The Administration of Drugs Via Enteral Feeding Tubes Clinical Guideline V5.0 February 2020 Summary General Notes GP/SWASFT Key: ED/MAU/SRU/Acute GP/Amb-Care In-patient wards Start Switch off feed if running Immediately flush the tube with water (at least 30mL) Check if a break is needed before drug administration Prepare medicine as instructed (see full guidance) Give medicine via feeding tube Draw up 15mL of water into the same syringe and flush down feeding tube to remove any residual drug Are there Yes more No Flush tube slowly with 30mL water, medicines to ensuring the tube is clean be given? Check if a break is needed after drug administration Restart feed if necessary End The Administration of Drugs Via Enteral Feeding Tubes Clinical Guideline V5.0 Page 2 of 17 1. Aim/Purpose of this Guideline 1.1. The purpose of this policy is to inform all practitioners of their responsibility in the safe and effective administration of medicines via enteral feeding tubes. 1.2. This document specifies the minimum standard procedure that should be applied to prescribing, preparation and administration of medicines via enteral feeding tubes to minimise risks to both healthcare personnel and patients. 1.3. This version supersedes any previous versions of this document. 1.4. Data Protection Act 2018 (General Data Protection Regulation – GDPR) Legislation The Trust has a duty under the DPA18 to ensure that there is a valid legal basis to process personal and sensitive data. The legal basis for processing must be identified and documented before the processing begins. In many cases we may need consent; this must be explicit, informed and documented. We can’t rely on Opt out, it must be Opt in. DPA18 is applicable to all staff; this includes those working as contractors and providers of services. For more information about your obligations under the DPA18 please see the ‘information use framework policy’, or contact the Information Governance Team [email protected] 2. The Guidance 2.1. Due to individual patient requirements, it is often necessary to administer medicines via enteral feeding tubes. 2.2. Crushing tablets, opening capsules and administration via feeding tubes usually falls outside a drug’s product licence and presents an increased risk for patients compared to other routes of administration. In these circumstances, the prescriber and practitioner accept liability for any adverse effects resulting from this route of administration. 2.3. Bioavailability cannot be guaranteed when medications have been modified via crushing or opening of capsules, or when drugs are administered via enteral feeding tubes. Changes to pharmacokinetic or pharmacodynamic properties following crushing tablets or opening capsules have rarely been studied. 2.4. Main types of feeding tubes Nasogastric (NG), a tube passed through the nose into the stomach. They come in two main types: Wide bore – Short term tube not sited specifically for enteral feeding (they are used for stomach aspiration and drainage). These tubes are usually made of The Administration of Drugs Via Enteral Feeding Tubes Clinical Guideline V5.0 Page 3 of 17 polyvinyl chloride with a bore size of 9-22 French Gauge (FG), e.g. Ryle’s tube. - These tubes should not be used for feeding or administration of medicines. Fine bore – These tubes are used for enteral feeding and may be left in situ for 7 days to 6 weeks. They have a bore size of 6-12 FG and are usually made of polyurethane, making them softer than large bore tubes. There are two types of fine bore tube, those with a guide wire (stylet) and those that are weighted. 2.5. Nasojejunal (NJ), a tube passed through the nose into the jejunum They come in two main types: Single lumen Double lumen (the second lumen is used as a gastric aspiration port) 2.6. Gastrostomy tube, a tube inserted through the abdominal wall into the stomach 2.6.1. There are a number of different types of gastrostomy tube based on size (9-24 FG), internal fixator (flange, balloon) and material. 2.6.2. Gastrostomy tubes may be inserted endoscopically (percutaneous endoscopic gastrostomy or PEG), radiologically (radiologically inserted gastrostomy tube, or RIG) or surgically inserted. 2.6.3. These tubes are used for longer-term feeding. 2.7. Surgical or percutaneous endoscopic jejunostomy (PEJ), a tube inserted through the abdominal wall into the jejunum These tubes are used for longer-term feeding. 2.8. Percutaneous endoscopic gastro-jejunostomy (PEGJ), a jejunostomy tube inserted via a PEG tube through the abdominal wall into the jejunum These tubes are used for longer-term feeding. 2.9. Considerations before administering drugs via a feeding tube 2.9.1. Can the patient still take their medicines orally? Liquid preparations are often available Some tablets and capsules can be crushed/opened and administered orally with water. Do NOT crush modified release (MR) or enteric coated (EC) preparations, or pierce soft gel capsules. 