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Sommerfeldt J, Sartorius H, von Sarnowski B, Klein S, Ritter CA. 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. Eur J Clin Pharmacol 2024; 80:1599-1623. [PMID: 39073438 PMCID: PMC11458809 DOI: 10.1007/s00228-024-03723-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 06/23/2024] [Indexed: 07/30/2024]
Abstract
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.
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Affiliation(s)
- Jana Sommerfeldt
- University of Greifswald, Institute of Pharmacy, Clinical Pharmacy, Greifswald, Germany
| | - Hannes Sartorius
- University of Greifswald, Institute of Pharmacy, Clinical Pharmacy, Greifswald, Germany
| | | | - Sandra Klein
- University of Greifswald, Institute of Pharmacy, Biopharmaceutics and Pharmaceutical Technology, Greifswald, Germany
| | - Christoph A Ritter
- University of Greifswald, Institute of Pharmacy, Clinical Pharmacy, Greifswald, Germany.
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2
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Sabaghnejad E, Nikvarz N, Nematollahi M. Effect of Virtual Education on Knowledge and Practice of Critical Care Nurses Regarding the Administration of Drugs Through Enteral Feeding Tubes: A Prospective Randomized Pre-Post Intervention Study. Crit Care Nurs Q 2024; 47:286-295. [PMID: 39265110 DOI: 10.1097/cnq.0000000000000524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/14/2024]
Abstract
A study was conducted to evaluate the effect of virtual education on knowledge and practice of nurses regarding administration of drugs through enteral feeding tubes (EFTs). Sixty nurses working in 4 intensive care units were enrolled. A questionnaire evaluating knowledge and practice of nurses regarding drug administration through EFTs was used. At the pre-intervention stage, all nurses responded to the questionnaire. Then an educational videoclip was provided to the intervention group. One month later, post-intervention stage, both groups answered to the questionnaire again. At the end of the study, the scores of all items in the knowledge domain including medication preparation (mean difference [MD] [95% CI]: 1.11 [0.57; 1.66]), tube flushing (MD [95% CI]: 2.15 [1.59; 2.79]), recognizing drug-drug/drug-feed interactions (MD [95% CI]: 0.57 [0.05; 1.09]), and recognizing dosage forms (MD [95% CI]: 1.51 [0.94; 2.10]) and practice domain including medication preparation (MD [95% CI]: 1.63 [1.04; 2.21]), tube flushing (MD [95% CI]: 1.19 [0.64; 1.74]), and recognizing drug-drug/drug-feed interactions [MD (95% CI): 2.16 (1.53; 2.80)] in the intervention group were significantly higher than those in the control group (P < .05). Education of proper technics of preparation and administration of drugs through EFTs improved knowledge and practice of the participants.
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Affiliation(s)
- Elnaz Sabaghnejad
- Author Affiliations: Department of Clinical Pharmacy, Faculty of Pharmacy (Ms Sabaghnejad), Herbal and Traditional Medicines Research Center (Dr Nikvarz), Nursing Research Center (Ms Nematollahi), Kerman University of Medical Sciences, Kerman, Iran
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3
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Tatterton M, Mulcahy J, Mankelow J, Harding M, Scrace J, Fisher M, Bethell C. Checking nasogastric tube safety in children cared for in the community: a re-examination of the evidence base. Nurs Child Young People 2024; 36:16-22. [PMID: 38433664 DOI: 10.7748/ncyp.2024.e1493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/07/2023] [Indexed: 03/05/2024]
Abstract
Nasogastric tube feeding is generally considered safe provided a nasogastric aspirate with a pH ≤5.5, which indicates that the end of tube is correctly located in the stomach, can be obtained. When this is not possible, hospital attendance or admission is usually required so that an X-ray can be undertaken to check the tube's position. This practice is based on an interpretation of the evidence that places undue importance on nasogastric aspirate pH testing before every use of a tube that is already in place, with potential negative consequences for children cared for in the community and their families. Following a re-examination of the evidence base, a revised approach is proposed in this article: when a child has a tube in place, provided its position has been confirmed as correct on initial placement using aspirate pH testing, nurses can use checks other than aspirate pH testing, alongside their clinical judgement, to determine whether it is safe and appropriate to use the tube. This proposed revised approach would reduce delayed or missed administration of fluids, feeds and medicines and enable more children to remain at home.
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Affiliation(s)
- Michael Tatterton
- Bluebell Wood Children's Hospice, Sheffield, and associate professor of children and young people's nursing, University of Bradford, Bradford, England
| | - Jane Mulcahy
- Sussex Community NHS Foundation Trust, East Sussex, England
| | | | - Maria Harding
- Sussex Community NHS Foundation Trust, East Sussex, England
| | | | | | - Claire Bethell
- Bluebell Wood Children's Hospice, Sheffield, and lecturer in children and young people's nursing, University of Bradford, Bradford, England
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4
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Vashi V, Laramy J, Kamin M, Ferrari L, Hand A. Relative Bioavailability of Cenobamate Administered as a Crushed Tablet, Either Orally or via Nasogastric Tube, versus an Intact Whole Tablet. J Clin Pharmacol 2024; 64:922-931. [PMID: 38683027 DOI: 10.1002/jcph.2439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 03/19/2024] [Indexed: 05/01/2024]
Abstract
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.
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Affiliation(s)
| | | | | | | | - Alan Hand
- Worldwide Clinical Trials, San Antonio, TX, USA
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5
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Cavelier M, Hervouët C, Varin R, Gondé H. Devices for securing and administering pediatric compounded oral liquids: survey results from French university hospitals. Eur J Pediatr 2024:10.1007/s00431-024-05547-x. [PMID: 38573361 DOI: 10.1007/s00431-024-05547-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/25/2024] [Accepted: 03/27/2024] [Indexed: 04/05/2024]
Abstract
Oral liquid forms, either commercial or compounded, are preferred in pediatrics due to their suitability for weight-based dosing and acceptability for children. The choice of dosing delivery devices associated with oral liquid forms is important to ensure accurate dosing, ease of administration, and patient safety. Given the prevalence of compounding in pediatric settings, this study aimed to investigate the practices among French university hospitals concerning the selection of dosing delivery devices associated with compounding oral liquid forms for children. An online survey was distributed to pharmacists involved in compounding in French university hospitals. The survey covered aspects such as the presence of child-resistant caps, types of dosing devices, the presence of bottle adapters, and the type of bottle adapters used. Among the 36 hospital pharmacies contacted, 24 responded to the survey. One pharmacy employed child-resistant caps for compounded liquid forms. Enteral syringes emerged as the primary dosing device (71%), with a minority using luer/luer-lock syringes (21%). Spoon and measuring cup usage was reported by none. Approximately two-thirds of the pharmacies (67%) used a bottle adapter in conjunction with the sampling device. Conclusion: The study highlighted diversity in the practices of French university hospitals regarding dosing delivery devices associated with compounding oral liquid forms for pediatric patients. The findings underscored the need for standardized guidelines to streamline practices and enhance safety and precision in compounded medication administration for children. What is Known: • Administration devices are important to ensure the correct administration of the required dose of oral liquids in pediatrics. • For compounded oral liquid forms, the selection and supply of administration devices are managed by compounding pharmacies from those available on the market. What is New: • The study highlighted the variability of administration devices associated with compounded liquids for oral use in French hospital pharmacies.
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Affiliation(s)
- Marine Cavelier
- Department of Pharmacy, CHU Rouen, Normandie University, UNIROUEN, EA7510 ESCAPE, F-76000, Rouen, France.
| | | | - Rémi Varin
- Department of Pharmacy, CHU Rouen, Normandie University, UNIROUEN, U1234, F-76000, Rouen, France
| | - Henri Gondé
- Department of Pharmacy, CHU Rouen, Normandie University, UNIROUEN, U1234, F-76000, Rouen, France
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Wilson S, Farabaugh J, Liu Y, Liu Z, Meyers R, Santangelo M, Thompson K. Oral Drug Product Administration via Enteral Feeding Tubes: In Vitro Testing. AAPS J 2024; 26:43. [PMID: 38575754 DOI: 10.1208/s12248-024-00896-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/29/2024] [Indexed: 04/06/2024] Open
Abstract
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.
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Affiliation(s)
- Selina Wilson
- Eli Lilly and Company, Indianapolis, Indiana, 46285, USA
| | | | - Yemin Liu
- AbbVie Inc., 1 N Waukegan Road, North Chicago, Illinois, 60064, USA
| | - Zhao Liu
- Merck & Co., Inc., Rahway, New Jersey, 07065, USA
| | - Rachel Meyers
- Ernest Mario School of Pharmacy, Rutgers University, 160 Frelinghuysen Road, Piscataway, New Jersey, 08854, USA
- Cooperman Barnabas Medical Center, Livingston, New Jersey, 07039, USA
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Logrippo S, Ganzetti R, Sestili M, Perinelli DR, Cespi M, Bonacucina G. Enteral Delivery of Pravastatin Sodium Tablets: Effect of Compounding into a Liquid Form and Co-Administration of Enteral Nutrition. PHARMACY 2024; 12:32. [PMID: 38392939 PMCID: PMC10892702 DOI: 10.3390/pharmacy12010032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 01/29/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
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.
