Handbook of Drug Administration via Enteral Feeding Tubes

Handbook of Drug Administration via Enteral Feeding Tubes

THIRD EDITION

Rebecca WhiteBSc (Hons) MSc MRPharmS (I Presc) FFRPSMedical Advisor, Baxter Healthcare LtdCompton, UK

Vicky BradnamBPharm (Hons) ClinDip MBAOpen MRPharmSPharmaceutical Consultant, Kent, UK

On behalf of the British Pharmaceutical Nutrition Group

Published by Pharmaceutical Press

1 Lambeth High Street, London SE1 7JN, UK

© Pharmaceutical Press 2015

is a trade mark of Pharmaceutical Press

Pharmaceutical Press is the publishing division of the Royal Pharmaceutical Society

First edition 2007

Second edition 2011

Third edition 2015

Typeset by Newgen, India

Printed in Great Britain by TJ International, Padstow, Cornwall

ISBN 978 0 85711 162 3 (print)

ISBN 978 0 85711 221 7 (ePDF)

ISBN 978 0 85711 222 4 (ePub)

ISBN 978 0 85711 223 1 (Mobi)

All rights reserved. No part of this publication may be reproduced, stored in a retrieval

system, or transmitted in any form or by any means, without the prior written permis-

sion of the copyright holder.

The publisher makes no representation, express or implied, with regard to the accuracy

of the information contained in this book and cannot accept any legal responsibility or

liability for any errors or omissions that may be made.

The right of Rebecca White and Vicky Bradnam to be identified as the authors of this

work has been asserted by them in accordance with the Copyright, Designs and Patents

Act, 1988.

Contents

Foreword xiPreface xiiAbout the authors xiiiContributors xvAbbreviations xviiiNotes on the use of this book xx

1. Introduction 1

2. Types of enteral feeding tube 4

3. Flushing enteral feeding tubes 9

4. Restoring and maintaining patency of enteral feeding tubes 15

5. Drug therapy review 23

6. Choice of medication formulation 25

7. The legal and professional consequences of administering drugs via enteral feeding tubes 38

8. Health and safety and clinical risk management 47

9. Syringes and ports 51

10. Defining interactions 55

11. Medicines optimisation 61

Individual drug monographs:

Abacavir 63

Acamprosate calcium 65

Acarbose 66

Acebutolol 67

Aceclofenac 69

Acemetacin 70

Acenocoumarol (Nicoumalone) 71

Acetazolamide 72

Acetylcysteine 74

Aciclovir 75

Acipimox 77

Acitretin 78

Adefovir dipivoxil 79

Alendronic acid 81

Alfacalcidol 84

Alfuzosin hydrochloride 86

Alimemazine (Trimeprazine) tartrate 88

Alitretinoin 89

Allopurinol 90

Almotriptan 92

Aluminium hydroxide 93

Alverine citrate 94

Amantadine hydrochloride 95

Amiloride hydrochloride 96

Aminophylline 98

Amiodarone hydrochloride 99

Amisulpride 101

vi Contents

Amitriptyline hydrochloride 102

Amlodipine 104Amoxicillin 106Anastrozole 108Arginine 109Ascorbic acid 111Aspirin 112Atenolol 113Atorvastatin 116Azathioprine 117Baclofen 120Balsalazide sodium 122Beclometasone dipropionate 122Bendroflumethiazide 123Betahistine dihydrochloride 125Betaine 126Betamethasone 128Bethanechol chloride 129Bexarotene 130Bezafibrate 131Bicalutamide 133Bisacodyl 134Bisoprolol fumarate 135Bromocriptine 137Budesonide 139Bumetanide 140Busulfan 141Cabergoline 143Caffeine citrate 144Calcium folinate (Calcium leucovorin) 146Calcium salts 147Calcium salts with vitamin D 150Candesartan cilexetil 152Captopril 154Carbamazepine 156Carbimazole 158Carbocisteine 159Carvedilol 161Cefalexin (Cephalexin) 162Cefixime 164Cefradine (Cephradine) 166Cefuroxime 167Celecoxib 169

