Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective

Drug administration via feeding tubes-a procedure that carries risks: systematic identification of critical factors based on commonly administered drugs in a cohort of stroke patients

PURPOSE

Drug administration via feeding tubes is considered a process with many uncertainties. This review aimed to give a comprehensive overview of data available on feeding tube application and to carry out risk assessments for drug substances commonly administered to stroke patients.

METHODS

Drugs frequently administered via feeding tubes were identified through a retrospective analysis of discharge letters from a stroke unit. Physicochemical, pharmacokinetic, and stability properties of these drugs and data on drug-enteral nutrition interactions were systematically searched for in the European Pharmacopoeia, Hagers Handbook of Pharmaceutical Practice, Birchers clinical-pharmacological data compilation, and the Martindale Complete Drug Reference, as well as from databases including DrugBank, DrugDex, PubChem, Google Scholar, and PubMed.

RESULTS

Of the drugs most commonly administered via feeding tubes in the present stroke patient cohort, bisoprolol, candesartan, and ramipril could be considered the least critical due to their overall favourable properties. Acetylsalicylic acid, amlodipine, hydrochlorothiazide, omeprazole and esomeprazole, simvastatin, and torasemide pose risks based on pH or light-dependent instability or proposed food effects. The most critical drugs to be administered via feeding tubes are considered to be furosemide, levodopa, and levothyroxine as they show relevant instabilities under administration conditions and substantial food effects; the latter two even possess a narrow therapeutic index. However, little information is available on drug-tube and drug-formula interactions.

CONCLUSION

Feeding tube administration of medications turned out to be a highly complex process with several unmet risks. Therefore, investigations that systematically assess these risk factors using clinically relevant model systems are urgently needed.

Enteral nutrition: An underappreciated source of patient safety events

Enteral nutrition (EN) therapies are prescribed for patients not able to maintain adequate nutrition through the oral route. Medical errors and close calls associated with the provision of EN therapy leading to actual and potential patient harm have been reported. The purpose of this study was to determine the number, type, and severity of safety events related to the provision of EN therapies reported to a national database and provide workable recommendations from the literature to improve safety. An interdisciplinary team queried the National Center for Patient Safety (NCPS) Joint Patient Safety Reporting (JPSR) system using keywords related to EN therapy use. The team reviewed the number, type, and severity of reported events and safety codes as categorized by the NCPS and then thematically classified the narratives using the Medication Use Process (MUP). Our query revealed 1227 safety events related to the EN keywords. Thematic analysis of the top five event subtypes (n = 1030) revealed that there were 691 EN safety reports directly related to an MUP step, and the majority fell into the steps of administering (31%), followed by monitoring (28%), dispensing (26%), prescribing (11%), and transcription (4%), with many events involving more than one MUP step. Safety events associated with the provision of EN therapies leading to patient harm have been reported to the JPSR system. To improve safety related to EN use, modifications to prescribing, transcribing/documenting, dispensing, administering, and monitoring of prescribed EN therapies are needed.

Pharmacy students' knowledge, perceptions, and satisfaction in a nutrition course

BACKGROUND AND PURPOSE

Little is known about nutrition education in pharmacy programs. This study reports on the outcomes assessment of pharmacy students' knowledge, perceptions, and satisfaction in a clinical nutrition course.

EDUCATIONAL ACTIVITY AND SETTING

A 2-credit required course in clinical nutrition and diet therapy provides third-year professional pharmacy students with knowledge on various diet and nutrition topics. These relate to nutrition concepts in health and disease, the prevention and treatment of diet- and nutrition-related health conditions, and enteral and parenteral nutrition.

FINDINGS

Between the academic years 2012 and 2021, 720 students were enrolled in the course. Direct assessment data were collected from 227 students, and indirect assessment data from 173 students. On average, 85.7% of students acquired the necessary knowledge on all 23 course learning objectives. Average course evaluation ratings by students on a 5-point Likert scale (strongly disagree = 1; disagree = 2; somewhat agree = 3; agree = 4; strongly agree = 5) were high (4.43). High ratings were also recorded for students' satisfaction with the course structure (4.46) and teaching effectiveness (4.39). Students appreciated the clear presentation of the course learning objectives, requirements, and teaching effectiveness. They also acknowledged the quality of the learning experience and the course's relevance to pharmacy.

DISCUSSION

Students highly rated the course in achieving its learning objectives in addition to their satisfaction with its content, structure, delivery, and relevance to pharmacy education and practice. Furthermore, the course content addressed the accreditation requirements for nutrition education and covered the topics listed in the American College of Clinical Pharmacy (ACCP) Pharmacotherapy Didactic Curriculum Toolkits.