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Affiliation(s)
- Serena Logrippo
- Hospital Pharmacy, Santa Maria della Stella Hospital, USL Umbria 2, 05018 Orvieto, Italy;
- Hospital Pharmacy, Engles Profili Hospital, AST Ancona, 60044 Fabriano, Italy
| | - Roberta Ganzetti
- Hospital Pharmacy, Carlo Urbani Hospital, AST Ancona, 60035 Jesi, Italy;
| | - Matteo Sestili
- Territorial Pharmaceutical Service, AST Ancona, 60035 Jesi, Italy;
| | - Diego Romano Perinelli
- CHIP Building, School of Pharmacy, University of Camerino, 62032 Camerino, Italy; (D.R.P.); (G.B.)
| | - Marco Cespi
- CHIP Building, School of Pharmacy, University of Camerino, 62032 Camerino, Italy; (D.R.P.); (G.B.)
| | - Giulia Bonacucina
- CHIP Building, School of Pharmacy, University of Camerino, 62032 Camerino, Italy; (D.R.P.); (G.B.)
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8
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Bifari N, N. Bifari I, Ahmed Alharbi Y. Unraveling medication errors in enteral tube administration: A cross-sectional study in geriatric patients receiving home health care. Saudi Pharm J 2024; 32:101938. [PMID: 38261870 PMCID: PMC10797149 DOI: 10.1016/j.jsps.2023.101938] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 12/25/2023] [Indexed: 01/25/2024] Open
Abstract
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.
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Affiliation(s)
- Nisrin Bifari
- Pharmaceutical Practices Department, College of Pharmacy, Umm Al-Qura University, Makkah, Saudi Arabia
| | - Ibtihaj N. Bifari
- Family Medicine Senior Registrar, Ministry of Health, Makkah, Saudi Arabia
| | - Yusuf Ahmed Alharbi
- Family Medicine Consultant, Family Medicine Academy, Ministry of Health, Makkah, Saudi Arabia
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Karkossa F, Bading A, Klein S. What to consider for successful administration of oral liquids via enteral feeding tubes? a case study with paediatric ibuprofen suspensions. Int J Pharm 2024; 649:123628. [PMID: 37984617 DOI: 10.1016/j.ijpharm.2023.123628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 11/16/2023] [Accepted: 11/17/2023] [Indexed: 11/22/2023]
Abstract
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.
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Affiliation(s)
- Frank Karkossa
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport (C_DAT), Felix-Hausdorff-Straße 3, 17489 Greifswald, Germany
| | - Annelie Bading
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport (C_DAT), Felix-Hausdorff-Straße 3, 17489 Greifswald, Germany
| | - Sandra Klein
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport (C_DAT), Felix-Hausdorff-Straße 3, 17489 Greifswald, Germany.
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García González D, Martín-Suárez A, Salvador Sánchez JJ, Sánchez Serrano JÁ, Calvo MV. Medication delivery errors in outpatients with percutaneous endoscopic gastrostomy: effect on tube feeding replacement. Sci Rep 2023; 13:21727. [PMID: 38066068 PMCID: PMC10709553 DOI: 10.1038/s41598-023-48629-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/28/2023] [Indexed: 12/18/2023] Open
Abstract
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.
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Affiliation(s)
- David García González
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Ciencias Farmacéuticas, Facultad de Farmacia, Universidad de Salamanca, Salamanca, Spain
| | - Ana Martín-Suárez
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain
- Departamento de Ciencias Farmacéuticas, Facultad de Farmacia, Universidad de Salamanca, Salamanca, Spain
| | | | | | - M Victoria Calvo
- Institute for Biomedical Research of Salamanca (IBSAL), Salamanca, Spain.
- Departamento de Ciencias Farmacéuticas, Facultad de Farmacia, Universidad de Salamanca, Salamanca, Spain.
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Webb AJ, Avramovska S, Qualls S, Lo CK, Roberts RJ, Barra ME. Impact of an enteral nutrition holding guideline on daily nutrition goals in patients taking phenytoin. Nutr Clin Pract 2023; 38:1334-1342. [PMID: 37537901 DOI: 10.1002/ncp.11051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 06/26/2023] [Accepted: 07/09/2023] [Indexed: 08/05/2023] Open
Abstract
BACKGROUND Concomitant administration of enteral nutrition (EN) and phenytoin decreases phenytoin absorption. Concerns over impaired nutrition, however, may prevent EN from being held surrounding phenytoin administration. This study aimed to evaluate whether EN holding guidelines impacted nutrition goal achievement in patients taking phenytoin. METHODS Adult patients administered enteral phenytoin for acute or chronic seizures while receiving EN during a neurocritical care admission 6 months before and after EN holding guideline implementation were eligible. Patients without phenytoin concentrations or a clinical registered dietitian assessment were excluded. The primary outcome was the percentage of nutrition daily goals attained before and after implementation. Secondary end points included the incidence of hypoglycemia, differences in measured phenytoin concentrations, and rates of therapeutic (10-20 mcg/ml) and high-therapeutic (15-20 mcg/ml) concentration attainment. Concentrations were adjusted for hypoalbuminemia using the Winter-Tozer equation. RESULTS Fifty-five patients representing 412 patient days and 1110 phenytoin administrations were included with 29 preimplementation and 26 postimplementation patients. Median percent attainment of daily EN goals was consistent preimplementation and postimplementation (86% vs 83%, P = 0.48). No significant change in rates of days with hypoglycemia was observed. Adjusted phenytoin concentrations were similar before and after implementation (14.1 vs 15.2 mcg/ml, P = 0.45), but the preimplementation cohort had a lower proportion of high-therapeutic concentrations (23% vs 36%, P = 0.018). CONCLUSION Holding EN for phenytoin did not impact attainment of daily nutrition goals and was not associated with increased rates of hypoglycemia. This is the first study to evaluate the effect of EN holding on nutrition goals in patients receiving phenytoin.
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Affiliation(s)
- Andrew J Webb
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Simona Avramovska
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
- Department of Pharmacy, Tufts University Medical Center, Boston, Massachusetts, USA
| | - Stephanie Qualls
- Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carmen Kaman Lo
- Department of Nutrition and Food Services, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Russel J Roberts
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Megan E Barra
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, USA
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Banov D, Liu Y, Ip K, Shan A, Vu C, Zdoryk O, Bassani AS, Carvalho M. Analysis of the Physical Characteristics of an Anhydrous Vehicle for Compounded Pediatric Oral Liquids. Pharmaceutics 2023; 15:2642. [PMID: 38004620 PMCID: PMC10674891 DOI: 10.3390/pharmaceutics15112642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 10/25/2023] [Accepted: 11/01/2023] [Indexed: 11/26/2023] Open
Abstract
The paucity of suitable drug formulations for pediatric patients generates a need for customized, compounded medications. This research study was set out to comprehensively analyze the physical properties of the new, proprietary anhydrous oral vehicle SuspendIt® Anhydrous, which was designed for compounding pediatric oral liquids. A wide range of tests was used, including sedimentation volume, viscosity, droplet size after dispersion in simulated gastric fluid, microscopic examination and content uniformity measurements to evaluate the properties of the anhydrous vehicle. The results showed that the vehicle exhibited consistent physical properties under varying conditions and maintained stability over time. This can be attributed to the unique blend of excipients in its formulation, which not only maintain its viscosity but also confer thixotropic behavior. The unique combination of viscous, thixotropic and self-emulsifying properties allows for rapid redispersibility, sedimentation stability, accurate dosing, potential drug solubility, dispersion and promotion of enhanced gastrointestinal distribution and absorption. Furthermore, the vehicle demonstrated long-term sedimentation stability and content uniformity for a list of 13 anhydrous suspensions. These results suggest that the anhydrous oral vehicle could serve as a versatile base for pediatric formulation, potentially filling an important gap in pediatric drug delivery. Future studies can further investigate its compatibility, stability and performance with other drugs and in different clinical scenarios.
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Affiliation(s)
- Daniel Banov
- Professional Compounding Centers of America (PCCA), Houston 77099, TX, USA
| | - Yi Liu
- Professional Compounding Centers of America (PCCA), Houston 77099, TX, USA
| | - Kendice Ip
- Professional Compounding Centers of America (PCCA), Houston 77099, TX, USA
| | - Ashley Shan
- Professional Compounding Centers of America (PCCA), Houston 77099, TX, USA
| | - Christine Vu
- Professional Compounding Centers of America (PCCA), Houston 77099, TX, USA
| | - Oleksandr Zdoryk
- Institute for Pharma Technology, School of Life Sciences, University of Applied Sciences und Arts Northwestern Switzerland, 4132 Muttenz, Switzerland
- Department of Pharmaceutical Technologies and Medicines Quality Assurance, Institute of the Professional Skills Improvement in the Field of Pharmacy, National University of Pharmacy, 61002 Kharkiv, Ukraine
| | - August S. Bassani
- Professional Compounding Centers of America (PCCA), Houston 77099, TX, USA
| | - Maria Carvalho
- Professional Compounding Centers of America (PCCA), Houston 77099, TX, USA
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Walsh J, Hermans E, Salunke S. Navigating the complexities of medicating paediatric patients: Insights from an enteral feeding tube workshop. Eur J Pharm Biopharm 2023; 191:259-264. [PMID: 37633500 DOI: 10.1016/j.ejpb.2023.08.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Accepted: 08/23/2023] [Indexed: 08/28/2023]
Abstract
Enteral feeding tubes (EFT) are used to administer nutrition into the gastrointestinal tract of patients who are unable to take nutrition via mouth. A wide range of children may require enteral feeding through EFT which are also used to administer medication. However, many medicines are not licensed for administration via this route. Numerous factors can impact EFT medicine administration, including for example, dosage form properties and composition, EFT size, design and material, and operational aspects such as tube flushing. As a result, the risk of sub-optimal dosing and medication error is much higher in patients with EFT compared to those without. EuPFI organised a preconference workshop to review the current state of knowledge around aspects to be considered in the verification of EFT administration of medications to children, and considerations for EFT use, and to highlight the areas that remain challenging. Healthcare professional, pharmaceutical industry and regulatory agency perspectives were shared, and case studies discussed. It was agreed that simple and clear standardised global procedures are required for the evaluation and administration of medicines via EFT, and collaboration between all key stakeholders is recommended.
