feeding tube

Flush feeding tube

Stop the feeding and flush the tube with at least   15 mL of purified water before and after administering each medication. This is considered the single most effective action in prolonging the life of any enteral feeding tube.

Restart the feeding

The feeding can usually be restarted after drug administration and flushing (some drugs require a delay of 30 minutes or more)

General Recommendation

Consult pharmacists for assistance in selecting appropriate formulations or therapeutic equivalents, as well as for recommendations to minimize drug–nutrient interactions and ensure optimum drug delivery

References:

• White, Rebecca, and Vicky Bradnam (2011). Handbook of drug administration via enteral feeding tubes. London: Pharmaceutical Press.

• Preventing errors when administering drugs via an enteral feeding tube. ISMP; 2010: 8 (3): 1-4