Therapeutic concerns when oral medications are administered nasogastrically

Relative Bioavailability of Cenobamate Administered as a Crushed Tablet, Either Orally or via Nasogastric Tube, versus an Intact Whole Tablet

Cenobamate is approved for the treatment of focal seizures in adults and is currently available as an oral tablet. Alternative methods of drug administration are needed for patients who are unable to swallow whole intact tablets. This phase 1, open-label, randomized, single-dose, three-way crossover (3-period, 3-treatment, 6-sequence) study (NCT05572255), conducted in healthy volunteers, assessed the relative bioavailability of a crushed 200-mg cenobamate tablet administered orally or via nasogastric (NG) tube compared with an intact 200-mg tablet. Each treatment was separated by a 13-day washout period. Plasma samples for cenobamate concentration analysis were collected pre-dose and at multiple time points up to 264 h post-dose. Standard bioequivalence study criteria were applied to the relative bioavailability assessments. All 90% confidence intervals of test-to-reference geometric mean ratios for cenobamate pharmacokinetic parameters (Cmax, AUClast, and AUCinf) were within 85-110% (predefined limit, 80-125%), suggesting no difference in cenobamate exposures following administration of an intact tablet orally or a crushed tablet orally or via NG tube. All treatment-emergent adverse events (TEAEs) were classified as mild and resolved. There were no deaths or other serious AEs (SAEs), and no TEAEs led to discontinuation. Our results indicate that the administration of cenobamate as a crushed tablet taken orally or via an NG tube can provide additional flexibility when patients cannot swallow intact tablets. Based on the results of this study, cenobamate is now approved by FDA to be taken whole or the tablets can be crushed. The crushed tablet can be mixed with water and either administered by mouth as an oral suspension or administered via a nasogastric tube.

Enhancing nasogastric tube insertion skill performance by using updated checklist among nursing students

Background

Nasogastric tube (NGT) insertion is one of the most commonly performed procedures for critically ill patients through the nostril or mouth into the stomach, which is indicated for multiple reasons.

Objective

This study is, therefore, aimed to enhance the NGT insertion skill performance of third-year nursing students using the updated checklist, 2021.

Method

A facility-based pre-post intervention study was conducted among third-year nursing students of the School of Nursing, Jimma University. An updated checklist and intervention package were used among 26 randomly selected nursing students. The collected data was entered into EpiData version 3.1, EpiData Association, Denmark and exported to SPSS version 23, IBM Corp, Armonk, NewYork for analysis. Descriptive statistics were made for each item and Paired T-test analysis was conducted to summarize the findings.

Result

The highest NGT skill insertion performance score from 40% before the intervention was 35; however, after the intervention, the score increased to 40.3. Their mean score in NGT skill performance was increased by 11 after the intervention of implementing the intervention package using the updated checklist from 26.5 ±5 0.3 the pre-intervention to 37.8 ±5 1.7 post-intervention. The finding indicated that the improvement was statistically significant at p < 0.001.

Conclusion

Implementing an intervention package and employing an updated NGT insertion checklist improved the performance of third-year nursing students' NGT insertion skills by an average of 11 points compared to their pre-test scores. A large-scale control randomized trial study was recommended to control for the effects of confounding factors on the implementation of intervention packages.

Enteral Delivery of Pravastatin Sodium Tablets: Effect of Compounding into a Liquid Form and Co-Administration of Enteral Nutrition

BACKGROUND

Compounding solid oral dosage forms into liquid preparations is a common practice for administering drug therapy to patients with swallowing difficulties. This is particularly relevant for those on enteral nutrition, where factors such as the administration procedure and co-administration of enteral nutrition play crucial roles in effective drug delivery. Due to the limited studies focused on this practice, the impact of co-administered nutrition remains unclear.

METHODS

Pravastatin tablets were compounded into two liquid formulations and administered through three independent tubes for ten cycles. The drug amount was quantified upstream and downstream of the tubes both with and without different (fiber content) nutritional boluses.

RESULTS

The compounding procedure did not lower the drug amount with respect to the original tablets. However, when the liquid formulation was pumped through the tubes, a statistically significant reduction in the pravastatin administered (between 4.6% and 11.3%) was observed. The co-administration of different nutritional boluses or the compounding procedure did not affect the general results.

CONCLUSIONS

Pravastatin loss appears unavoidable when administered via the enteral tube. Although, in this case, the loss was of limited clinical relevance, it is important not to underestimate this phenomenon, especially with drugs having a narrow therapeutic index.

