Sorbitol content of selected oral liquids

Practices Involved in the Enteral Delivery of Drugs

PURPOSE OF REVIEW

While the delivery of medications through enteral tubes is common in critically ill patients, there are complications and a lack of unified practices between institutions. The purpose of this review is to evaluate current practices and literature evidence regarding this administration route. The effect of this administration on the medication's efficacy, safety, tolerability, and pharmacokinetics was examined, as well as other considerations to ensure that this route of delivery is both safe and effective for patients.

RECENT FINDINGS

Studies have found crushed oral tablets are the most frequent cause of obstructed feeding tubes. Complications such as this are primarily due to inadequate personnel training and failure to properly access medications before enteral administration. There are many factors that should be considered in order to effectively administer drugs via enteral tubes. Formal training and use of a multi-disciplinary approach that includes pharmacists and dieticians has been shown to reduce tube obstructions and administration errors.

Associations of hyperosmolar medications administered via nasogastric or nasoduodenal tubes and feeding adequacy, food intolerance and gastrointestinal complications amongst critically ill patients: A retrospective study

BACKGROUND

Adequate nutrition is essential during critical illness. However, providing adequate nutrition is often hindered by gastro-intestinal complications, including feeding intolerance. It is suggested that hyperosmolar medications could be causally involved in the development of gastro-intestinal complications. The aims of the present study were 1) to determine the osmolality of common enterally administered dissolved medications and 2) to study the associations between nasogastric and nasoduodenal administered hyperosmolar medications and nutritional adequacy as well as food intolerance and gastro-intestinal symptoms.

METHODS

This retrospective observational cohort study was performed in a medical-surgical ICU in the Netherlands. Adult critically ill patients receiving enteral nutrition and admitted for a minimum ICU duration of 7 days were eligible. The osmolalities of commonly used enterally administrated medications were measured using an osmometer. Patients were divided in two groups: Use of hyperosmolar medications (>500 mOsm/kg) on at least one day during the first week versus none. The associations between the use of hyperosmolar medications and nutritional adequacy were assessed using multiple logistic regression analysis. The associations between hyperosmolar medication and food intolerance as well as gastrointestinal symptoms were assessed using ordinal logistic regression.

RESULTS

In total 443 patients met the inclusion criteria. Of the assessed medications, only three medications were found hyperosmolar. We observed no associations between the use of hyperosmolar medications and nutritional adequacy in the first week of ICU admission (caloric intake β -0.27 95%CI -1.38; 0.83, protein intake β 0.32 95%CI -0.90; 1.53). In addition, no associations were found for enteral feeding intolerance, diarrhea, obstipation, gastric residual volume, nausea and vomiting in ICU patients receiving hyperosmolar medications via a nasogastric tube. A subgroup analysis of patients on duodenal feeding showed that postpyloric administration of hyperosmolar medications was associated with increased risk of diarrhea (OR 138.7 95%CI 2.33; 8245).

CONCLUSIONS

Our results suggest that nasogastric administration of hyperosmolar medication via a nasogastric tube does not affect nutritional adequacy, development of enteral feeding intolerance and other gastro-intestinal complications during the first week after ICU admission. During nasoduodenal administration an increased diarrhea incidence may be encountered.

Spectrum of Drug-induced Chronic Diarrhea

The evaluation of a patient with chronic diarrhea can be quite frustrating, as it is expensive and involves multiple diagnostic studies. Moreover, identification of a drug as a cause of chronic diarrhea is a challenge in patients taking multiple medications. The disease may either be associated with intestinal mucosal changes, mimicking diseases such as celiac disease, or purely functional, with no histopathologic change. Drug-induced diarrhea may or may not be associated with malabsorption of nutrients, and a clinical improvement may occur within days of discontinuation of the drug, or may take longer when associated with mucosal injury. Diarrhea in diabetics, often attributed to poor management and lack of control, may be due to oral hypoglycaemic agents. Chemotherapy can result in diffuse or segmental colitis, whereas olmesartan and a few other medications infrequently induce a disease that mimics celiac disease, but is not associated with gluten intolerance. In short, increased awareness of a drug, as a cause for diarrhea and a clear understanding of the clinical manifestations will help clinicians to solve this challenging problem. This article aims to review drug-induced diarrhea to (a) understand known pathophysiological mechanisms; (b) assess the risk associated with frequently prescribed medications, and discuss the pathogenesis; and

Enteral Nutrition for Adults in the Hospital Setting

In patients unable to tolerate oral intake, multiple options of nutrient delivery are available to the clinician. Administration of enteral nutrition (EN) has long been considered the standard of care for nutrition support among patients unable to meet energy and protein requirements orally. Healthcare practitioners must make careful decisions related to ordering, administering, and monitoring EN therapy. In the hospital setting, the registered dietitian is a key resource in enteral formula selection and method of administration, monitoring for and troubleshooting EN-related complications, and transitioning to oral feeding. The hospital setting also presents many unique challenges in providing optimal nutrition to the enterally fed patient.