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Affiliation(s)
- Jennifer Walsh
- Jenny Walsh Consulting Ltd., East Midlands Chamber, 8 Experian Way, ng2 Business Park, Nottingham NG1 1EP, UK
| | | | - Smita Salunke
- European Paediatric Formulation Initiative (EuPFI), University College London School of Pharmacy, 29-39 Brunswick Square, London WC1N 1AX, United Kingdom.
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14
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Kato G, Mitome H, Miyauchi Y, Takeda S, Toyota Y, Hidaka N, Tanaka M, Akira K. A study on the chemical stability of cholesterol-lowering drugs in concomitant simple suspensions with magnesium oxide. J Pharm Health Care Sci 2023; 9:32. [PMID: 37644559 PMCID: PMC10464426 DOI: 10.1186/s40780-023-00301-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 08/20/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND Difficulty in taking solid medicines is a common issue particularly for the elderly because of a decline in swallowing function, also known as dysphagia. For patients with such a dysfunction, a simple suspension method, in which solid medicines are disintegrated and suspended using warm water, has been developed and widely used in Japanese clinical settings. However, there is little information on drug stability in the simple co-suspension of multiple formulations especially including acidic or alkaline ones. In this study, the chemical stability of typical cholesterol-lowering drugs was investigated in a simple co-suspension with alkaline magnesium oxide (MgO) which is frequently used as a laxative or antacid in Japan. METHODS A cholesterol-lowering drug (one tablet) was soaked with or without MgO in warm water (55°C), and the vessel was left at room temperature for 10 min or 5 h. The suspensions prepared were then analyzed by high-performance liquid chromatography. Degradation products were analyzed by nuclear magnetic resonance spectroscopy and mass spectrometry for the structural elucidation. RESULTS In the simple co-suspension with MgO, no significant degradation was observed for atorvastatin or pravastatin, while a significant decrease of the recovery from the co-suspension was observed for rosuvastatin after 5 h. On the other hand, simvastatin and ezetimibe co-suspended with MgO were partially degraded to simvastatin acid and a pyran compound, respectively. CONCLUSIONS A simple co-suspension with MgO is feasible for atorvastatin, pravastatin, and rosuvastatin, although the rosuvastatin tablet should not be left soaking for a long time. Further it is inadvisable to suspend simvastatin or ezetimibe together with MgO because of their partial degradation.
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Affiliation(s)
- Ginjiro Kato
- Laboratory of Pharmaceutical Analytical Chemistry, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-Cho, Matsuyama, Ehime, 790-8578, Japan
| | - Hidemichi Mitome
- Laboratory of Pharmaceutical Analytical Chemistry, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-Cho, Matsuyama, Ehime, 790-8578, Japan
| | - Yusura Miyauchi
- Laboratory of Pharmaceutical Analytical Chemistry, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-Cho, Matsuyama, Ehime, 790-8578, Japan
| | - Syu Takeda
- Laboratory of Pharmaceutical Analytical Chemistry, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-Cho, Matsuyama, Ehime, 790-8578, Japan
| | - Yoshito Toyota
- Laboratory of Pharmaceutical Analytical Chemistry, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-Cho, Matsuyama, Ehime, 790-8578, Japan
| | - Noriaki Hidaka
- Division of Pharmacy, Ehime University Hospital, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Mamoru Tanaka
- Division of Pharmacy, Ehime University Hospital, 454 Shitsukawa, Toon, Ehime, 791-0295, Japan
| | - Kazuki Akira
- Laboratory of Pharmaceutical Analytical Chemistry, College of Pharmaceutical Sciences, Matsuyama University, 4-2 Bunkyo-Cho, Matsuyama, Ehime, 790-8578, Japan.
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15
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Butranova OI, Ushkalova EA, Zyryanov SK, Chenkurov MS, Baybulatova EA. Pharmacokinetics of Antibacterial Agents in the Elderly: The Body of Evidence. Biomedicines 2023; 11:1633. [PMID: 37371728 DOI: 10.3390/biomedicines11061633] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 05/31/2023] [Accepted: 06/01/2023] [Indexed: 06/29/2023] Open
Abstract
Infections are important factors contributing to the morbidity and mortality among elderly patients. High rates of consumption of antimicrobial agents by the elderly may result in increased risk of toxic reactions, deteriorating functions of various organs and systems and leading to the prolongation of hospital stay, admission to the intensive care unit, disability, and lethal outcome. Both safety and efficacy of antibiotics are determined by the values of their plasma concentrations, widely affected by physiologic and pathologic age-related changes specific for the elderly population. Drug absorption, distribution, metabolism, and excretion are altered in different extents depending on functional and morphological changes in the cardiovascular system, gastrointestinal tract, liver, and kidneys. Water and fat content, skeletal muscle mass, nutritional status, use of concomitant drugs are other determinants of pharmacokinetics changes observed in the elderly. The choice of a proper dosing regimen is essential to provide effective and safe antibiotic therapy in terms of attainment of certain pharmacodynamic targets. The objective of this review is to perform a structure of evidence on the age-related changes contributing to the alteration of pharmacokinetic parameters in the elderly.
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Affiliation(s)
- Olga I Butranova
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
| | - Elena A Ushkalova
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
| | - Sergey K Zyryanov
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
- State Budgetary Institution of Healthcare of the City of Moscow "City Clinical Hospital No. 24 of the Moscow City Health Department", Pistzovaya Srt. 10, 127015 Moscow, Russia
| | - Mikhail S Chenkurov
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
| | - Elena A Baybulatova
- Department of General and Clinical Pharmacology, Peoples' Friendship University of Russia named after Patrice Lumumba (RUDN University), 6 Miklukho-Maklaya St., 117198 Moscow, Russia
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16
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Wojcinski J, Nathan K, Zhao F. In Vitro Assessment of Compounded Lurasidone Suspensions for Enteral Feeding Tubes. Hosp Pharm 2023; 58:304-308. [PMID: 37216072 PMCID: PMC10192993 DOI: 10.1177/00185787221139421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/04/2024]
Abstract
Purpose: Extemporaneously compounded drug suspensions are often necessary for patients who are intubated or receiving nutrition through enteral feeding tubes. Lurasidone is a relatively new antipsychotic medication available only as oral tablets (Latuda®), and there is no data to support its use in this patient population as a compounded liquid formulation. This study was designed to assess the feasibility of preparing lurasidone suspensions from tablets and their compatibility with enteral feeding tubes. Methods: Representative nasogastric tubes were selected for this study, including polyurethane, polyvinylchloride, and silicone tubes with a range of 8 to 12 Fr (2.7-4.0 mm) in diameter and 35 to 55″ in length. Two strengths of lurasidone suspensions, 1 and 8 mg/mL, were prepared by the standard mortar-pestle method. Latuda® tablet 120 mg was used as the drug source, and a 1:1 mixture of Ora-Plus®:water was used as the suspension vehicle. The drug suspensions were delivered through the tubes mounted on a peg board to simulate patient position in a hospital bed. The ease of administration through the tubes was evaluated visually. The drug concentration before and after the tube delivery was analyzed by high performance liquid chromatography (HPLC). In addition, a 14-day stability study of the compounded suspensions was performed at room temperature to support the beyond-use dating. Results: Freshly prepared lurasidone suspensions, 1 and 8 mg/mL, met the potency and uniformity requirements. Both strengths of suspensions exhibited satisfactory flowability through all the tube types studied with no signs of clogging. The HPLC results confirmed that greater than 97% of drug concentration was retained after tube delivery. During the 14-day stability study, the suspensions retained greater than 93% of their original concentration. There was no significant change in pH or visual appearance. Conclusions: The study demonstrated a practical procedure to prepare 1 and 8 mg/mL lurasidone suspensions that are compatible with commonly used enteral feeding tube materials and dimensions. A beyond-use date of 14-day was established for the suspensions stored at room temperature.
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Affiliation(s)
| | | | - Fang Zhao
- St. John Fisher College, Rochester, NY,
USA
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17
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Klang MG. Developing guidance for feeding tube administration of oral medications. JPEN J Parenter Enteral Nutr 2023; 47:519-540. [PMID: 36847617 PMCID: PMC10508335 DOI: 10.1002/jpen.2490] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 02/09/2023] [Accepted: 02/21/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Drug administration through feeding tubes presents many challenges to the healthcare provider. There is little information available on medications than can be delivered safely when crushed and what efforts can be implemented to minimize clogging the feeding tube. Our institution requested a comprehensive examination of all oral medications for the feeding tube route. METHODS This report is a synopsis of the physical evaluation of 323 different oral medications for their appropriateness for feeding tube administration with distal site in either the stomach or jejunum. A worksheet was created for each medication. This document contained a review of the chemical and physical properties that would contribute to delivery of the medication. Each medication was then studied for the degree of disintegration, pH, osmolality, and potential to form clogs. For drugs that needed to be crushed, the volume of water needed to dissolve the drug, time for that process, and volume needed to rinse the tube after administration was also studied. RESULTS The results of this review are summarized in a table and based on a composite of the documents cited, tests conducted, and author's judgements based all the data collected. Thirty-six medications were identified as inappropriate for feeding tube administration, and an additional 46 medications were identified as inappropriate for direct jejunal administration. CONCLUSION The information produced by this study will enable clinicians to make informed choices in selecting, compounding, and rinsing medications through feeding tubes. Using the template provided, they will be able to evaluate a drug not studied here for potential issues in feeding tube administration.