In vitro optimization of crushed drug-sensitive antituberculosis medication when administered via a nasogastric tube

IMPORTANCE

The incidence of tuberculosis (TB) in intensive care units (ICUs) can be as high as 3% in high-burden settings, translating to more than 7,500 patients admitted to the ICU annually. In resource-limited settings, the lack or absence of intravenous formulations of drug-sensitive antituberculosis medications necessitates healthcare practitioners to crush, dissolve, and administer the drugs to critically ill patients via a nasogastric tube (NGT). This off-label practice has been linked to plasma concentrations below the recommended target concentrations, particularly of rifampicin and isoniazid, leading to clinical failure and the development of drug resistance. Optimizing the delivery of crushed drug-sensitive antituberculosis medication via the NGT to critically ill patients is of utmost importance.

Assessment of Good Practice Guidelines for Administration of Drugs via Feeding Tubes by a Clinical Pharmacist in the Intensive Care Unit

Background

In intensive care units, patients are frequently unable to take oral drugs because of orotracheal intubation or sedation.

Local Problem

Adverse events occurred during the administration of drugs by feeding tube. This study assessed the impact of implementing good practice guidelines by a clinical pharmacist on the prescription and administration of drugs through feeding tubes.

Methods

Nonconformity of drug prescription and administration in patients with feeding tubes was assessed before and after implementation of good practice guidelines in the intensive care unit of a large teaching hospital. Data were collected from medical records and interviews with physicians and nurses using a standardized form. Assessment of prescription nonconformity included compatibility of a drug’s absorption site with the administration route. Assessment of administration nonconformity included the preparation method.

Results

The analysis included 288 prescriptions and 80 administrations before implementation and 385 prescriptions and 211 administrations after implementation. Prescriptions in which the drug’s absorption site was not compatible with the administration route decreased significantly after implementation (19.8% vs 7.5%, P &lt; .01). Administration nonconformity decreased significantly in regard to crushing tablets and opening capsules (51.2% vs 4.3%, P &lt; .01) and the solvent used (67.1% vs 3.5%, P &lt; .01). Simultaneous mixing of drugs in the same syringe did not decrease significantly (71.2% vs 62.9%, P = .17).

Conclusion

Implementation of good practice guidelines by a multidisciplinary team in the intensive care unit significantly improved practices for administering crushed, opened, and dissolved oral forms of drugs by feeding tube.

Pharmacokinetic study of high-dose oral rifampicin in critically Ill patients with multidrug-resistant Acinetobacter baumannii infection

PURPOSE

Although rifampicin (RIF) is used as a synergistic agent for multidrug-resistant Acinetobacter baumannii (MDR-AB) infection, the optimal pharmacokinetic (PK) indices of this medication have not been studied in the intensive care unit (ICU) settings. This study aimed to evaluate the PK of high dose oral RIF following fasting versus fed conditions in terms of achieving the therapeutic goals in critically ill patients with MDR-AB infections.

METHODS

29 critically ill patients were included in this study. Under fasting and non-fasting conditions, RIF was given at 1200 mg once daily through a nasogastric tube. Blood samples were obtained at seven time points: exactly before administration of the drug, and at 1, 2, 4, 8, 12, and 24 h after RIF ingestion. To quantify RIF in serum samples, high-performance liquid chromatography (HPLC) was used. The MONOLIX Software and the Monte Carlo simulations were employed to estimate the PK parameters and describe the population PK model.

RESULTS

The mean area under the curve over the last 24-h (AUC0-24) value and accuracy (mean ± standard deviation) in the fasting and fed states were 220.24 ± 119.15 and 290.55 ± 276.20 μg × h/mL, respectively. There was no significant difference among AUCs following fasting and non-fasting conditions (P > 0.05). The probability of reaching the therapeutic goals at the minimum inhibitory concentration (MIC) of 4 mg/L, was only 1.6%.

CONCLUSION

In critically ill patients with MDR-AB infections, neither fasting nor non-fasting administrations of high-dose oral RIF achieve the therapeutic aims. More research is needed in larger populations and with measuring the amount of protein-unbound RIF levels.

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.

Alterations in drug disposition in older adults: a focus on geriatric syndromes

INTRODUCTION

Age-associated physiological changes can alter the disposition of drugs, however, pathophysiological changes associated with geriatric syndromes in older adults may lead to even greater heterogeneity in pharmacokinetics. Geriatric syndromes are common health problems in older adults which have multifactorial causes and do not fit into distinct organ-based disease categories. With older adults being the greatest users of medications, understanding both age- and geriatric syndrome-related changes is important clinically to ensure safe and effective medication use.