Celiprolol hydrochloride 170Cetirizine hydrochloride 171Chloral hydrate 173Chloroquine 175Chlorphenamine (Chlorpheniramine) maleate 176Chlorpromazine hydrochloride 178Chlortalidone (Chlorthalidone) 180Ciclosporin 181Cilazapril 183Cimetidine 184Cinnarizine 186Ciprofloxacin 187Citalopram 189Clarithromycin 191Clindamycin 193Clobazam 195Clomipramine hydrochloride 196Clonazepam 198Clonidine hydrochloride 200Clopidogrel 201Clozapine 204Co-amilofruse 205Co-amilozide 207Co-amoxiclav 208Co-codamol 210Co-fluampicil 212Co-flumactone 213Codeine phosphate 214Colchicine 216Colecalciferol 217Colestyramine 218Co-magaldrox 220Co-phenotrope 221Co-trimoxazole 222Cyclizine 224Cyclophosphamide 226Dantron (Danthron) 228Dapsone 229Deferasirox 231Deferiprone 232Deflazacort 233Demeclocycline hydrochloride 234

Contents vii

Desloratadine 235Desmopressin 236Dexamethasone 239Dexibuprofen 241Diazepam 241Diazoxide 244Diclofenac 245Dicycloverine (Dicyclomine) hydrochloride 248Digoxin 249Dihydrocodeine tartrate 251Diltiazem hydrochloride 252Dipyridamole 255Disodium etidronate 258Docusate sodium 259Domperidone 261Donepezil hydrochloride 263Dosulepin (Dothiepin) hydrochloride 264Doxazosin mesilate 266Doxepin 268Doxycycline 270Duloxetine hydrochloride 272Efavirenz 274Eletriptan 276Enalapril maleate 277Entacapone 279Eprosartan 280Ergocalciferol 282Erythromycin 283Escitalopram 285Esomeprazole 286Ethambutol hydrochloride 289Ethinylestradiol 290Ethosuximide 291Etodolac 293Etoposide 294Etoricoxib 295Ezetimibe 297Famciclovir 299Famotidine 300Felodipine 301Fentanyl 302Fesoterodine fumarate 304

Fexofenadine hydrochloride 305Finasteride 306Flavoxate hydrochloride 307Flecainide acetate 309Flucloxacillin 310Fluconazole 312Fludrocortisone acetate 314Fluoxetine 315Flupentixol (Flupenthixol) 317Flutamide 319Fluvastatin 320Fluvoxamine maleate 322Folic acid 323Fosamprenavir 324Fosinopril sodium 325Frovatriptan 326Furosemide (Frusemide) 327Gabapentin 330Galantamine 332Ganciclovir 334Glibenclamide 335Gliclazide 336Glimepiride 338Glipizide 339Glyceryl trinitrate 341Glycopyrronium bromide 342Granisetron 343Griseofulvin 345Haloperidol 347Hydralazine hydrochloride 349Hydrocortisone 350Hydromorphone hydrochloride 352Hydroxycarbamide (Hydroxyurea) 353Hydroxyzine hydrochloride 354Hyoscine butylbromide 355Hyoscine hydrobromide 357Ibandronic acid 358Ibuprofen 359Imipramine hydrochloride 361Indapamide 363Indometacin (Indomethacin) 364Indoramin 365Inositol nicotinate 367

viii Contents

Irbesartan 368Iron preparations 370Isoniazid 373Isosorbide dinitrate 374Isosorbide mononitrate 375Ispaghula husk 377Isradipine 378Itraconazole 379Ketamine 381Ketoconazole 382Ketoprofen 384Ketorolac trometamol 385Labetalol hydrochloride 387Lacidipine 388Lacosamide 389Lactulose 390Lamivudine 392Lamotrigine 394Lansoprazole 395Leflunomide 397Lercanidipine hydrochloride 399Levetiracetam 400Levocetirizine hydrochloride 402Levodopa 403Levofloxacin 406Levomepromazine (Methotrimeprazine) 408Levothyroxine sodium 410Linezolid 412Lisinopril 413Lithium 416Lofepramine 417Loperamide hydrochloride 419Lopinavir with ritonavir 420Loratadine 421Lorazepam 423Losartan potassium 424Macrogols 427Magnesium preparations 428Maraviroc 430Mebendazole 431Mebeverine hydrochloride 432Mecysteine 434