Critical illness, gastrointestinal complications, and medication therapy during enteral feeding in critically ill adult patients

Critically ill patients who are subjected to high stress or with severe injury can rapidly break down their body protein and energy stores. Unless adequate nutrition is provided, malnutrition and protein wasting may occur, which can negatively affect patient outcome. Enteral nutrition (EN) is the mainstay of nutrition support therapy in patients with a functional gastrointestinal (GI) tract who cannot take adequate oral nutrition. EN in critically ill patients provides the benefits of maintaining gut functionality, integrity, and immunity as well as decreasing infectious complications. However, the ability to provide timely and adequate EN to critically ill patients is often hindered by GI motility disorders and complications associated with EN. This paper reviews the GI complications and intolerances associated with EN in critically ill patients and provides recommendations for their prevention and treatment. It also addresses the role of commonly used medications in the intensive care unit and their impact on GI motility and EN delivery.

The impact of intestinal failure on oral drug absorption: a review

INTRODUCTION

Intestinal failure is a complex gastroenterological condition that occurs as a result of reduced intestinal absorption of nutrients and/or water and electrolytes. Without treatment, nutritional depletion and/or dehydration will result. It can be acute or chronic and occurs secondary to a variety of causes, including massive bowel resection, inflammatory bowel diseases of the bowel, and small bowel dysfunction.

RESULTS AND DISCUSSION

Resection of the small bowel results in a range of physiological changes that affect the absorption of nutrients, water, and electrolytes. In addition, these changes may also affect the absorption of orally administered medication. However, there is only minimal published literature regarding this, with the publications limited to case reports of failure or efficacy of certain medicines such as digoxin and warfarin in individual patients. Due to the highly heterogeneous nature of intestinal failure patients, there is little generalizability of the information within these articles to other patients. Only one article seeks to provide limited practical advice regarding prescribing in this complex patient group.

CONCLUSION

The input of specialist pharmacists is necessary in the management of these patients to ensure that appropriate drugs and formulations are prescribed in a timely manner to optimize absorption and resultant efficacy.

Pneumatosis intestinalis (PI) following severe traumatic brain injury

PRIMARY OBJECTIVE

To report a case of pneumatosis intestinalis complicated with sorbitol containing medicines.

RESEARCH DESIGN

Case report.

METHODS AND PROCEDURES

Clinical course and literature review.

EXPERIMENTAL INTERVENTIONS

Chart review.

MAIN OUTCOMES AND RESULTS

Large amount of sorbital may cause a reversible gastrointestinal complication, pneumatosis intestinalis.

CONCLUSIONS

In the assessment of enteral abnormalities, all components of medications, active and 'inactive', must be evaluated as possible aetiological factors of pneumatosis intestinalis.

Re-examination of risk factors for non-Clostridium difficile-associated diarrhoea in hospitalized patients

AIM

This paper is a report of a study to determine the incidence of non-Clostridium difficile-associated diarrhoea in hospitalized patients and to re-evaluate clinical characteristics and other risk factors related to non-C. difficile-associated diarrhoea.

BACKGROUND

Numerous factors are thought to be responsible for diarrhoea in hospitalized patients. Reports about the diarrhoeal effects of some medications administered concomitantly with tube feeding have stimulated reappraisal of the influence of tube feeding as a potential cause.

METHOD

This study was a secondary analysis of data of 154 hospitalized patients collected during a prospective epidemiological study from 1992 to 1993. The secondary analysis was completed in 2006 in order to investigate unanswered questions of current importance.

FINDINGS

The sample was predominantly male and middle aged; approximately 50% were tube fed, and 25% were in an intensive care unit. The incidence of diarrhoea was 35%. Increased severity of illness as well as the combination of sorbitol-containing medication administration and tube feeding were found to be statistically significant factors in the development of diarrhoea.

CONCLUSION

As diarrhoea in hospitalized patients appears to be multifactorial, use of an algorithm to systematically evaluate and manage related factors is recommended.

