1. How does the enteral feed affect medication delivery?

2. Types of Drug Formulations: Liquid solutions Solid immediate release tablets & capsules Enteric coated tablets Sustained release tablets & capsules Hard gelatin capsules Others

3. Liquid Preparations All liquid formulation will be suitable ?. Elixirs or suspensions or syrup(clumping)? Advantages: allows accurate dosing, ready to use Easily measured. Disadvantages, Co-solvents like sorbitol, large amount(child formulations), higher osmolarity (not written on bottle),viscosity

4. Medications That Have an Osmolality of ≥ 3000 mOsm/kg

5. Liquid Medications That Contain Considerable Amounts of Sorbitol With Typical Daily Dosing

6. Medications Physically Incompatible With Most Enteral Nutrition

7. Solid Dosage Forms

9. Medication Delivery Systems(1) Began as simple extract of plants made into powders Present day: complex delivery systems

10. Solid Dosage Forms

11. To Crush or Not to Crush? Extended release products- suffixes for sustained-release, controlled-release, or controlled-delivery products include: 12-hour, 24-hour, CC, CD, CR, ER, LA, Retard, SA, Slo-, SR, XL, XR, or XT. Enteric coated tablets

12. To Crush or Not to Crush? Extended-Release formulations Capsules- opened, sprinkled,… Lansoprazole Diltiazem Duloxetine Tablets- K-Dur Tegretol CR

13. To Crush or Not to Crush? Enteric Coated tablets No Enteric coating will not dissolve Switch to regular tablet

14. To Crush or Not to Crush? Taste Altered texture of medication Local anesthetic effect Stain teeth Irritate mouth, esophageal mucosa or stomach lining Coating on tablets or capsules to mask bitter or unpleasant taste

15. To Crush or Not to Crush? Risk to Nurse Crushing some potential teratogenic/carcinogenic/allergenic medications can put nurse at risk. Drugs: Bosentan Methotrexate Dutasteride Mycophenolate Raloxifene Finasteride

16. Types of Drug Formulations: Solid immediate release tablets & capsules Enteric coated tablets Sustained release tablets & capsules Liquid solutions Buccal or sublingual preparations carcinogenic, teratogenic, or cytotoxic properties should also not be crushed.

17. Best Practice Guidelines from ASPEN:Methods of Administering Medications via Enteral Feed Tubes (1) Do not add medication directly to an enteral feeding formula. Administer each medication separately through an appropriate access site. Liquid dosage forms should be used when available and if appropriate. Only immediate-release solid dosage forms may be substituted. Grind simple compressed tablets to a fine powder and mix with sterile water. Open hard gelatin capsules and mix the powder with sterile water. Avoid mixing together medication intended for administration through an enteral feeding tube, given the risks of physical and chemical incompatibilities, tube obstruction, and altered drug responses.

18. Best Practice Guidelines from ASPEN:Methods of Administering Medications via Enteral Feed Tubes (1 Before administering medicatoin, stop feeding and flush the tube with at least 15ml of sterile water. Dilute the solid or liquid medication as appropriate and administer using a clean oral syringe that’s 30ml or larger. Flush the tube again with at least 15ml of sterile water, taking into account the patient’s volume status. Repeat the previous three steps before administering the next medication. After all the medications have been administerd, flush the tube one final time with at least 15ml of sterile water. Restart feeding in a timely manner to avoid compromising the patient’s nutritional status. Feeding may be delayed for 30minutes or longer, when appropriate, to avoid altering the bioavailability of the drug. Consult with a pharmacist as needed.

19. Methods to Unclog Feeding Tubes: Flushes before and after medication administration Use a syringe of greater than 30mls to avoid rupture of tube Warm Water flushes, CB or Cra. JUICE Sodium Bicarbonate 325mg tab and Pancreatic Enzyme capsule mechanical declogging device

20. Specific Medications: Phenytoin (70% less abs.) Carbamazepine Fluoroquinolones Warfarin Proton Pump Inhibitors

21. Methods of crushing: Mortar and pestle Silent knight Crushing syringe

22. Interdisciplinary Team Communication Physician Nurse Pharmacist Dietician Medication Administration Record Links to resources

23. Conclusions Reduce drug therapy to the minimum necessary. Transfer QD formulations with a long half- life where possible (not modified- slow- release formulations). Determine alt. formulations and routes available where possible. Effectively monitored with each change.