Medroxyprogesterone acetate 435Mefenamic acid 436Megestrol acetate 437Melatonin 438Meloxicam 439Memantine hydrochloride 440Menadiol sodium phosphate (Vitamin K) 441Meptazinol 442Mercaptamine 443Mercaptopurine 444Mesalazine 445Mesna 447Mesterolone 448Metformin hydrochloride 449Methadone hydrochloride 451Methenamine hippurate (Hexamine hippurate) 452Methotrexate 453Methyldopa 455Methylprednisolone 456Metoclopramide hydrochloride 457Metolazone 459Metoprolol tartrate 460Metronidazole 462Metyrapone 465Mexiletine hydrochloride 466Midazolam 467Minoxidil 469Mirtazapine 470Misoprostol 472Mizolastine 473Moclobemide 474Modafinil 475Moexipril hydrochloride 476Montelukast 477Morphine sulfate 479Moxonidine 482Multivitamin preparations 483Mycophenolate mofetil 486Nabumetone 488Nadolol 489Naftidrofuryl oxalate 490

Contents ix

Naproxen 492Naratriptan 493Nebivolol 494Nefopam hydrochloride 495Neomycin sulfate 496Neostigmine 498Nevirapine 499Nicardipine hydrochloride 500Nicorandil 501Nifedipine 503Nimodipine 505Nitrazepam 506Nitrofurantoin 508Nizatidine 509Norethisterone 510Ofloxacin 512Olanzapine 513Olmesartan medoxomil 515Olsalazine sodium 516Omeprazole 518Ondansetron 520Orlistat 522Orphenadrine hydrochloride 523Oseltamivir 525Oxazepam 528Oxcarbazepine 529Oxprenolol hydrochloride 531Oxybutynin hydrochloride 532Oxycodone hydrochloride 534Oxytetracycline 536Paliperidone 538Pancreatin supplements 539Pantoprazole 542Paracetamol 543Paroxetine 545Pentoxifylline (Oxpentifylline) 546Perindopril erbumine 547Phenelzine 548Phenobarbital (Phenobarbitone) 549Phenoxybenzamine hydrochloride 551Phenoxymethylpenicillin 552Phenytoin 553Phosphates 556

Piroxicam 557Pizotifen 559Polystyrene sulfonate resins 560Posaconazole 561Potassium chloride 562Pravastatin sodium 564Prazosin 565Prednisolone 567Pregabalin 568Primidone 569Prochlorperazine 571Procyclidine hydrochloride 573Promethazine hydrochloride 574Propranolol hydrochloride 576Pyrazinamide 578Pyridostigmine 579Pyridoxine hydrochloride 581Pyrimethamine 582Quinapril 583Rabeprazole sodium 584Ramipril 585Ranitidine 587Ranolazine 589Reboxetine 590Rifabutin 591Rifampicin 592Rifaximin 594Riluzole 595Risedronate sodium 596Risperidone 599Rivastigmine 601Rizatriptan 602Ropinirole 603Rosuvastatin 605Saquinavir 607Selegiline hydrochloride 608Senna 609Sertraline 610Sildenafil 612Simvastatin 614Sodium clodronate 616Sodium picosulfate 617Sodium valproate 619

x Contents

Sotalol hydrochloride 622Spironolactone 623Stavudine 625Sucralfate 627Sulfasalazine 628Sulpiride 630Sumatriptan 631Tacrolimus 634Tamoxifen 636Tamsulosin hydrochloride 637Telithromycin 639Telmisartan 640Temazepam 641Tenofovir disoproxil 642Terbinafine 645Theophylline 646Thiamine hydrochloride 648Tiagabine 650Timolol maleate 651Tipranavir 652Tizanidine 654Tolbutamide 655Tolterodine tartrate 656Tolvaptan 658Topiramate 659Tramadol hydrochloride 660Trandolapril 663Tranexamic acid 664Trazodone hydrochloride 665Trifluoperazine 667Trihexyphenidyl (Benzhexol) hydrochloride 668

Trimethoprim 670Trimipramine 671Ursodeoxycholic acid 673Valaciclovir 675Valsartan 677Vancomycin 678Vardenafil 680Varenicline 681Venlafaxine 682Verapamil hydrochloride 685Vigabatrin 687Vildagliptin 688Vitamin B compound preparations 689Vitamin E (Alpha tocopheryl acetate) 691Voriconazole 693Warfarin sodium 695Xipamide 697Zafirlukast 698Zaleplon 699Zidovudine 700Zinc sulfate 702Zolmitriptan 703Zolpidem tartrate 704Zonisamide 705Zopiclone 707Zuclopenthixol 708