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Affiliation(s)
- Mark G Klang
- Research Pharmacy, Sloan Kettering Institute, Memorial Sloan Kettering Cancer Center, New York, New York, USA
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18
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De Lucia SS, Candelli M, Polito G, Maresca R, Mezza T, Schepis T, Pellegrino A, Zileri Dal Verme L, Nicoletti A, Franceschi F, Gasbarrini A, Nista EC. Nutrition in Acute Pancreatitis: From the Old Paradigm to the New Evidence. Nutrients 2023; 15:1939. [PMID: 37111158 PMCID: PMC10144915 DOI: 10.3390/nu15081939] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 04/12/2023] [Accepted: 04/14/2023] [Indexed: 04/29/2023] Open
Abstract
The nutritional management of acute pancreatitis (AP) patients has widely changed over time. The "pancreatic rest" was the cornerstone of the old paradigm, and nutritional support was not even included in AP management. Traditional management of AP was based on intestinal rest, with or without complete parenteral feeding. Recently, evidence-based data underlined the superiority of early oral or enteral feeding with significantly decreased multiple-organ failure, systemic infections, surgery need, and mortality rate. Despite the current recommendations, experts still debate the best route for enteral nutritional support and the best enteral formula. The aim of this work is to collect and analyze evidence over the nutritional aspects of AP management to investigate its impact. Moreover, the role of immunonutrition and probiotics in modulating inflammatory response and gut dysbiosis during AP was extensively studied. However, we have no significant data for their use in clinical practice. This is the first work to move beyond the mere opposition between the old and the new paradigm, including an analysis of several topics still under debate in order to provide a comprehensive overview of nutritional management of AP.
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Affiliation(s)
- Sara Sofia De Lucia
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Marcello Candelli
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Giorgia Polito
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Rossella Maresca
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Teresa Mezza
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Tommaso Schepis
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Antonio Pellegrino
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Lorenzo Zileri Dal Verme
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Alberto Nicoletti
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Francesco Franceschi
- Department of Emergency, Anesthesiological and Reanimation Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Antonio Gasbarrini
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
| | - Enrico Celestino Nista
- Department of Medical and Surgical Sciences, Università Cattolica del Sacro Cuore, Fondazione Policlinico Universitario A. Gemelli IRCSS, 00168 Rome, Italy
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19
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Bauters T, Buyle F, Schelstraete P, Dhooge C. Administration of ciprofloxacin through a nasogastric tube in pediatric oncology and stem cell transplantation patients. J Oncol Pharm Pract 2023; 29:413-415. [PMID: 36572994 DOI: 10.1177/10781552221147891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Pediatric oncology and hematopoietic stem cell transplantation patients are facing many gastrointestinal side effects of chemotherapy, including nausea, vomiting, mucositis, and diarrhea. International guidelines advise early enteral tube feeding as the first option of nutritional support in children undergoing myeloablative hematopoietic stem cell transplantation. When using enteral feeding tubes for nutritional purposes as well as drug administration, some pharmaceutical, nursing, and technical issues have to be taken into account. Ciprofloxacin is a fluoroquinolone, widely used because of its broad spectrum antimicrobial activity and favorable pharmacokinetic properties. However, its co-administration with polyvalent cations (as present in enteral feeding) makes the absorption of ciprofloxacin more difficult and may alter the pharmacokinetic parameters. Literature data are conflicting on how long the enteral feeding should be discontinued for patients receiving ciprofloxacin via an enteral feeding tube, ranging from 2 h before to 6 h after the administration of ciprofloxacin. Our research question was guided by challenges and concerns of nurses about the delay time between ciprofloxacin administration and restart of the enteral feeding without compromising the nutritional intake of the children. Our guideline was adapted, nurses were instructed accordingly, and patient leaflets with correct information were created.
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Affiliation(s)
- Tiene Bauters
- Pediatric Hematology, Oncology and Stem Cell Transplantation, 60200Ghent University Hospital, Ghent, Belgium.,Pharmacy Department, 60200Ghent University Hospital, Ghent, Belgium
| | - Franky Buyle
- Pharmacy Department, 60200Ghent University Hospital, Ghent, Belgium
| | - Petra Schelstraete
- Department of Pediatric Pulmonology and Infectious Diseases, 60200Ghent University Hospital, Ghent, Belgium
| | - Catharina Dhooge
- Pediatric Hematology, Oncology and Stem Cell Transplantation, 60200Ghent University Hospital, Ghent, Belgium
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20
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MacLaren R. Considerations when administering medications enterally in the critically ill. Curr Opin Clin Nutr Metab Care 2023; 26:302-306. [PMID: 36942898 DOI: 10.1097/mco.0000000000000921] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/23/2023]
Abstract
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.
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Affiliation(s)
- Robert MacLaren
- Department of Clinical Pharmacy, University of Colorado Skaggs School of Pharmacy and Pharmaceutical Sciences
- University of Colorado Hospital Department of Pharmacy, Aurora, Colorado, USA
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21
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Fouad A, Quintiliani R, Nicolau DP, Asempa TE. Relative bioavailability of crushed tebipenem administered through a nasogastric tube with and without enteral feeding. J Antimicrob Chemother 2022; 78:205-208. [PMID: 36374528 DOI: 10.1093/jac/dkac375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/17/2022] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE Tebipenem pivoxil hydrobromide is an orally bioavailable carbapenem prodrug of the active agent tebipenem with broad-spectrum activity against drug-resistant Enterobacterales. This study aimed to evaluate the relative bioavailability of crushed tebipenem tablets administered via nasogastric tube (NGT) with or without concomitant enteral feeds. METHODS This Phase 1, open label study randomized 12 healthy subjects to receive a crushed tebipenem tablet via NGT (n = 6) or via NGT with concomitant Osmolite® enteral feeds (n = 6) on Study Day 1, followed by oral administration of tebipenem whole tablet (reference formulation) on Study Day 2. Tebipenem plasma concentrations were measured by LC with mass spectrometry. Bioequivalence was determined using pharmacokinetic parameters derived through non-compartmental analyses. RESULTS Mean ± SD tebipenem pharmacokinetic parameters in plasma for subjects who received a crushed tablet via NGT (relative to whole tablet) and a crushed tablet with enteral feeds (relative to whole tablet) were as follows: maximum total plasma concentration (Cmax), 11.1 ± 3.9 (12 ± 3.4) and 10.2 ± 1.9 (10 ± 4) mg/L; area under the curve (AUC0-8), 17.5 ± 3.5 (17.9 ± 2.3) and 15 ± 4.3 (13.4 ± 5.3) mg•h/L. Using the 90% CI criteria, Cmaxand AUC0-8 values for tebipenem were found to be bioequivalent following alternative methods of administration compared with oral dosing of the whole tablet. The three methods of administration were well tolerated. CONCLUSION Results demonstrate that tebipenem maintained bioequivalence when crushed and administered via NGT with and without accompanying enteral feeds in healthy subjects, relative to whole tablet oral administration. Data therefore support alternative methods of tebipenem administration depending on patient condition.
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Affiliation(s)
- Aliaa Fouad
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
| | | | - David P Nicolau
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA.,Division of Infectious Diseases, Hartford Hospital, Hartford, CT, USA
| | - Tomefa E Asempa
- Center for Anti-Infective Research and Development, Hartford Hospital, Hartford, CT, USA
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22
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Bernsen EC, Hogenes VJ, Nuijen B, Hanff LM, Huitema ADR, Diekstra MHM. Practical Recommendations for the Manipulation of Kinase Inhibitor Formulations to Age-Appropriate Dosage Forms. Pharmaceutics 2022; 14:2834. [PMID: 36559327 PMCID: PMC9782008 DOI: 10.3390/pharmaceutics14122834] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2022] [Revised: 12/07/2022] [Accepted: 12/12/2022] [Indexed: 12/24/2022] Open
Abstract
Over 75 kinase inhibitors (KIs) have been approved for the treatment of various cancers. KIs are orally administrated but mostly lack pediatric age-appropriate dosage forms or instructions for dose manipulation. This is highly problematic for clinical practice in pediatric oncology, as flexible oral formulations are essential to individually set dosages and to adjust it to a child's swallowability. Most KIs are poorly soluble, categorized in Biopharmaceutics Classification System (BCS) class II or IV, and improperly manipulating the KI formulation can alter pharmacokinetics and jeopardize KI drug safety and efficacy. Therefore, the goals of this review were to provide practical recommendations for manipulating the formulation of the 15 most frequently used KIs in pediatric oncology (i.e., bosutinib, cabozantinib, cobimetinib, crizotinib, dabrafenib, dasatinib, entrectinib, imatinib, larotrectinib, nilotinib, ponatinib, ruxolitinib, selumetinib, sunitinib and trametinib) based on available literature studies and fundamental drug characteristics and to establish a decision tool that supports decisions regarding formulation manipulation of solid oral dosages of KIs that have been or will be licensed (for adult and/or pediatric cancers) but are not included in this review.
