As a critical care pharmacist, questions often come up about giving medications via an enteral tube. Dosage form, Liquid medications are often the best option if available. But point out that hyperglycemia may occur if sugar content in liquid meds is high. Plus GI side effects are possible with hyperosmolar medications (acetaminophen, potassium, etc) or sorbitol above 10 to 15 g/day. Recommend diluting liquid medications with 10 to 30 mL of water before administration, to prevent cramping and diarrhea.
Approach
Evaluate alternatives if needed, such as crushing tabs, opening caps, or giving the injectable form via the tube. Consider the tube size, since small tubes (jejunostomy tubes, etc) are prone to clogging. Most immediate-release tabs can be crushed and mixed with 10 to 15 mL of water. Pellets in some caps (amphetamine mixed salts XR, etc) can be given INTACT via large-bore tubes, usually 14 French or larger. But advise NOT to crush most medications with a coating or modified-release mechanism (CR, LA, SR, etc) or hazardous medications (tamoxifen, etc).
Interactions
Discourage giving multiple medications at once, or mixing medications in feeds, since a precipitate may form with some meds (iron, etc). Reinforce to flush with 15 to 30 mL of water before and after giving medications, and 5 to 10 mL between EACH medication, to limit tube clogging. For medications that must be given on an empty stomach, generally advise holding tube feeds 30 minutes before and after drug administration.
Point out that tube feeds can reduce absorption of some medications, such as penicillin, quinolones, and warfarin. Advise stopping tube feeds 1 hour before and for 1 to 2 hours after giving these medications. But stopping feeds 2 hours before and after antiseizure medications isn’t clearly shown to improve absorption, despite what many of us were taught. Advise close monitoring of these and other narrow therapeutic index medications (digoxin, warfarin, etc) if giving via a feeding tube. For clogged tubes, suggest first trying a warm water flush. Advise NOT to use juice or soda, these are acidic and might worsen a clog.
References
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Boullata JI. Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective. Nutr Clin Pract. 2021 Feb;36(1):111-132. Available at: https://aspenjournals.onlinelibrary.wiley.com/doi/10.1002/ncp.10615
Williams NT. Medication administration through enteral feeding tubes. Am J Health Syst Pharm. 2008 Dec 15;65(24):2347-57. Available at: https://academic.oup.com/ajhp/article-abstract/65/24/2347/5129507?redirectedFrom=fulltext&login=false
Dandeles LM, Lodolce AE. Efficacy of agents to prevent and treat enteral feeding tube clogs. Ann Pharmacother. 2011 May;45(5):676-80. Available at: https://pubmed.ncbi.nlm.nih.gov/21521858
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