Index 711

Foreword

The need for this text has been highlighted within the British Pharmaceutical Nutrition

Group (BPNG) and the British Association of Parenteral and Enteral Nutrition (BAPEN)

by healthcare professionals who are challenged on a daily basis by complex patients

whose need for medicines does not fit neatly into the categories used by the pharma-

ceutical industry as part of their process for licensing medicines. To provide the right

level of care for these patients, professionals have to make complex and rational deci-

sions concerning medication, which may mean stepping outside the product licence

for the medication needed. As healthcare progresses and becomes more technical, such

dilemmas become more commonplace. We hope this book will assist healthcare profes-

sionals who have an input into either the patients’ medicines or their enteral nutrition

to understand the necessary decision process they must enter into and how best to

optimise their patient care, thereby ensuring the desired outcomes to meet the patients’

medical and personal needs.

The data in the individual drug monographs is based on available evidence sup-

plied by the drug companies, to whom we are very grateful for their support, and also

on research undertaken by pharmacists.

The production of this text has raised many questions concerning the data avail-

able relating to this method of medication administration; the BPNG will continue to

support research in this growing area of practice.

Thanks are due to all the healthcare professionals who have given their time and

expertise to ensure the practical applicability of this book. Thanks must also go to

Rebecca White who has led tirelessly on this project and undertaken much of the

research to produce this comprehensive guide to drugs and enteral feeding tubes.

Vicky Bradnam

Pharmaceutical Consultant

The initiative to prepare these guidelines was taken by the British Pharmaceutical

Nutrition Group (BPNG) with the support of the British Association of Enteral and

Parenteral Nutrition (BAPEN).

This book reflects current practice and the information available at the time of

going to press. Although the authors have made every effort to ensure that the infor-

mation contained in this reference is correct, no responsibility can be accepted for any

errors.

It is important to note that owing to the method of administration concerned,

most of the recommendations and suggestions in this reference fall outside of the terms

of the product licence for the drugs concerned. It must be borne in mind that any pre-

scriber and practitioner administering a drug outside of the terms of its product licence

accepts liability for any adverse effects experienced by the patient.

Readers outside the United Kingdom are reminded to take into account local and

national differences in clinical practice, legal requirements, and possible formulation

differences.

All enquiries should be addressed to:

Rebecca White at pharmpresseditorial@rpharms.com

Preface

The British Pharmaceutical Nutrition Group, founded in 1988, is an organisation with

a professional interest in nutrition support. The members of this group are pharmacists,

technicians and scientists from the health service, academia and industry. The aims of

the group are to promote the role of pharmaceutical expertise and experience in the

area of clinical nutrition and to ensure the safe and effective preparation and adminis-

tration of parenteral nutrition through effective education and research initiatives, and

to encourage debate into pharmaceutical aspects of nutritional support.

Rebecca White studied at Aston University, Birmingham, and qualified as a phar-

macist in 1994. Experience in aseptic services, intensive care and nutrition support was

gained through working at Central Middlesex Hospital, Charing Cross Hospital and

UCLH over a period of 10 years in London, qualifying as a non-medical prescriber in

2004. During this time Rebecca also completed an MSc, with the School of Pharmacy in

London, evaluating opinions, knowledge and protocols relating to drug administration

via enteral feeding tubes. In 2004, Rebecca took up the role of lead pharmacist for nu-

trition and surgery at Oxford University Hospitals NHS Trust, promoted to consultant

pharmacist in 2012.

Rebecca has been on the executive committee of the BPNG since 1997, and was a

BAPEN honorary officer between 2008 and 2011. In 2003 Rebecca chaired the BAPEN

multidisciplinary group that produced guidance on the safe administration of medica-

tion via enteral feeding tubes and was part of the NPSA group on wrong route errors.

Rebecca is currently Medical Advisor for Baxter Healthcare Ltd.

Apart from drug nutrient interactions, her other professional interests include par-

enteral nutrition, intestinal failure and pharmaceutical aspects of surgical and gastro-

enterological care. She is currently undertaking a part-time PhD under the supervision

of Dr David Wright at the University of East Anglia, investigating the ideal medication

characteristics for enteral tube drug administration.