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Affiliation(s)
- Emma C. Bernsen
- Princess Máxima Center for Pediatric Oncology, Department of Pharmacology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
| | - Valery J. Hogenes
- Princess Máxima Center for Pediatric Oncology, Department of Pharmacology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
| | - Bastiaan Nuijen
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
| | - Lidwien M. Hanff
- Princess Máxima Center for Pediatric Oncology, Department of Pharmacology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
| | - Alwin D. R. Huitema
- Princess Máxima Center for Pediatric Oncology, Department of Pharmacology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
- Department of Pharmacy & Pharmacology, The Netherlands Cancer Institute—Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands
- Department of Clinical Pharmacy, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX Utrecht, The Netherlands
| | - Meta H. M. Diekstra
- Princess Máxima Center for Pediatric Oncology, Department of Pharmacology, Heidelberglaan 25, 3584 CS Utrecht, The Netherlands
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23
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Cavagna P, Bizet S, Fieux F, Houillez E, Chirk C, Zulian C, Perreux J, Fernandez C, Lescot T, Antignac M. Assessment of Good Practice Guidelines for Administration of Drugs via Feeding Tubes by a Clinical Pharmacist in the Intensive Care Unit. Crit Care Nurse 2022; 42:54-65. [DOI: 10.4037/ccn2022395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
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 < .01). Administration nonconformity decreased significantly in regard to crushing tablets and opening capsules (51.2% vs 4.3%, P < .01) and the solvent used (67.1% vs 3.5%, P < .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.
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Affiliation(s)
- Pauline Cavagna
- Pauline Cavagna is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University, Paris, France
| | - Simon Bizet
- Simon Bizet is a physician, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Fabienne Fieux
- Fabienne Fieux is a physician, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Emilie Houillez
- Emilie Houillez is a nurse, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Caroline Chirk
- Caroline Chirk is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Chloé Zulian
- Chloé Zulian is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Jennifer Perreux
- Jennifer Perreux is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Christine Fernandez
- Christine Fernandez is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Thomas Lescot
- Thomas Lescot is a physician, surgical intensive care unit, Department of Anesthesiology and Critical Care Medicine, Saint-Antoine Hospital, AP-HP Sorbonne University
| | - Marie Antignac
- Marie Antignac is a pharmacist, Department of Pharmacy, Saint-Antoine Hospital, AP-HP Sorbonne University
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Bloom L, Seckel MA. Placement of Nasogastric Feeding Tube and Postinsertion Care Review. AACN Adv Crit Care 2022; 33:68-84. [PMID: 35259226 DOI: 10.4037/aacnacc2022306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Insertion and postinsertion care of enteral nasogastric feeding tubes are common procedures in the United States, with more than 1.2 million temporary nasogastric feeding tubes inserted annually. Although there are some evidence-based practice guidelines and recommendations for care of these tubes, variation in practice still exists. Additional research is needed to determine the best methodology for insertion and confirmation of nasogastric feeding tubes. Routine competency and training on feeding tube insertion, enteral nutrition, and postinsertion care is crucial to prevent patient safety events. Variable results have been reported with different technologies; however, radiographic confirmation remains the criterion standard. It is important that health care institutions develop standardized procedures for insertion and confirmation on the basis of evidence-based practices to minimize risks and complications from temporary nasogastric feeding tubes.
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Affiliation(s)
- Lindsey Bloom
- Lindsey Bloom is Critical Care Clinical Practice Specialist, Adventist Health, One Adventist Health Way, Roseville, CA 95661
| | - Maureen A Seckel
- Maureen A. Seckel is Critical Care Clinical Nurse Specialist and Sepsis Coordinator, ChristianaCare, Newark, Delaware
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In Vitro Stability and Recovery Studies of Pimavanserin in Water and in Different Vehicles Orally Administered. Drugs R D 2022; 22:95-104. [PMID: 35107816 PMCID: PMC8885838 DOI: 10.1007/s40268-022-00381-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/29/2021] [Indexed: 11/21/2022] Open
Abstract
Background and objective Swallowing difficulties (i.e., dysphagia) occur in up to 40% of the adult general population, particularly among the elderly prescribed solid oral dosage forms. Pimavanserin is approved for the treatment of hallucinations and delusions in patients with Parkinson’s disease psychosis (PDP) as a 34-mg capsule formulation. Patients with PDP may be at-risk for dysphagia that could affect administration of intact pimavanserin capsules. The stability of oral pimavanserin was evaluated in different liquid/soft food vehicles. Methods The stability of pimavanserin intended for oral administration was assessed by sprinkling the contents of 1 pimavanserin 34-mg capsule into water (40 mL), applesauce (40 g), vanilla Ensure (60 mL), or non-pulp orange juice (60 mL). Results The stability study demonstrated >95% recovery within 24 hours after contents of a 34-mg pimavanserin capsule were dispersed in applesauce, vanilla Ensure®, orange juice, or water. Assay values at 24 h for individual capsules were within 5% of time zero, and no significant change in the impurity profile was observed in any vehicle. Pimavanserin degradation products recovered from various food vehicles for individual and total degradation products were < 0.5% at all time points. In addition, the impurity profile of compatibility samples matched that obtained for a control sample. Conclusion These results support the ability of pimavanserin to be given orally by emptying the capsule contents into soft foods or liquids in accordance with the product label.
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Alsamet HM. Considerations regarding oral medications delivery to patients on nasoenteral tubes. NUTR CLIN METAB 2022. [DOI: 10.1016/j.nupar.2021.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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27
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Karkossa F, Lehmann N, Klein S. A systematic approach for assessing the suitability of enteral feeding tubes for the administration of controlled-release pellet formulations. Int J Pharm 2022; 612:121286. [PMID: 34775043 DOI: 10.1016/j.ijpharm.2021.121286] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2021] [Revised: 11/04/2021] [Accepted: 11/07/2021] [Indexed: 10/19/2022]
Abstract
Enteral nutrition plays an important role for patients who are unable to properly swallow food. In such patients, enteral feeding tubes are often used, through which food, but often also oral medications, are administered. However, this can pose the risk of tube clogging. Compared to the administration of crushed tablets, multiparticulate dosage forms are often considered easier to administer and furthermore have the advantage of enabling the administration of even controlled-release preparations. The objective of this systematic study was to identify tube- and formulation-related factors that contribute to successful administration of coated pellet formulations via a variety of commercially available feeding tube devices. The suitability of enteral feeding tubes for the administration of controlled-release pellet formulations that differed in size and type of starter core and functional coating was investigated in a stepwise approach using a novel in vitro setup. Results of the study indicate that pellet diameter and inner diameter of the feeding tube are by no means reliable parameters for estimating the tube's suitability for pellet administration, but that many other tube and formulation-related factors and combinations thereof must be considered to ensure safe and effective drug administration via enteral feeding tubes.
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Affiliation(s)
- Frank Karkossa
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, 3 Felix Hausdorff Street, Greifswald 17489, Germany
| | - Nicole Lehmann
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, 3 Felix Hausdorff Street, Greifswald 17489, Germany
| | - Sandra Klein
- University of Greifswald, Department of Pharmacy, Institute of Biopharmaceutics and Pharmaceutical Technology, Center of Drug Absorption and Transport, 3 Felix Hausdorff Street, Greifswald 17489, Germany.
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28
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Yin HS, Neuspiel DR, Paul IM, Franklin W, Tieder JS, Adirim T, Alvarez F, Brown JM, Bundy DG, Ferguson LE, Gleeson SP, Leu M, Mueller BU, Connor Phillips S, Quinonez RA, Rea C, Rinke ML, Shaikh U, Shiffman RN, Vickers Saarel E, Spencer Cockerham SP, Mack Walsh K, Jones B, Adler AC, Foster JH, Green TP, Houck CS, Laughon MM, Neville K, Reigart JR, Shenoi R, Sullivan JE, Van Den Anker JN, Verhoef PA. Preventing Home Medication Administration Errors. Pediatrics 2021; 148:183379. [PMID: 34851406 DOI: 10.1542/peds.2021-054666] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
Medication administration errors that take place in the home are common, especially when liquid preparations are used and complex medication schedules with multiple medications are involved; children with chronic conditions are disproportionately affected. Parents and other caregivers with low health literacy and/or limited English proficiency are at higher risk for making errors in administering medications to children in their care. Recommended strategies to reduce home medication errors relate to provider prescribing practices; health literacy-informed verbal counseling strategies (eg, teachback and showback) and written patient education materials (eg, pictographic information) for patients and/or caregivers across settings (inpatient, outpatient, emergency care, pharmacy); dosing-tool provision for liquid medication measurement; review of medication lists with patients and/or caregivers (medication reconciliation) that includes prescription and over-the-counter medications, as well as vitamins and supplements; leveraging the medical home; engaging adolescents and their adult caregivers; training of providers; safe disposal of medications; regulations related to medication dosing tools, labeling, packaging, and informational materials; use of electronic health records and other technologies; and research to identify novel ways to support safe home medication administration.