2.9.2. Review all medication. Is it all really necessary? 2.9.3. Can an alternative route be used? Rectal (e.g. aspirin, diclofenac, paracetamol) The Administration of Drugs Via Enteral Feeding Tubes Clinical Guideline V5.0 Page 4 of 17 Parenteral (IV, SC, IM) Transdermal (e.g. hyoscine, GTN, HRT) Sublingual/buccal (e.g. prochlorperazine, lorazepam) 2.9.4. Can an alternative drug be substituted that can be given by a more suitable method of administration? 2.9.5. Is the patient fluid restricted or a paediatric patient? Flushing volumes may need reducing. 2.9.6. Where is the end of the tube situated? Some drugs may have reduced absorption when administered to the jejunum. This is especially important for drugs with a narrow therapeutic index. Liquids containing large amounts of sorbitol can be problematic when administered to the jejunum and may need diluting. Where dilution affects the stability of a drug, an alternative may need to be sourced. 2.9.7. What type of tube is being used? Bore size and tube length can affect the chances of tube blockage. Some tubes have multi-lumens. Medication must not be administered down an aspiration/gastric decompression port. 2.9.8. Is the tube still correctly placed for fine bore tube feeding? Tube markings and pH indicator strips should be used to confirm correct placement prior to administration of medicines (NPSA/2011/PSA002). 2.10. Choosing a formulation 2.10.1. Can the drug be given via another route that is licensed? 2.10.2. Is there a commercial oral solution/suspension or dispersible tablet available? 2.10.3. Liquids may contain sorbitol, which can cause diarrhoea and cramps. Large doses of sorbitol should be avoided. 2.10.4. Liquids with high osmolality can cause osmotic diarrhoea. The risk of diarrhoea can be reduced by diluting the preparation – although note the stability of some liquid formulations may be adversely affected by dilution. 2.10.5. Bio-availability may vary between solid and liquid forms of a drug, and therefore dose adjustments may be required (e.g. citalopram, phenytoin, digoxin). 2.10.6. Large volumes may be required, especially if only paediatric preparations with low concentrations are available. This may increase cost. The Administration of Drugs Via Enteral Feeding Tubes Clinical Guideline V5.0 Page 5 of 17 2.10.7. Liquid preparations of the same drug may come in different concentrations, which could result in an incorrect dose given if the strength is not checked. 2.10.8. Some suspensions may block feeding tubes. 2.10.9. Some liquids have high alcohol contents. These liquids may be unsuitable for alcohol-dependant or epileptic patients, or patients on metronidazole, warfarin etc. This is especially a problem when given by PEJ/NJ. 2.10.10. Viscous liquids may require dilution, but this can affect stability. 2.10.11. Dispersible and effervescent tablets may be used via feeding tubes, but many contain sodium – caution in sodium-restricted patients. 2.10.12. Converting modified-release to immediate-release formulations may require a dose or frequency change. 2.11. Will crushed tablet/capsule contents disperse fully/form a fine suspension that will not block the tube? Is the tablet suitable for crushing? 2.11.1. Enteric coated, modified-release, cytotoxic, antibiotic and hormonal drugs should not be crushed, unless otherwise advised, due to the risk of toxic side effects or staff exposure to the drug. 2.11.2. Sublingual or buccal tablets should not be crushed, as this may result in reduced bio-availability. They may be used sublingually in place of oral preparations only if the patient is producing adequate amounts of saliva. 2.11.3. Fractional dosing from dispersed tablets is not recommended due to inaccuracy. 2.11.4. Many chewable tablets should not be crushed. Some preparations (e.g. Tegretol chewtabs) are designed so that some of the drug is absorbed in the mouth. 2.11.5. Although designed to be given orally, dispersible tablets will disintegrate when placed in a small amount of water, e.g. 10–15 mL; however, not all are suitable for administration via an enteral feeding tube, as the resultant particles or granules may be too large for administration via fine-bore tubes 2.12. Is the injection suitable for enteral use? 2.12.1. Some injections contain excipients that are not suitable for oral administration e.g. polyethylene glycol. 2.12.2. Many injections are hypertonic or have a high osmolality, and are unsuitable for oral administration, as they may cause osmotic diarrhoea. The Administration of Drugs Via Enteral Feeding Tubes Clinical Guideline V5.0 Page 6 of 17 2.12.3. Formulations may have an unsuitable pH or may degrade in the acidic stomach environment.