Vicky Bradnam studied at The School of Pharmacy, University of London and

qualified as a pharmacist in 1985. Experienced in all aspects of a pharmacy service and

specialised in paediatrics in 1990, worked as a lead clinical pharmacist in paediatrics,

About the authors

xiv About the authors

with an interest in paediatric nutrition, from 1990 to 2000, and continued to practise

clinically in paediatrics despite moving into departmental management. Vicky was the

Chief Pharmacist for Bromley Hospitals NHS Trust, which became part of South Lon-

don Healthcare NHS Trust, before leaving the organisation. She holds a Certificate and

Diploma in Clinical Pharmacy, an MBA and PRINCE2 practitioner level qualifications.

Over the 25 years working as a hospital pharmacist Vicky has worked in both large

teaching hospitals and DGHs. She has been involved in management, professional

development and leadership, lecturing, service planning, budgetary management and

clinical practice. Through her specialisation as a paediatric pharmacist, she has an in-

terest in unlicensed drug administration and the importance of standardising practice

for the safety and benefit of the patients. Vicky has been an active member of the BPNG

and chaired the group between 2002 and 2004, for her services to the group she was

awarded life membership in 2006.

Authors

Rebecca White BSc (Hons) MSc MRPharmS (I Presc) FFRPS, Medical Advisor,

Baxter Healthcare Ltd, Compton, UK

Vicky Bradnam BPharm (Hons) ClinDip MBAOpen MRPharmS, Pharmaceutical

Consultant, Kent, UK

Jane Fletcher MMedSci (Human Nutrition), BA, RGN, Nutrition Nurse Team

Leader, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK

Lynne Colagiovanni RGN, Independent Consultant, Birmingham, UK

Kate Pickering RGN DipN BA, Lead Nutrition Nurse Specialist, Leicester Royal

Infirmary, University Hospitals of Leicester, Leicester, UK

Professor David Wright BPharm (Hons), PhD, MRPharmS, Deputy Head of

School, Head of Medicines Management and Director of Admissions, School of Phar-

macy, University of East Anglia, Norwich, UK

Members of the original BAPEN Working Party

Chair: Rebecca White, Oxford Radcliffe Hospitals NHS Trust

Lynne Colagiavanni, University Hospitals Birmingham

Geoffrey Simmonett, PINTT Representative

Fiona Thompson, Glasgow Royal Infirmary

Kate Pickering, Leicester General Infirmary

Katie Nicholls, Princess Alexandra Hospital

Julian Thorne, Torbay Hospital

Julia Horwood, North Thames Medicines Information

Thanks to staff at the pharmacy departments of University College London Hospitals

and Oxford University Hospitals NHS Trust

Contributors

xvi Contributors

Reviewers

Sarah Zeraschi Consultant Pharmacist – Nutrition, Leeds Teaching Hospitals NHS

Trust, Leeds, UK

Clare Faulkner MPharm (Ipresc), Specialist Pharmacist, Oxford University Hospitals

NHS Trust, Oxford, UK

Vicky Bradnam BPharm(Hons) ClinDip MBAOpen MRPharmS, Pharmaceutical

Consultant, Kent, UK

Lucy Thompson MRPharmS, Principal Pharmacist, King’s Hospital, London, UK

Jackie Eastwood MRPharmS, Pharmacy Manager, St Mark’s Hospital, London, UK

Ruth Newton MRPharmS, Principal Pharmacist, City Hospital, Stoke-on-Trent, UK

Antonella Tonna PhD MRPharmS, Lecturer in Clinical Pharmacy, School of Pharmacy

and Life Sciences, Robert Gordon University, Aberdeen, UK

Mel Snelling MRPharmS, Lead Pharmacist – Infectious Diseases, Oxford Radcliffe

Hospitals NHS Trust, Oxford, UK

Yogini Jani PhD ClinDip, MRPharmS, Lead Pharmacist – Medication Safety, University

College London Hospitals NHS Foundation Trust, London, UK

Diane Evans MRPharmS, Lead Pharmacist – Medicine, Oxford Radcliffe Hospitals

NHS Trust, Oxford, UK

Venetia Simchowitz (nee Horn) MRPharmS, Senior Specialist Pharmacist – Clinical

Nutrition, Great Ormond Street NHS Trust, London, UK

Scott Harrison MRPharmS, Lead Pharmacist, Oxford Radcliffe Hospitals NHS Trust,

Oxford, UK

Mark Borthwick MRPharmS, Consultant Pharmacist, Intensive Care, Oxford

Radcliffe Hospitals NHS Trust, Oxford, UK

Allan Cosslett PhD MRPharmS, Lecturer, School of Pharmacy, Cardiff, UK

Contributors from the pharmaceutical industry

The companies listed below have provided information included in the drug mono-

graphs in this handbook. The information was supplied on the understanding that these

manufacturers do not advocate off-licence use of their products.