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Affiliation(s)
- H Shonna Yin
- Departments of Pediatrics and Population Health, Grossman School of Medicine, New York University, New York, New York
| | | | - Ian M Paul
- Departments of Pediatrics and Public Health Sciences, College of Medicine, Pennsylvania State University, Hershey, Pennsylvania
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29
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Teder K, Jõhvik L, Meos A, Saar M, Visbek A, Volmer D, Karjagin J. Solid oral medications' suitability for use in enteral feeding tubes. Nurs Crit Care 2021; 27:698-705. [PMID: 34755443 DOI: 10.1111/nicc.12729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/18/2021] [Accepted: 10/25/2021] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Kersti Teder
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Liisa Jõhvik
- Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Andres Meos
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Marika Saar
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Pharmacy Department, Tartu University Hospital, Tartu, Estonia
| | - Alesya Visbek
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Daisy Volmer
- Institute of Pharmacy, Faculty of Medicine, University of Tartu, Tartu, Estonia
| | - Juri Karjagin
- Institute of Clinical Medicine, Faculty of Medicine, University of Tartu, Tartu, Estonia.,Department of Anaesthesiology and Intensive Care, Tartu University Hospital, Tartu, Estonia
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30
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Kurish HP, Gabriel JM, Bruck CL, Stumpf JL. Efficacy of a Viokace Pancreatic Enzyme Protocol for Clearing Occluded Enteral Feeding Tubes: A Quality Assurance Evaluation. J Pharm Pract 2021; 36:271-275. [PMID: 34340577 DOI: 10.1177/08971900211036590] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: A previous retrospective study documented restored patency to 48.2% of occluded enteral feeding tubes using alkalinized Creon pancreatic enzyme capsules. In light of the low efficacy rate, the institutional enteral feeding tube clearance protocol was subsequently revised to incorporate a newly marketed non-enteric-coated Viokace pancreatic enzyme tablet, despite the lack of published data for this indication. Objective: This study aims to evaluate the effectiveness of a Viokace-based alkalinized pancreatic enzyme protocol to clear occluded enteral feeding tubes in a university health system. Methods: This retrospective, cohort quality assurance study included adult and pediatric patients receiving a Viokace-based pancreatic enzyme protocol for enteral feeding tube occlusions in a university health system during a 12-month period. The primary outcome was effectiveness in enteral tube clearance as documented in the electronic medical record. Efficacy of the new protocol was also compared with a Creon-based alkalinized solution using historical data. Results: The Viokace protocol successfully cleared 176 of the 277 (63.5%) occluded enteral feeding tubes occurring in 205 patients included in the analysis. The revised protocol was significantly more effective at clearing occluded enteral feeding tubes (P = 0.0056) than a protocol using Creon pancreatic enzyme capsules. Conclusion: According to this retrospective evaluation, an alkalinized Viokace pancreatic enzyme protocol was effective in clearing 63.5% of occluded enteral feeding tubes. This significantly higher success rate than previously documented with a Creon-based protocol supports the change in pancreatic enzyme formulations in the institutional protocol.
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Affiliation(s)
- Heena P Kurish
- BCOP, Clinical Pharmacy Specialist-Lymphoma and Multiple Myeloma, 2569Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Jacenta M Gabriel
- BCPS, Clinical Pharmacy Generalist-Internal Medicine, 2971Henry Ford Health System, Detroit, MI, USA
| | - Cheryl L Bruck
- Ambulatory Pharmacist, 2569Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Janice L Stumpf
- Emerita Clinical Associate Professor of Pharmacy, 15514University of Michigan College of Pharmacy, Ann Arbor, MI, USA
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Hoover A, Chitranshi P, Momot M, Tyner K, Wokovich A. In vitro evaluation of enteral tube administration of lansoprazole orally disintegrating tablets. Pharm Dev Technol 2021; 26:846-851. [PMID: 34182865 DOI: 10.1080/10837450.2021.1948567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Lansoprazole orally disintegrating tablets (ODTs) can be administered orally or through a nasogastric (NG) tube for patients who are unable to swallow. In addition, off-label administration through gastrostomy (G) or jejunal (J) tubes has been reported. The purpose of this study was to develop in vitro methods to assess the risk of clogging during administration of two lansoprazole ODTs through enteral feeding tubes. Feeding tubes of various compositions and geometries were selected for testing. Disintegration, sedimentation, percent recovery, acid phase dissolution testing, and particle size distribution measurements were performed. The results indicated that G tubes had the greatest risk of clogging compared to NG and J tubes. In addition, larger particles and an increased amount of insoluble excipients observed in Product B resulted in more irreversible enteral tube clogging than compared to Product A. The geometry and design of the tube also had an impact on the amount of lansoprazole recovered after enteral tube administration. Lansoprazole ODTs demonstrated acid resistance stability regardless of the water used for suspension. The in vitro methods discussed in this work could be used to evaluate in vitro equivalence and to assess the risk of delivering a drug product through an enteral feeding tube.
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Affiliation(s)
- Alicia Hoover
- Division of Pharmaceutical Analysis, Food and Drug Administration, Saint Louis, MO, USA
| | - Priyanka Chitranshi
- Division of Pharmaceutical Analysis, Food and Drug Administration, Saint Louis, MO, USA
| | - Magdalene Momot
- Division of Pharmaceutical Analysis, Food and Drug Administration, Saint Louis, MO, USA
| | - Katherine Tyner
- Office of Pharmaceutical Quality, Food and Drug Administration, Silver Spring, MD, USA
| | - Anna Wokovich
- Division of Pharmaceutical Analysis, Food and Drug Administration, Saint Louis, MO, USA
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32
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Santangelo M, Wood JA, Barnett KL, Wooding FGG, Bartlett JA. In Vitro Assessment for Dose Preparation and Simulated Administration of Azithromycin Suspensions via Enteral Feeding Tubes. Hosp Pharm 2021; 57:260-267. [PMID: 35601710 PMCID: PMC9117782 DOI: 10.1177/00185787211024216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Administration of medication via enteral feeding tubes (EFT) is common in cases where patients are unable to swallow the dosage form or a patient is intubated. The SARS-CoV-2 (COVID-19, coronavirus disease 2019) epidemic created a need to rapidly evaluate potential treatment options to address the global pandemic including evaluation of azithromycin (AZM) as a mono or combination therapy. Due to the complicating medical conditions of COVID-19, in some cases patients may be unable to take medication orally and could require medication administration by alternate routes such as an EFT. The aim of this study was an in vitro assessment for the dose preparation and simulated administration of AZM suspensions, prepared from tablets and capsules, via nasogastric feeding tubes (NGT). AZM tablets and capsules were used to prepare aqueous suspensions from 250 to 2000 mg for administration via NGT. NGT between 8 and 12 French (Fr), from common materials of construction and typical lengths were evaluated. About 20 mL syringes were used with water as the diluent. The preparation and simulated NGT administration steps for AZM suspensions were evaluated in the laboratory studies and included assessment of in-use stability of the aqueous suspensions, chemical compatibility of prepared aqueous suspensions with the syringe and NGT, ease of delivery and accuracy of simulated administration. Analysis of the prepared sample solutions for assay/impurities was performed using chromatographic conditions based on the USP-NF monograph. Verification of dose preparation and simulated administration was performed for intact tablets, crushed tablets, and capsules. Aqueous suspensions prepared from intact tablets and capsules were exposed to dosing materials (enteral syringe and NGT) for a period of up to 4 hours at ambient conditions. Assessment of the ease of dose delivery and analyses of the resulting samples for assay, purity and total degradation products were performed. The laboratory studies verified a procedure to reliably prepare suspensions from AZM tablets and capsules, over a range of 250 to 2000 mg, that can be accurately administered through NGT in sizes of 8 to 12 Fr. No incompatibilities of the prepared aqueous AZM suspension with dosing materials were observed and acceptable stability was demonstrated for up to 4 hours.
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Watson CJ, Whitledge JD, Siani AM, Burns MM. Pharmaceutical Compounding: a History, Regulatory Overview, and Systematic Review of Compounding Errors. J Med Toxicol 2021; 17:197-217. [PMID: 33140232 PMCID: PMC7605468 DOI: 10.1007/s13181-020-00814-3] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 09/13/2020] [Accepted: 09/17/2020] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Medications are compounded when a formulation of a medication is needed but not commercially available. Regulatory oversight of compounding is piecemeal and compounding errors have resulted in patient harm. We review compounding in the United States (US), including a history of compounding, a critique of current regulatory oversight, and a systematic review of compounding errors recorded in the literature. METHODS We gathered reports of compounding errors occurring in the US from 1990 to 2020 from PubMed, Embase, several relevant conference abstracts, and the US Food and Drug Administration "Drug Alerts and Statements" repository. We categorized reports into errors of "contamination," suprapotency," and "subpotency." Errors were also subdivided by whether they resulted in morbidity and mortality. We reported demographic, medication, and outcome data where available. RESULTS We screened 2155 reports and identified 63 errors. Twenty-one of 63 were errors of concentration, harming 36 patients. Twenty-seven of 63 were contamination errors, harming 1119 patients. Fifteen errors did not result in any identified harm. DISCUSSION Compounding errors are attributed to contamination or concentration. Concentration errors predominantly result from compounding a prescription for a single patient, and disproportionately affect children. Contamination errors largely occur during bulk distribution of compounded medications for parenteral use, and affect more patients. The burden falls on the government, pharmacy industry, and medical providers to reduce the risk of patient harm caused by compounding errors. CONCLUSION In the US, drug compounding is important in ensuring access to vital medications, but has the potential to cause patient harm without adequate safeguards.
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Affiliation(s)
- C James Watson
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA.