SUMMARY

The clinical nutrition and diet therapy course was well received. Educating pharmacy students on diet and nutrition prepares graduates for expanding their role in these domains in the community, hospital and clinical practice settings.

Oral Drug Product Administration via Enteral Feeding Tubes: In Vitro Testing

Medication administration via enteral feeding tubes (EFT) is a necessary practice for patients unable to swallow oral dosage forms due to a medical condition or treatment that affects the ability to swallow or the function of the gastrointestinal tract. Off-label administration of oral drug products via EFT raises concerns for pharmaceutical sponsors, regulators, and healthcare practitioners (HCPs) because of the potential risks this practice introduces to both the patient and the caregiver. These risks can be mitigated by generating data-supported instructions that patients and HCPs can use to ensure safe and accurate administration of oral drug products via EFT. This commentary presents an industry perspective on the testing that should be conducted to enable development of product-specific instructions in the labeling to support or advise against administration of oral drug products via enteral feeding tube. The proposal outlined in this commentary takes a risk-based approach, addressing recommendations from both regulatory agencies as well as considerations for expanding this testing to address needs specific to neonatal and pediatric populations.

Bifari I, Ahmed Alharbi Y. Unraveling medication errors in enteral tube administration: A cross-sectional study in geriatric patients receiving home health care

Background

Medication administration through enteral feeding tubes requires careful consideration, as several medications are unsuitable for such administration due to interactions with feeding formulas or adverse effects when crushed. These errors can lead to feeding tube obstruction, reduced drug efficacy, or drug toxicity.

Objective

This study aimed to assess medication errors in geriatric patients using enteral feeding tubes who were enrolled in a home health care program.

Method

This was a cross-sectional observational study conducted at the Ministry of Health Government Hospital in Makkah City, Saudi Arabia. Medication errors related to chronic oral drugs in geriatric patients using enteral feeding tubes were evaluated, including inappropriate medications for enteral tube administration, inappropriate preparation, drug-nutrient interaction, and availability of liquid formulation, following established guidelines.

Results

Of the total 233 medications prescribed to 46 patients receiving enteral tube feeding at home, 49.3% exhibited at least one form of medication error, totaling 135 errors. Medication errors were highly prevalent among the patients (93.4%), with the leading cause being the administration of medications unsuitable for enteral feeding tubes (33.3%), predominantly due to the use of controlled release or enteric-coated formulations.

Conclusion

This study underscores the high prevalence of medication errors in older patients receiving enteral feeding at home. To ensure patient safety and optimal outcomes, healthcare professionals should utilize available resources and seek expert advice when selecting medications and dosage forms for tube-fed patients. Pharmacists play a critical role in promoting safe drug use and can greatly contribute by educating patient caregivers on proper medication preparation and administration techniques, thus preventing harm to patients.

Nutrition support for patients on mechanical circulatory support

PURPOSE OF REVIEW

No specific guidelines on medical nutrition therapy (MNT) in patients on different types of mechanical circulatory support (MCS) devices yet exist and overall evidence is limited. The purpose of this narrative review is to provide an overview about current existing evidence, which might be of underrecognized importance for the patients' short-term and long-term clinical and functional outcomes.

RECENT FINDINGS

Patients on MCS inherit substantial metabolic, endocrinologic, inflammatory, and immunologic alterations, and together with the specificities of MCS therapy, technical modalities of respective devices, and concomitant medication, the consideration of individualized MNT approaches is indicated in routine clinical practice. Exemplarily, the evaluation of the patients' individual nutrition status, determination of nutrition targets, progressive increase of energy and protein supply throughout the different phases of disease, prevention of micronutrient deficiencies, implementation of nutrition protocols, appropriate monitoring strategies, and continuous quality improvement are essential elements of MNT in patients on MCS.

SUMMARY

The importance of MNT for patients on MCS still often remains underrecognized, which might be of particular relevance in view of the significant metabolic alterations, the long treatment period, and severity of illness in these patients. Further research on more targeted MNT approaches in those patients is urgently needed for the generation of evidence-based guidelines for this specific cohort of critically ill patients.

What to consider for successful administration of oral liquids via enteral feeding tubes? a case study with paediatric ibuprofen suspensions

Administration of medications via enteral feeding tubes (EFTs) is a common practice for children who cannot swallow properly. Although liquid formulations are the preferred dosage forms for this route of administration, little attention has been paid to the amount of drug that reaches the site of absorption after administration via an EFT. This systematic in vitro study aimed to identify formulation parameters and administration approaches that are critical for successful dose delivery via EFTs. For this purpose, drug recovery after administration of three different paediatric ibuprofen suspensions via different types of EFTs was studied using derivative UV spectrophotometry for quantification. Study results indicate that in addition to formulation parameters, feeding tube characteristics and the administration process can have a significant impact on the administered dose. The ratio between the total administered fluid volume (TAV), represented by the sum of dose- and flushing volume, and the feeding tube volume (FTV) proved to be a valuable indicator for assessing successful administration. Incorrect dosing and complications could be avoided if the TAV/FTV ratio was greater than 4. This and other knowledge gained in the study will help to make the administration of liquid paediatric medicines via EFTs both more effective and safer.

Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement

Patients with enteral access usually receive oral drugs via feeding tubes and correct drug administration remains a challenge. The aim of this study was to identify common medication delivery errors (MDEs) in outpatients with percutaneous endoscopic gastrostomy (PEG) and evaluate their association with the need for tube replacement due to deterioration or clogging. A 2-year retrospective study that comprised adult outpatients with a placed/replaced PEG tube and whose electronic medical record included home medication was carried out. Treatment with medication that should not be crushed and administered through an enteral feeding tube was considered an MDE. We included 269 patients and 213 MDEs (20% of oral prescriptions) were detected in 159. Ninety-two percent of the medications associated with MDEs could be substituted by appropriate formulations. Tube replacement due to obstruction was needed in 85 patients. MDEs were associated with increased risk for tube replacement (OR 2.17; 95% CI 1.10-4.27). Omeprazole enteric-coated capsules were associated with the greatest risk (OR 2.24; 95% CI 1.01-4.93). PEG outpatients are highly exposed to MDEs, leading to a significant increase in the odds of tube replacement, mainly when treated with omeprazole. The use of appropriate alternative therapies would prevent unnecessary adverse events.

Considerations when administering medications enterally in the critically ill

PURPOSE OF REVIEW

Enteral administration of medications to critically ill patients may be advantageous to other routes of administration. This review summarizes key considerations for the bedside clinician when medications are administered through enteral access devices (EADs).

RECENT FINDINGS

Critical illness is associated with gastrointestinal dysfunction that inconsistently affects drug dispersion and absorption and may enhance or reduce bioavailability. Other factors such as the first-pass metabolism, microbiome alterations and the concomitant use of other medications (vasopressors, acid suppressants) may influence drug absorption. Concurrent administration of medications with enteral nutrition is fraught with potential errors. Drug-nutrient and drug-drug interactions may lead to tube occlusion. Although liquid formulations of medications are preferred over solid dosage forms for EAD administration, they may be hyperosmotic or contain sorbitol to cause gastrointestinal disturbances. The size and placement of the EAD tube may influence drug dispersion and absorption to affect the pharmacokinetic profile and efficacy of a particular drug.

SUMMARY

The therapeutic effect may be diminished, or toxicity enhanced when medications are administered through EADs in the critically ill. The bedside clinician must be aware of factors impacting the bioavailability of enterally administered medications and be cognizant that the effect will differ by medication.

The Value of Nutrition Support Pharmacist Interventions

The PHarmacist Avoidance or Reductions in Medical Costs in CRITically Ill Adults: PHARM-CRIT Study by Rech et al demonstrated the value of critical care pharmacists’ interventions. The services provided by nutrition support pharmacists were briefly mentioned. This article aims to highlight the value of interventions provided by nutrition support pharmacists.

Solid oral medications' suitability for use in enteral feeding tubes

BACKGROUND

There is a lack of specific data about the efficacy and safety of medications administered via feeding tubes, although there is a general awareness that not all drug formulations are suitable.

AIMS AND OBJECTIVES

To overview the current situation with solid medications administered through feeding tubes in the Tartu University Hospital intensive care units. To evaluate the availability of information on the suitability of drug formulations for administration via feeding tubes.

DESIGN

This was a descriptive retrospective document analysis study.

METHODS

During visits to the intensive care units, medication data for current patients were collected from paper medical charts and nurses. In addition, package information leaflets, summaries of product characteristics, and two practical handbooks were used for evaluating the medicines' suitability for administration via feeding tubes. A request for information was also sent to manufacturers or marketing authorization holders.

RESULTS

In 3 months, data were collected from 113 intensive care patients' medical charts. A total of 306 medication administrations via feeding tubes were documented and analysed, 67% of which were solid oral dosage forms. Exactly 91.2% of these were conventional tablets. After the analysis of information availability, 88% of the medications were classified as suitable for administration via feeding tubes, but only 48% had the manufacturer-provided information.

CONCLUSION

This study showed that the information about the suitability of formulations administration through a feeding tube is not readily available for almost half of the medications. The manufacturers seem to have the relevant information, but it is not always added to their medications' official information, putting these patients at higher risk for errors.

RELEVANCE TO CLINICAL PRACTICE

This study shows that if there is no clear statement about administration through feeding tubes on official manufacturers' information, this should be sought directly from manufacturers or marketing authorization holders, and the data could be incorporated into local guidelines.