Drug information

Actavis Ltd (previously Alpharma Ltd)

Alliance Pharmaceuticals Ltd

AstraZeneca UK Ltd

Aventis Pharma Ltd

Bayer plc

Boehringer Ingelheim Ltd

Bristol-Myers Squibb Pharmaceuticals Ltd

Celltech Pharmaceuticals Ltd

Cephalon UK Ltd

Contributors xvii

CP Pharmaceuticals Ltd

Eisai Ltd

Elan Pharma Ltd

Ferring Pharmaceuticals (UK)

GlaxoSmithKline

Hawgreen Ltd

Janssen-Cilag Ltd

Leo Pharma

Merck Pharmaceuticals

Napp Pharmaceuticals Ltd

Norgine Ltd

Novartis Pharmaceuticals UK Ltd

Paynes & Byrne Ltd

Pfizer Ltd

Pharmacia Ltd

Procter & Gamble UK

Provalis Healthcare Ltd

Roche Products Ltd

Rosemont Pharmaceuticals Ltd

Sanofi-Synthelabo

Schwartz Pharma Ltd

Servier Laboratories Ltd

Shire Pharmaceuticals Ltd

Solvay Healthcare Ltd

Special Products Limited

UCB Pharma Ltd

Zentiva Ltd

Enteral feeding tube information

Baxa Ltd

Fresenius Kabi Ltd

Merck Gastroenterology

Novartis Consumer Health

Tyco Healthcare

Vygon (UK) Ltd

5-ASA 5-aminosalicylic acid

ACE angiotensin-converting enzyme

AUC area under the concentration–time curve

b.d. twice daily

BAPEN British Association of Parenteral and Enteral Nutrition

BNF British National Formulary

BPNG British Pharmaceutical Nutrition Group

Cmax maximum plasma concentration

COX-II cyclooxygenase oxidase II

CQC Care Quality Commission

CSM Committee on Safety of Medicines (UK)

E/C enteric coated

EFT enteral feeding tube

ETF enteral tube feed

Fr French gauge (diameter of feeding tube; 1 Fr ~0.33 mm)

GI gastrointestinal

GP general practitioner

GTN glyceryl trinitrate

HETF home enteral tube feeding

HRT hormone replacement therapy

i.m. intramuscular

i.v. intravenous

ICU intensive care unit

INR international normalised ratio

IU international unit

LDL low-density lipoprotein

M/R modified-release

MAOI monoamine oxidase inhibitor

Abbreviations

Abbreviations xix

MIC minimum inhibitory concentration

NBM nil by mouth

ND nasoduodenal

NDT nasoduodenal tube

NG nasogastric

NJ nasojejunal

NMC National Midwifery Council

NPSA National Patient Safety Agency

NSAID nonsteroidal anti-inflammatory drug

OTC over the counter

PEG percutaneous endoscopic gastrostomy

PEGJ percutaneous endoscopic gastrojejunostomy

PEJ percutaneous endoscopic jejunostomy

PIL product information leaflet

PUR polyurethane

PVC polyvinylchloride

q.d.s four times daily

RPSGB Royal Pharmaceutical Society of Great Britain

s.c. subcutaneous

s/c sugar-coated

SPC Summary of Product Characteristics

SSRI selective serotonin re-uptake inhibitor

t.d.s. three times daily

tmax time to reach maximum plasma concentration

w/w weight for weight

The information provided in this resource is intended to support healthcare profession-

als in the safe and effective prescribing and administration of drugs via enteral feeding

tubes. It is a comprehensive guide covering the legal, practical and technical aspects

that healthcare professionals should consider before attempting to prescribe or admin-

ister drugs via an enteral feeding tube.

The following chapters are intended to provide background knowledge to inform

clinical decisions and we recommend that readers familiarise themselves with the

contents of these chapters before using the information contained within the mono-

graphs.