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
| | - James D Whitledge
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | | | - Michele M Burns
- Harvard Medical Toxicology Program, Boston Children's Hospital, 333 Longwood Avenue, Mailstop 3025, Boston, MA, 02215, USA
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, USA
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A Safe Way to Administer Drugs Through a Nutrition Tube-The Simple Suspension Method. Dysphagia 2021; 37:318-322. [PMID: 33719015 PMCID: PMC8948140 DOI: 10.1007/s00455-021-10280-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 02/24/2021] [Indexed: 02/07/2023]
Abstract
The simple suspension method (SSM), developed by Kurata in 1997, is a way to suspend tablets and capsules in warm water for decay and suspension prior to their administration. This method is safe and has various advantages such as the avoidance of tube clogging and the loss of the drug. This study aimed to investigate whether a higher percentage of commonly used drugs could pass through nutrition tubes effectively using SSM, relative to that using the conventional crushing method. A tablet or capsule was inserted into a 20 mL syringe with warm water (at 55 °C). After 10 min, it was shaken in the syringe. The suspension liquid was injected into tubes of the following sizes: 8 Fr, 10 Fr, 12 Fr, 14 Fr, 16 Fr, and 18 Fr. A total of 3686 tablets and 432 capsules that are frequently used in Japan were tested. Using SSM, 3377 (91.6%) tablets and 359 (83.1%) capsules disintegrated within 10 min and passed through the tube without clogging it in the tube passage test. With the conventional crushing method, 2117 tablets (57.4%) and 272 capsules (63.0%) could be crushed. SSM reduced the risk of tube clogging and drug loss with more drugs than that with the conventional crushing method. The number of drugs indicated for administration by SSM is greater than that indicated by the conventional crushing method. Further studies are needed to consider its utility compared to conventional methods for dysphagia patients in clinical settings.
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Abu Hdaib N, Albsoul-Younes A, Wazaify M. Oral medications administration through enteral feeding tube: Clinical pharmacist-led educational intervention to improve knowledge of Intensive care units' nurses at Jordan University Hospital. Saudi Pharm J 2021; 29:134-142. [PMID: 33679176 PMCID: PMC7910138 DOI: 10.1016/j.jsps.2020.12.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/31/2020] [Indexed: 01/10/2023] Open
Abstract
Introduction Medication administration through enteral feeding tubes is a practice that is commonly encountered in hospital settings, particularly in critically ill patients. This study aims to evaluate the knowledge of intensive care unit nurses regarding enteral medication administration and evaluate the effect of an educational intervention led by a clinical pharmacist that would improve nurses’ knowledge regarding the subject. Methods A pre/post interventional study was conducted. Improvement in nurses’ knowledge regarding medication administration through an enteral feeding tube was assessed using a validated questionnaire. Results Data were coded, entered, and analyzed using the Statistical Package for Social Sciences (IBM SPSS statistics 22). Independent samples t-test and paired t-test were used to detect any statistically significant differences in the mean total knowledge scores both between and within each group respectively. A P-value of <0.05 was considered statistically significant. The mean total knowledge score for nurses in the intervention and control group at the pre-interventional phase of the study was inadequate. There was a statistically significant improvement in the mean total knowledge score for the interventional group at the post-interventional phase of the study, while that of the control group remained inadequate (Intervention group total mean knowledge score at baseline 12.11 ± 3.75, post-intervention 21.50 ± 2.36, p-value <0.001; Control group total mean knowledge score at baseline 12.05 ± 3.12, post-intervention 12.60 ± 3.76, p-value 0.96). Conclusion Incorrect drug preparation and administration for patients with feeding tubes can affect patients. The knowledge of nurses regarding the subject can be improved significantly via an educational intervention. The activation of clinical pharmacists’ role and collaboration between pharmacists, physicians, and nurses is highly recommended in this clinical setting.
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Affiliation(s)
- N. Abu Hdaib
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Jordan
- Department of Pharmacy, Faculty of Pharmacy, Middle East University, Amman, Jordan
| | - A. Albsoul-Younes
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Jordan
| | - M. Wazaify
- Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Jordan
- Corresponding author at: Department of Biopharmaceutics and Clinical Pharmacy, School of Pharmacy, The University of Jordan, Amman 11942, Jordan.
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Gkolfakis P, Arvanitakis M, Despott EJ, Ballarin A, Beyna T, Boeykens K, Elbe P, Gisbertz I, Hoyois A, Mosteanu O, Sanders DS, Schmidt PT, Schneider SM, van Hooft JE. Endoscopic management of enteral tubes in adult patients - Part 2: Peri- and post-procedural management. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53:178-195. [PMID: 33348410 DOI: 10.1055/a-1331-8080] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
ESGE recommends the "pull" technique as the standard method for percutaneous endoscopic gastrostomy (PEG) placement.Strong recommendation, low quality evidence.ESGE recommends the direct percutaneous introducer ("push") technique for PEG placement in cases where the "pull" method is contraindicated, for example in severe esophageal stenosis or in patients with head and neck cancer (HNC) or esophageal cancer.Strong recommendation, low quality evidence.ESGE recommends the intravenous administration of a prophylactic single dose of a beta-lactam antibiotic (or appropriate alternative antibiotic, in the case of allergy) to decrease the risk of post-procedural wound infection.Strong recommendation, moderate quality evidence.ESGE recommends that inadvertent insertion of a nasogastric tube (NGT) into the respiratory tract should be considered a serious but avoidable adverse event (AE).Strong recommendation, low quality evidence.ESGE recommends that each institution should have a dedicated protocol to confirm correct positioning of NGTs placed "blindly" at the patient's bedside; this should include: radiography, pH testing of the aspirate, and end-tidal carbon dioxide monitoring, but not auscultation alone.Strong recommendation, low quality evidence.ESGE recommends confirmation of correct NGT placement by radiography in high-risk patients (intensive care unit [ICU] patients or those with altered consciousness or absent gag/cough reflex).Strong recommendation, low quality evidence.ESGE recommends that EN may be started within 3 - 4 hours after uncomplicated placement of a PEG or PEG-J.Strong recommendation, high quality evidence.ESGE recommends that daily tube mobilization (pushing inward) along with a loose position of the external PEG bumper (1 - 2 cm from the abdominal wall) could mitigate the risk of development of buried bumper syndrome.Strong recommendation, low quality evidence.
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Affiliation(s)
- Paraskevas Gkolfakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Marianna Arvanitakis
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Edward J Despott
- Royal Free Unit for Endoscopy and Centre for Gastroenterology, UCL Institute for Liver and Digestive Health, The Royal Free Hospital, London, United Kingdom
| | - Asuncion Ballarin
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Torsten Beyna
- Department of Gastroenterology and Therapeutic Endoscopy, Evangelisches Krankenhaus Düsseldorf, Germany
| | - Kurt Boeykens
- Nutrition Support Team, AZ Nikolaas Hospital, Moerlandstraat 1, 9100, Sint-Niklaas, Belgium
| | - Peter Elbe
- Department of Upper Digestive Diseases, Karolinska University Hospital, Stockholm, Sweden.,Division of Surgery, Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Ingrid Gisbertz
- Department of Gastroenterology, Bernhoven Hospital, Uden, the Netherlands
| | - Alice Hoyois
- Department of Gastroenterology, Hepatopancreatology, and Digestive Oncology, CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Ofelia Mosteanu
- Department of Gastroenterology, Iuliu Hatieganu University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - David S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital & University of Sheffield, United Kingdom
| | - Peter T Schmidt
- Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden.,Department of Medicine, Ersta Hospital, Stockholm, Sweden
| | - Stéphane M Schneider
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, Gastroentérologie et Nutrition, Nice, France
| | - Jeanin E van Hooft
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
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Changes in Clozapine Bioavailability in a Percutaneous Endoscopic Gastrostomy-Fed Patient With Treatment-Resistant Schizophrenia. J Clin Psychopharmacol 2021; 40:306-308. [PMID: 32332469 DOI: 10.1097/jcp.0000000000001207] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Boullata JI. Enteral Medication for the Tube-Fed Patient: Making This Route Safe and Effective. Nutr Clin Pract 2020; 36:111-132. [PMID: 33373487 DOI: 10.1002/ncp.10615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/15/2020] [Indexed: 12/26/2022] Open
Abstract
The administration of medication through an enteral access device requires important forethought. Meeting a patient's therapeutic needs requires achieving expected drug bioavailability without increasing the risk for toxicity, therapeutic failure, or feeding tube occlusion. Superimposing gut dysfunction, critical illness, or enteral nutrition-drug interaction further increases the need for a systematic approach to prescribing, evaluating, and preparing a drug for administration through an enteral access device. This review will explain the fundamental factors involved in drug bioavailability through the gut, address the influencing considerations for the enterally fed patient, and describe best practices for enteral drug preparation and administration.
