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Crushing Tablets & Drug Administration via Enteral Feeding Tubes

Welcome to the crushing tablets and drug administration via enteral feeding tubes section for pharmacists. This section includes links to clinical practice resources on crushing tablets for patients with dysphagia / swallowing difficulties, medication administration via enteral feeding tubes and drug-enteral feeding interactions.

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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Last Checked: 18/11/16   Link Error: Report It

 

Administration of drugs to patients with swallowing difficulties

This article aims to highlight a few issues which one encounters when advising about how best to administer a medicine to a patient who cannot swallow or who has an enteral feeding tube.

Unfortunately, crushing tablets is mistakenly taken for granted by some healthcare professionals without considering that the properties of the medication may be affected.

Source: mcppnet.org
Clinical Resource: Journal Article
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Last Checked: 18/11/16   Link Error: Report It

 

Guidelines for Breaking or Crushing Tablets
Humber NHS foundation Trust

The reasons for considering tablet crushing are numerous, however crushing tablets has repercussions on the licensed status of the medicine and how the medicine may affect the patient. This guide is intended to give information to aid decision making on altering a licensed medicine by crushing, opening capsules etc

Source: humber.nhs.uk
Clinical Resource: Guideline
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Last Checked: 18/11/16 Link Error: Report It

 

''Do Not Crush'' List

Oral Dosage Forms That Should Not Be Crushed, sometimes known as the "Do Not Crush" list. From John F. Mitchell, Pharm.D, FASHP, Medication Safety Consultant, Canton, MI An updated list in PDF form.

Source: ismp.org
Clinical Resource: List
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Last Checked: 18/11/16 Link Error: Report It

 

A Crushing Problem

Swallowing poses a challenge for medication administration. When patients cannot swallow tablets whole, they or their carers often crush them.

Source: nevdgp.org.au
Clinical Resource: News
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Last Checked: 18/11/16 Link Error: Report It

 

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: awmsg.org
Clinical Resource: Guidance
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Last Checked: 18/11/16 Link Error: Report It

 

What are the therapeutic options for patients unable to take solid oral dosage forms?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals

This Medicines Q&A reviews the therapeutic options for patients unable to take solid oral dosage forms, and gives advice on how to choose the most appropriate preparation for a patient.

Source: sps.nhs.uk
Clinical Resource: Medicines Question and Answer
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Last Checked: 22/09/16 Link Error: Report It

 

Managing medication for patients with swallowing difficulties

Suggested alternative

Source: northkirkleesccg.nhs.uk
Clinical Resource: Table
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Last Checked: 18/11/16 Link Error: Report It

 

Which injections can be given enterally?
Prepared by UK Medicines Information (UKMi) pharmacists for NHS healthcare professionals

This Medicines Q&A aims to provide information on injections which may be administered either orally or enterally via an enteral feeding tube.

Source: sps.nhs.uk
Clinical Resource: Medicines Question and Answer
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Last Checked: 22/09/16 Link Error: Report It

 

Oral Antiretroviral Administration: Information on Crushing and Liquid Drug Formulations

Source: hivclinic.ca
Clinical Resource: Table
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Last Checked: 18/11/16 Link Error: Report It

 

Antiretroviral Dosage Forms for Swallowing Difficulties

Available Liquid Formulations - NRTIs & NNRTIs
Available Liquid Formulations – Protease Inhibitors
Tablets Which May Be Crushed or Dispersed
Other Licensed Formulations – Granules, Injections, Chewable Tablets

Source: hiv-druginteractions.org
Clinical Resource: Table
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Last Checked: 18/11/16 Link Error: Report It

 

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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Last Checked: 18/11/16 Link Error: Report It

 

Crushing Buprenorphine

This item describes (with the aid of photographs) the procedure for crushing and administering supervised buprenorphine doses, as well as briefly discussing the pros, cons and legalities of doing so.

Source: smmgp.org.uk
Clinical Resource: Question and Answer
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Last Checked: 18/11/16 Link Error: Report It

 

Drug Administration Via Enteral Feeding Tubes
A Guide for General Practitioners and Community Pharmacists

Produced by the British Association for Parenteral and Enteral Nutrition and The British Pharmaceutical Nutrition Group

Source: bapen.org.uk
Clinical Resource: Leaflet
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Last Checked: 18/11/16 Link Error: Report It

 

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

Source: nutritioncare.org
Clinical Resource: Guideline
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Last Checked: 18/11/16 Link Error: Report It

 

North East Essex Medicines Management Committee Guidelines for Tablet Crushing in Patients With Swallowing Difficulties

Source: neessexccg.nhs.uk
Clinical Resource: Guideline
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Last Checked: 08/08/16 Link Error: Report It

 

Medication and Enteral Feeding Guidelines - 3rd Edition
Calderdale and Huddersfield

Information on these web-pages is intended as a guide to administration of medication to patients with swallowing problems. Such administration is usually outside the product licence.