AREAS COVERED

This review provides an overview of current evidence regarding pharmacokinetic alterations that occur with aging and in common geriatric syndromes, including frailty, sarcopenia, dementia, polypharmacy and enteral feeding. The evidence is presented according to the four primary pharmacokinetic processes (Absorption, Distribution, Metabolism and Excretion).

EXPERT OPINION

There is some evidence to inform our understanding of the impact of chronological aging and various geriatric syndromes on drug disposition. However, many areas require more research, including drug induced inhibition and induction of cytochrome P450 enzymes and the clinical utility of emerging methods for estimating renal function. There is a need to develop tools to predict alterations in drug disposition in subgroups of older adults, particularly where the currently available clinical information is sparse.

Clinical Pharmacology Considerations for Developing Small-Molecule Treatments for COVID-19

Numerous drugs are being investigated for the treatment of COVID‐19, including antivirals and therapies targeting complications related to COVID‐19. The clinical presentation of COVID‐19 varies from mild fever, cough, and dyspnea in the early stages of disease to severe complications such as acute respiratory distress syndrome, systemic hyperinflammation, and sepsis. A thorough understanding of the disease pathogenesis and the disease complications is essential to developing effective therapies to treat this potentially life‐threatening disease. This review offers key clinical pharmacology considerations involved in the development of small molecules for the treatment of COVID‐19. They are based on the major observed disease complications that impact drug absorption, distribution, metabolism, and elimination. We also address considerations regarding potential drug interactions, alternative routes and methods of administration, and dosing in patients on hemodialysis.

Potassium canrenoate compounding for administration via enteral feeding tubes: a physical and microbiological stability study

Background

Swallowing difficulties are arising in an increasing number of patients, especially in elderly people. When deglutition ability is completely compromised, enteral administration of a drug via feeding tubes is used. Licensed pharmacists have to compound the original solid forms to enable this drug therapy.

Objectives

To evaluate the possibility of compounding original commercial tablets to produce a liquid formulation suitable for administering via a feeding tube.

Methods

Two liquid formulations containing potassium canrenoate 5 mg/mL were prepared: a standard solution obtained by solubilising raw material and an extemporaneous preparation obtained by dissolving film-coated 100 mg tablets. Spectrophotometric determinations (UV range) of the drug established chemical stability of the analyte up to 60 days. Samples were tested for microbial growth. Gravimetric quantifications of liquid formulations were used to check any weight loss during the different steps before enteral administration.

Results

UV data confirmed the chemical stability of potassium canrenoate up to 60 days. Samples showed no microbial growth. A higher weight loss was recorded in extemporaneous preparations than in the standard solution (10.7% vs 7.6%) according to the gravimetric quantification.

Conclusion

It is possible to compound the original tablets into a liquid formulation suitable for administration via a feeding tube.

Carers' experiences of home enteral feeding: A survey exploring medicines administration challenges and strategies

What is known and objectives

The use of enteral tube feeding at home is becoming more widespread, with patients ranging in age and diseases. Dysphagia and swallowing difficulties can compromise nutritional intake and the administration of oral medications, affecting therapeutic outcomes negatively. Carers’ experiences of medicines administration and medicines optimization have not been explored fully. The objectives of this study were to identify issues carers experience in medicines administration; the strategies they have developed to cope; and suggestions to improve the medicines administration process.

Methods

An online survey was promoted nationally; 42 carers completed it. Descriptive statistical analysis was applied, as well as thematic analysis of open‐ended responses. Results were compared against the 4 principles of medicines optimization.

Results and discussion

93% of respondents administered medications with enteral feeding tubes, but only 62% had received advice from healthcare professionals and only 8% had received written information on how to do so. Responses identified 5 medicines administration issues experienced by carers; 4 strategies they developed to cope; and 3 main areas of suggestions to improve medicines administration via enteral feeding at home.

What is new and conclusion

The 4 principles of medicines optimization have not previously been applied to enteral feeding. We present a novel account of carers’ experiences, for example coping with ill‐suited formulations and a lack of training and support, which should inform better practice (Principle 1). Carers sometimes experience suboptimal choice of medicines (Principle 2). Carers’ practices are not always well‐informed and may affect therapeutic outcomes and safety (Principle 3). There is scope for improvement in carer training, education and support to better support medicines optimization (Principle 4).

Going down the tubes! Impact on seizure control of antiepileptic medication given via percutaneous feeding tubes

BACKGROUND

Long-term feeding by percutaneous endoscopic gastrostomy tube (PEG) is uncommon but can present significant issues when both nutrition and medication have to be fed down the same tube. This is especially important in people with epilepsy where the dose and bioavailability of antiepileptic drugs are critical to maintain adequate seizure control. This group with long-term PEG tubes is particularly vulnerable and dependent on their carers to provide high standard of care. Indeed, approximately half of the people with long-term feeding tubes suffer from severe intellectual disability which requires careful coordination of all members of the multidisciplinary team. It is all the more important when consideration is given that around 50% of people with severe ID have seizures, mostly treatment resistant.