Home enteral-tube feeding: The changing role of the dietitian

Enteral feeding in primary care has increased markedly over the last decade. It allows patients to be discharged to home or residential care who previously would have remained in hospital. Difficulties do arise for patients, their carers and health professionals, as care of these patients and support for health professionals is often patchy or non-existent. Dietitians are uniquely placed to participate in the management of tube feeding in primary care, provide support and education to patients and their carers, evaluate treatment and promote better outcomes for patients receiving tube feeding.

A Modern View of Excipient Effects on Bioequivalence: Case Study of Sorbitol

PURPOSE

To examine the effect of common excipients such as sugars (sorbitol versus sucrose) on bioequivalence between pharmaceutical formulations, using ranitidine and metoprolol as model drugs.

METHODS

Two single-dose, replicated, crossover studies were first conducted in healthy volunteers (N=20 each) to compare the effect of 5 Gm of sorbitol and sucrose on bioequivalence of 150 mg ranitidine or 50 mg metoprolol in aqueous solution, followed by a single-dose, nonreplicated, crossover study (N=24) to determine the threshold of sorbitol effect on bioequivalence of 150 mg ranitidine in solution.

RESULTS

Ranitidine Cmax and AUC0-infinity were decreased by approximately 50% and 45%, respectively, in the presence of sorbitol versus sucrose. Similarly, sorbitol reduced metoprolol Cmax by 23% but had no significant effect on AUC0-infinity. An appreciable subject-by-formulation interaction was found for ranitidine Cmax and AUC0-infinity, as well as metoprolol Cmax. Sorbitol decreased the systemic exposure of ranitidine in a dose-dependent manner and affected bioequivalence at a level of 1.25 Gm or greater.

CONCLUSIONS

As exemplified by sorbitol, some common excipients have unexpected effect on bioavailability/bioequivalence, depending on the pharmacokinetic characteristics of the drug, as well as the type and amount of the excipient present in the formulation. More research is warranted to examine other 'common' excipients that may have unintended influence on bioavailability/bioequivalence.

Cholera toxin induces expression of ion channels and carriers in rat small intestinal mucosa

Cholera toxin causes cyclic adenosine monophosphate (cAMP)-induced electrolyte and water secretion in the small intestine. The toxin-induced change in gene expression in rat small intestine was evaluated with microarray technique and the results were confirmed by semiquantitative polymerase chain reaction (PCR). The transporter CNT2 for nucleosides was upregulated between 6 and 18 h after challenge, whereas the level of GLUT1 transporter for glucose became elevated at 6 h. Both changes probably facilitate uptake of these nutrients in the gut. At 18 h, the major chloride channel in the villus, ClC2, was upregulated. Aquaporin 8 was downregulated at 6 h and two mucin-producing genes were upregulated 18 h after toxin challenge. The expression was back to normal after 72 h, which is the turnover time for intestinal epithelial cells.

Fecal incontinence in hospitalized patients who are acutely ill

BACKGROUND

Information about fecal incontinence experienced by patients in acute-care settings is lacking. The relationship of fecal incontinence to several well-known nosocomial or iatrogenic causes of diarrhea has not been determined.

OBJECTIVES

To determine the cumulative incidence of fecal incontinence in hospitalized patients who are acutely ill, and to ascertain the relationship between fecal incontinence and stool consistency, and between diarrhea and two well-known nosocomial or iatrogenic etiologies of diarrhea: Clostridium difficile and tube feeding. The relationship of fecal incontinence and risk factors for diarrhea associated with C. difficile and tube feeding in hospitalized patients was examined.

METHODS

Fecal incontinence, stool frequency and consistency, administration of tube feeding and medications, severity of illness, and nutritional data were prospectively recorded in 152 patients on acute or critical care units of a university-affiliated Veterans' Affairs Medical Center. Rectal swabs and stool specimens from patients were obtained weekly for C. difficile culture. C. difficile culture and cytotoxin assay were performed on diarrheal stools. HindIII restriction endonuclease analysis (REA) was used for typing of C. difficile isolates.

RESULTS

In this study, 33% (50/152) of the patients had fecal incontinence. The proportion of total surveillance days with fecal incontinence in these patients was 0.50 +/- 0.06. A greater percentage of patients with diarrhea had fecal incontinence than patients without diarrhea (23/53 [43%] vs. 27/99 [27%]; p = 0.04). Incontinence was more frequent in patients with loose/liquid stool consistency than in patients with hard/soft stool consistency (48/50 [96%] vs. 71/100 [71%]; p < 0.001). The proportion of surveillance days with fecal incontinence was related to the proportion of surveillance days with diarrhea (r = 0.69; p < 0.001) and the proportion of surveillance days with loose/liquid stools (r = 0.64; p < 0.001). Multivariate risk factors for fecal incontinence were unformed/loose or liquid consistency of stool (RR = 11.1; 95% confidence interval [CI] = 2.2, 56.7), severity of illness (RR = 5.7; CI = 2.6, 12.3), and age (RR = 1.1; CI = 1, 1.1).