Drugs should only be put down a feeding tube as a last resort because of the implications for drug therapy and nutritional status.

Source: formulary.cht.nhs.uk
Clinical Resource: Guideline
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Last Checked: 18/11/16 Link Error: Report It

 

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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Last Checked: 18/11/16 Link Error: Report It

 

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: Article
Register to Access Content: Yes - registration is FREE

Last Checked: 01/06/15 Link Error: Report It

 

Medication administration via enteral feeding tubes

Presentation by Tom Richardson, Alfred clinical pharmacists

Source: alfredhealth.org.au
Clinical Resource: Presentation
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Last Checked: 01/06/15 Link Error: Report It

 

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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Last Checked: 18/11/16 Link Error: Report It

 

Therapeutic options for adult patients unable to take solid oral dosage forms

Source: niformulary.hscni.net
Clinical Resource: Table
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Last Checked: 18/11/16 Link Error: Report It

 

Choosing medicines for patients unable to take solid oral dosage forms

Selecting suitable formulations for adult patients with swallowing difficulties or feeding tubes

Source: mm.wirral.nhs.uk
Clinical Resource: Guide
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Last Checked: 18/11/16 Link Error: Report It

 

Handling Drug/Tube Feeding Interactions

Source: mywispen.com
Clinical Resource: Presentation
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Last Checked: 18/11/16 Link Error: Report It

 

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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Last Checked: 18/11/16 Link Error: Report It

 

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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Last Checked: 18/11/16 Link Error: Report It

 

Considerations for Drug-Enteral Tube Feeding Interaction

Continuous enteral feedings has been used extensively in critically ill patients, these patients are often administered medications through their feeding tubes out of necessity. As not all oral medications may be compatible with enteral nutrition, complications associated with administration of medications through feeding tubes may arise. Moreover, improper management of these interactions may lead to therapeutic failure or adversely affect the patients.

In the discussions below, we will highlight some drug - enteral tube feeding interactions which have been found to be clinically important.

Source: shphk.org.hk
Clinical Resource: Clinical Pearl
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Last Checked: 18/11/16 Link Error: Report It

 

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.

Source: cpnp.org
Clinical Resource: Article
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Last Checked: 18/11/16 Link Error: Report It

 

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

Last Checked: 18/11/16 Link Error: Report It

 

Administering Drugs Via Enteral Feeding Tubes
A Practical Guide

The A3 poster is suitable for use on the ward or in clinics. The flow diagram provides a step by step guide for safe drug administration via this route. The poster also includes basic information on legal implications, health and safety and drug interactions.

Source: bapen.org.uk
Clinical Resource: Poster
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Last Checked: 18/11/16 Link Error: Report It

 

Tube feeding and Pancreatic Enzymes (Creon)

Source: virginia.edu
Clinical Resource:
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Last Checked: 18/11/16 Link Error: Report It

 

Tube Feeding and Pancreatic Enzymes (Zenpep)

Source: virginia.edu
Clinical Resource:
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Last Checked: 18/11/16 Link Error: Report It

 

Evaluation of Different Lansoprazole Formulations for Nasogastric or Orogastric Administration

Critically ill patients who require treatment with proton pump inhibitors are often unable to swallow solid dosage forms and have nasogastric (NG) or orogastric (OG) tube placement. Many of these patients will need medications in a liquid dosage form for easy administration. The aim of this study was to determine which extemporaneous preparation of lansoprazole is least likely to cause NG or OG tube blockage.

Source: thomasland.com
Clinical Resource: Journal Article
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Last Checked: 18/11/16 Link Error: Report It

 

Warfarin Resistance and Enteral Tube Feeding: An Old Problem With a New Solution

The pharmaceutical industry subsequently responded to this problem by significantly reducing the vitamin K content of the liquid enteral nutrition formulations. However, despite these efforts with vitamin K content reduction, we still periodically experienced problems of achieving therapeutic anticoagulation when warfarin was given concomitantly with continuous liquid enteral feeding or experienced significant increases in the international normalized ratio (INR) for prothrombin time when the enteral feeding was discontinued.

Source: thomasland.com
Clinical Resource: Journal Article
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Last Checked: 18/11/16 Link Error: Report It

 

Antiepileptic Drug Preparations Delivered via Enteric Tubes

Source: epilepsy.com
Clinical Resource: Table
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Last Checked: 18/11/16 Link Error: Report It

 

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