METHOD

A detailed literature review was conducted with the focus on the numerous factors that can affect medication delivery and absorption with the potential to destabilize seizure control in people with PEG. Issues concerning the site of drug absorption, excipients and dilution, interaction between antiepileptic drugs and the nutritional feed, bioavailability, and problems with the PEG tube are considered.

RESULTS

There is limited research in this area and the studies are often based on small numbers, healthy volunteers or in vitro findings.

CONCLUSION

In the absence of sound research data, seizure control in each patient with a PEG needs to be considered on an individual basis. Establishing a baseline by measuring the serum levels prior to the tube insertion may be helpful, followed by checking the levels after PEG insertion.

Medicamentos orais de uma unidade hospitalar: adequação ao uso por cateteres enterais

RESUMO Objetivo: descrever o perfil de medicamentos orais padronizados em uma unidade hospitalar e verificar sua adequação quanto ao uso por cateteres enterais, de acordo com recomendações da literatura. Método: estudo descritivo, com dados sobre medicamentos coletados do Sistema de Dispensação do Serviço de Farmácia. As recomendações específicas para uso de tais medicamentos por cateteres enterais foram obtidas após busca em bases literárias, livros, manuais, guidelines e bulários. Resultados: dos 236 medicamentos orais dispensados, 86% estavam na forma sólida; destes, 32 eram "não trituráveis", havendo disponibilidade da forma líquida na instituição. Foram identificados 28 medicamentos com potenciais interações com a nutrição enteral. Sessenta porcento deles apresentavam recomendações específicas sobre sua administração por cateter enteral. Conclusão: a participação conjunta das equipes multidisciplinares de terapia nutricional e de assistência e a implementação de programas para treinamento contínuo constituem estratégias sugeridas para a prevenção de potenciais problemas na administração de medicamentos no espaço hospitalar.

Confirming nasogastric tube placement: Is the colorimeter as sensitive and specific as X-ray? A diagnostic accuracy study

BACKGROUND

The effect of delivering enteral nutrition or medications via a nasogastric tube that is inadvertently located in the tracheobronchial tract can cause respiratory complications. Although radiographic examination is accepted as the gold standard for confirming the position of patients' enteral tubes, it is costly, involves risks of radiation, and is not failsafe. Studies using carbon dioxide sensors to detect inadvertent nasogastric tube placements have been conducted in intensive care settings. However, none involved patients in general wards.

OBJECTIVE

The objective of this study was to ascertain the diagnostic measure of colorimeter, with radiographic examination as the reference standard, to confirm the location of nasogastric tubes in patients.

DESIGN

A prospective observational study of a diagnostic test.

SETTING

This study was conducted in the general wards of an approximately 1100-bed acute care tertiary hospital of an Academic Medical Center in Singapore.

PARTICIPANTS

Adult patients with nasogastric tubes admitted to the general wards were recruited into the study.

METHODS

The colorimeter was attached to the nasogastric tube to detect for the presence of carbon dioxide, suggestive of a tracheobronchial placement. The exact location of the nasogastric tube was subsequently confirmed by a radiographic examination.

RESULTS

A total of 192 tests were undertaken. The colorimeter detected carbon dioxide in 29 tested nasogastric tubes, of which radiographic examination confirmed that four tubes were located in the tracheobronchial tract. The colorimeter failed to detect carbon dioxide in one nasogastric tube that was located in the tracheobronchial tract, thus, demonstrating a sensitivity of 0.80 [95% CI (0.376, 0.964)]. The colorimeter detected absence of carbon dioxide in 163 tested nasogastric tubes in which radiographic examination confirmed 160 gastrointestinal and one tracheobronchial placements, demonstrating a specificity of 0.865 [95% CI (0.808, 0.907)]. The colorimeter detected one tracheobronchial nasogastric tube placement that the radiographic examination was misinterpreted.

CONCLUSION

The study found that the use of the colorimeter in the general ward setting was not 100% sensitive or specific in ascertaining the location of a nasogastric tube as previously reported by many studies undertaken in intensive care settings. This is the first study on the use of a colorimeter to confirm the placement of a nasogastric tube in adult patients in the general ward setting. More research on the use of a colorimeter in the general ward setting and its potential use in certain processes for confirming the placement of a nasogastric tube is warranted.