CONCLUSIONS

Fecal incontinence is common in hospitalized patients who are acutely ill, but the condition was not associated with any specific cause of diarrhea. Because loose or liquid stool consistency is a risk factor for fecal incontinence, use of treatments that result in a more formed stool may be beneficial in managing fecal incontinence. However, treatments that slow intestinal transit should be avoided in patients with C. difficile-associated diarrhea.

Clinical Management of the Adult Home Nutrition Support Patient

Nutrition Support Consultant features issues pertinent to the clinical aspects of pharmacy nutritional support practice. The column is edited by Roland N. Dickerson, PharmD, BCNSP, CNS, FACN, Associate Professor of Clinical Pharmacy, University of Tennessee, Memphis.

Diarrhea associated with lorazepam solution in a tube-fed patient

A 43-year-old patient with adult respiratory distress syndrome, alcoholic hallucinosis, and delirium required significant amounts of lorazepam, morphine, and midazolam for management of agitation and increased peak airway pressures. Broad-spectrum antibiotics and intermittent pancuronium therapy were instituted. A nasoenteral feeding tube was placed for nutrition and medication administration during mechanical ventilation. Tube feedings were well tolerated except for intermittent bouts of large amounts of diarrhea. Clostridium difficile culture and toxin results were negative. Lorazepam and morphine administration were converted from the IV to enteral route to decrease the amount of fluid administered. The tube feeding was changed to an electrolyte rehydration solution and eventually discontinued. A search for drug-related contributing factors to the diarrhea revealed polyethylene glycol present in the lorazepam solution. It was postulated that this could be a contributing cause to the diarrhea. The lorazepam solution was changed to enterally administered crushed tablets with subsequent resolution of diarrhea.

Gastrointestinal gas formation and infantile colic

Gastrointestinal gas causes distress in many patients and their parents. Most often, patients do not have an actual increase in gastrointestinal gas volume, but rather their complaints derive from a misunderstanding of normal physiology, a misinterpretation of symptoms (colic), or an increase in intestinal sensitivity (irritable bowel syndrome). Symptoms from actual increases in intestinal gas volume are seen most frequently in children who swallow excessive amounts of air, have a dysmotility syndrome, or consume foods containing poorly absorbed carbohydrates. Although many therapies are used in the treatment of gas-related symptoms, under close scrutiny, the commonly recommended agents (e.g. simethicone) do not have proven efficacy. An understanding of the physiology of gas production and disposal is of practical use to pediatricians in determining the appropriate method of intervention for patients with these complaints.

Pentobarbital coma in neurosurgical patients: nutrition considerations

Neurosurgical patients in pentobarbital coma are a complex nutrition support population. Physiologic changes associated with the primary injury to the brain, combined with the pharmacodynamic influences of barbiturate therapy, contribute to the difficulties of initiating aggressive nutrition support. Early nutritional repletion is important to the overall outcome of traumatically injured patients. Consequently, factors that influence nutrition support decisions must be understood to assure appropriate intervention. The metabolic changes associated with traumatic head injury, pentobarbital therapy, and nutrition support strategies are reviewed.

Gastrointestinal effects of sorbitol as an additive in liquid medications

Certain sugar alcohols, notably sorbitol, are widely used as a vehicle for drugs in liquid oral dosage forms. Gastrointestinal side effects due to osmotically active excipients have been described, but remain an underappreciated cause of diarrhea. Quantitating amounts of sorbitol is difficult due to a lack of compendial listings of such information. A computer search of Physicians' Desk Reference monographs was conducted to identify products that listed or potentially contained sorbitol as an inert ingredient. Standard form letters and telephone calls were used to collect information on the sorbitol content of products identified. Data were compiled for 142 products, and each value was converted to mg/mL as crystalline sorbitol. Some difficulty occurred obtaining requested information from some manufacturers in their effort to maintain product formulation confidentiality. Pharmaceutical manufacturers should recognize that technically inert ingredients are not necessarily pharmacologically inactive. Manufacturers should therefore comply with requests for, and more openly publish, quantitative information regarding such ingredients, to facilitate the assessment and treatment of patient symptoms.