The individual monographs contain guidance on the safe administration of specific

drugs and formulations. Wherever possible, a licensed formulation route should always

be used, and the monographs point the reader to alternatives for consideration. Where

alternative routes/formulations are not available, the monographs make recommenda-

tions for safe administration via the enteral feeding tube. Any decisions on appropriate

drug therapy must be made with the complete clinical condition and wishes of the

individual patient in mind. Thought should be given to the care setting the patient

is in presently, the future need for administration of medicines via an enteral feeding

tube, and the patient’s/carer’s ability to undertake such administration should care be

continued at home.

Notes on the use of this book

Key Points

1

Rebecca White

The use of enteral feeding tubes for short- and long-term feeding has increased in both

primary and secondary care as a result of a heightened awareness of the importance of

adequate nutritional intake. An enteral feeding tube (EFT) provides a means of main-

taining nutritional intake when oral intake is inadequate or when there is restricted

access to the gastrointestinal (GI) tract, e.g. owing to obstruction. Enteral tube feeds

(ETFs) are now commonly used for a wide range of clinical conditions and across a wide

age range of people.

The British Artificial Nutrition Survey,1 which was undertaken by the British Asso-

ciation for Parenteral and Enteral Nutrition, remains the largest annual survey of home

artificial nutrition support. The data from the 2011 report indicate that the age distri-

bution of adult patients on home enteral tube feeding (HETF) is skewed to the older

age range, with 41% of new registrations being over 70 years. Currently 60% of adult

patients on HETF require either some or total support with their HETF. Cerebrovascular

accident remains the commonest diagnosis in adults on HETF, but the percentage of

patients with cancer has been increasing. A conservative estimate suggests that there

2

are currently over 30,000 patients in the community using HETF. The majority of these

patients have a permanent feeding device, with only 19% using nasoenteric tubes.

It can be difficult to find a suitable drug formulation for administration to a pa-

tient with limited GI access or with dysphagia. Although parenteral administration can

be used and often guarantees 100% absorption, repeated intravenous, subcutaneous

or intramuscular injections are associated with complications and are not suitable for

continuous long-term use. There are also other routes that can be considered, such as

transdermal, buccal, rectal or topical, but the drugs available in these formulations are

limited (see Chapter 6 for further information). In these patients the feeding tube is

often the only means of enteral access and is increasingly being used as a route for drug

administration.

The nursing profession has shown an increasing interest in this route of drug

administration. More publications cover a number of issues relating to this method

of drug administration, not least the implications of administering a drug via an un-

licensed route (see Chapter 7 for more information). Before any drug is considered

for administration via an enteral feeding tube, the patient should be assessed to see

whether they can tolerate and manage oral drug administration of appropriate licensed

formulations (see Chapter 5 for further information).

Administering a drug via an enteral feeding tube usually falls outside of the terms

of the drug’s product licence. This has implications for the professionals responsible

for prescribing, supplying and administering the drug, as they become liable for any

adverse event that the patient may experience. When a drug is administered outside of

the terms of its product licence (for e.g. by crushing tablets before administration)*, the

manufacturer is no longer responsible for any adverse event or treatment failure. For

further information on unlicensed use of medicines, see Chapter 7.

The administration of drugs via enteral feeding tubes also raises a number of other

issues – nursing, pharmaceutical, technical and professional. Examples are drug errors

associated with the use of i.v. syringes for enteral drug administration; the obstruction

of feeding tubes with inappropriate drug formulations; the risk of cross-contamination

from sharing of tablet crushing devices; and the risks of occupational exposure to drug

powders through inappropriate handling.

There is also a degree of semantics: if the drug is prescribed via the oral route but

intended to be given via the feeding tube, then this is a prescribing error. However, if

the drug was intended to be given orally but the nurse administered it via the feeding

tube, then this is classed as an administration error.

The pharmacist has several key responsibilities and must have access to all the

necessary information relating not only to the drug and formulation but also to the pa-

tient’s condition, the type of feeding tube, and the enteral feed and regimen being used.

Pharmacists must be able to assimilate all this information to be able to recommend a

suitable formulation for administration via this route. It is also their responsibility to

* Crushing of tablets and opening of capsules are the most common ways in which the product licence is breached; using an injection solution for oral or enteral administration is another example.