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Affiliation(s)
- Joseph I Boullata
- Department of Clinical Nutrition Support Services, Penn Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Maher D, Ailabouni N, Mangoni AA, Wiese MD, Reeve E. Alterations in drug disposition in older adults: a focus on geriatric syndromes. Expert Opin Drug Metab Toxicol 2020; 17:41-52. [PMID: 33078628 DOI: 10.1080/17425255.2021.1839413] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Dorsa Maher
- Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia , Adelaide, Australia
| | - Nagham Ailabouni
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia , Australia
| | - Arduino A Mangoni
- Department of Clinical Pharmacology, Flinders University and Flinders Medical Centre , Bedford Park, Australia
| | - Michael D Wiese
- Health and Biomedical Innovation, UniSA: Clinical and Health Sciences, University of South Australia , Adelaide, Australia
| | - Emily Reeve
- Quality Use of Medicines and Pharmacy Research Centre, UniSA: Clinical and Health Sciences, University of South Australia , Australia.,Geriatric Medicine Research, Faculty of Medicine, and College of Pharmacy, Dalhousie University and Nova Scotia Health Authority , Halifax, Canada
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Zaher SA, Al-Subaihi R, Al-Alshaya A, Al-Saggaf M, Al Amoudi MO, Babtain H, Neyaz A. Pilot Study to Investigate Enteral Feeding Practices and the Incidence of Underfeeding Among Mechanically Ventilated Critically Ill Patients at a Specialist Tertiary Care Hospital in Saudi Arabia. JPEN J Parenter Enteral Nutr 2020; 45:1327-1337. [PMID: 32924151 DOI: 10.1002/jpen.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 07/29/2020] [Accepted: 09/08/2020] [Indexed: 01/03/2023]
Abstract
BACKGROUND Enteral nutrition (EN) is an essential therapeutic intervention. Many studies internationally have reviewed feeding practices in intensive care units (ICUs) and recorded the incidence of underfeeding in these settings, yet none were performed in the Middle East, including Saudi Arabia. The purpose of the study is to assess the adequacy of EN delivery and investigate the enteral feeding practices in the ICU at a specialized tertiary care hospital in Saudi Arabia. METHODS In this observational study, we prospectively monitored energy and protein delivery for 6 consecutive days in critically ill patients. Malnutrition was assessed by Nutrition Risk Screening (NRS-2002) scores. Underfeeding was identified by comparing the intake against the calculated requirements. Patients were categorized into early and late EN starters to investigate whether the time of EN initiation impacts the cumulative nutrition intake. RESULTS This study included 43 patients. About 44% (19 of 43) of the patients were malnourished on admission to ICU, and the prevalence of underfeeding was >90%. The median cumulative intake of energy and protein was 39% and 31% of the estimated requirements, respectively. Patients who started early EN had statistically higher cumulative energy and protein intake (P-value = .00). Patients treated with inotropes received less energy and protein compared with those who did not receive inotropes (P-value = .00). Higher NRS-2002 score was associated with fewer ventilation-free hours (r = -0.369, P-value = .045). CONCLUSION Protein underfeeding remains a significant problem in ICU settings. The time of EN initiation plays a major role in determining when the nutrition requirements will be met. Therefore, it is crucial to implement effective feeding protocols to ensure early initiation of EN when permissible.
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Affiliation(s)
- Sara A Zaher
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Raghad Al-Subaihi
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Aeshah Al-Alshaya
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Manar Al-Saggaf
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Mariam O Al Amoudi
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Hala Babtain
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
| | - Arwa Neyaz
- Clinical Nutrition Department, Faculty of Applied Medical Sciences, Taibah University, Madinah, Saudi Arabia
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Bandy KS, Albrecht S, Parag B, McClave SA. Practices Involved in the Enteral Delivery of Drugs. Curr Nutr Rep 2020; 8:356-362. [PMID: 31606851 DOI: 10.1007/s13668-019-00290-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
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.
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Affiliation(s)
- Kathryn S Bandy
- Department of Pharmacy, University of Louisville Hospital, 530 S Jackson St., Louisville, KY, 40202, USA.
| | - Stephanie Albrecht
- Department of Pharmacy, University of Louisville Hospital, 530 S Jackson St., Louisville, KY, 40202, USA
| | - Bhavyata Parag
- Department of Pharmacy, Houston Methodist Clear Lake Hospital, 18300 Houston Methodist Dr, Houston, TX, 77058, USA
| | - Stephen A McClave
- Division of Gastroenterology, Hepatology, and Nutrition, University of Louisville Hospital, 530 S Jackson St., Louisville, KY, 40202, USA.,Department of Digestive and Liver Health, University of Louisville Physicians Outpatient Center, 401 E. Chestnut St., Louisville, KY, 40202, USA
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Brunsdon P, Saluja B, Sahajwalla C. Clinical Pharmacology Considerations for Developing Small-Molecule Treatments for COVID-19. J Clin Pharmacol 2020; 60:1147-1154. [PMID: 32579707 PMCID: PMC7361784 DOI: 10.1002/jcph.1697] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 06/19/2020] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Priya Brunsdon
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Bhawana Saluja
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
| | - Chandrahas Sahajwalla
- Division of Inflammation and Immune Pharmacology, Office of Clinical Pharmacology, Office of Translational Sciences, Center for Drug Evaluation and Research, U.S. Food and Drug Administration, Silver Spring, Maryland, USA
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Abstract
BACKGROUND Cenobamate is a new, Food and Drug Administration (FDA)-approved oral antiepileptic drug for treatment of focal seizures in adults. This study examined recovery of cenobamate from suspensions administered through ex vivo enteral feeding tubes. METHODS Suspensions containing 100 and 200 mg of cenobamate were prepared (five duplicates for each dose), passed through five vertically standing tubes, and collected into flasks. The flasks containing the suspensions were rinsed with deionized water, and this content was also injected into the tubes and collected in the flasks. Acetonitrile, isopropyl alcohol, and trifluoroacetic acid were added to the flasks, followed by deionized water to a concentration of 500 (100-mg cenobamate) and 400 (200-mg cenobamate) µg/mL. A 3-mL aliquot from each suspension was placed into a 10-mL flask, diluted to volume, and mixed, resulting in final concentrations of 150 and 120 µg/mL, respectively. All suspensions were analyzed by high-performance liquid chromatography (LC). The % LC recovery of cenobamate was calculated for each suspension, and mean % LC for duplicates. RESULTS The % LC recovery of cenobamate from the 100-mg suspensions ranged from 96.2 to 99.1%, with mean % LC recovery between 96.3 and 98.3%. The % LC recovery of cenobamate from the 200-mg suspensions ranged from 97.1 to 102.6%, with mean % LC recovery between 98.5 and 101.7%. CONCLUSION The mean % LC recovery of cenobamate was within the predetermined acceptable range of 90.0-110.0%, suggesting no adhesion or adsorption of cenobamate to enteral feeding tubes. Delivery of cenobamate suspension via enteral feeding tubes may be a viable route of administration for patients who cannot swallow tablets.
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Affiliation(s)
- Louis Ferrari
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ, 07652, USA.
| | - Arkady Nisman
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ, 07652, USA
| | - Augustin Pegan
- SK Life Science, Inc., 461 From Road, Fifth Floor, Paramus, NJ, 07652, USA
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Cober MP, Gura KM. Enteral and parenteral nutrition considerations in pediatric patients. Am J Health Syst Pharm 2020; 76:1492-1510. [PMID: 31532507 DOI: 10.1093/ajhp/zxz174] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
PURPOSE Current clinical practice guidelines on management of enteral nutrition (EN) and parenteral nutrition (PN) in pediatric patients are reviewed. SUMMARY The provision of EN and PN in pediatric patients poses many unique considerations and challenges. Although indications for use of EN and PN are similar in adult and pediatric populations, recommended EN and PN practices differ for pediatric versus adult patients in areas such as selection of EN and PN formulations, timing of EN and PN initiation, advancement of nutrition support, and EN and PN goals. Additionally, provision of EN and PN to pediatric patients poses unique compounding and medication administration challenges. This article provides a review of current EN and PN best practices and special nutrition considerations for neonates, infants, and other pediatric patients. CONCLUSION The provision of EN and PN to pediatric patients presents many unique challenges. It is important for pharmacists to keep current with pediatric- and neonatal-specific guidelines on nutritional management of various disease states, as well as strategies to address compounding and medication administration challenges, in order to optimize EN and PN outcomes.
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Affiliation(s)
- Mary Petrea Cober
- Department of Pharmacy, Akron Children's Hospital, Akron, OH, and Northeast Ohio Medical University, Rootstown, OH
| | - Kathleen M Gura
- Department of Pharmacy, Boston Children's Hospital, Boston, MA, and Harvard Medical School, Boston, MA
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45
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Spencer SH, Menard SM, Labedz MZ, Krueger CD, Sarna KV. Enteral tube administration of oral chemotherapy drugs. J Oncol Pharm Pract 2020; 26:703-717. [PMID: 31955701 DOI: 10.1177/1078155219893449] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Objective Patients receiving oral chemotherapies face treatment interruptions if they require placement of an enteral tube for nutrition, potentially leading to adverse outcomes in cancer treatment. Enteral tube medication administration can provide a suitable alternative. The purpose of this review is to compile available data that describe enteral tube administration of oral chemotherapy agents.
Data sources: A systematic evaluation of all Food and Drug Administration-approved oral chemotherapy agents through 31 July 2019 was conducted. Information on crushing or opening of the tablet or capsule, enteral tube administration, and extemporaneous formulations was compiled from the prescribing information, tertiary resources, and primary literature. Drug manufacturers were contacted for additional information.
Data summary: A total of 87 oral chemotherapy agents were evaluated. Of the 87 drugs, 33 agents (37.9%) had information regarding enteral tube administration with only four drugs with nasogastric or gastric tube administration instructions in their prescribing information. The strength of evidence varied from non-peer reviewed data to complete evaluations of efficacy and safety. The majority of chemotherapies (62%) had no available data on enteral tube administration. Conclusions The results of this review suggest that there is limited data surrounding enteral tube administration of most oral chemotherapies, demonstrating the need for more studies to be conducted to provide more guidance to healthcare providers when administration via an enteral tube is needed in their patients.
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Affiliation(s)
- Samantha H Spencer
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Shannon M Menard
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | | | - Courtney D Krueger
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
| | - Katherine V Sarna
- College of Pharmacy, University of Illinois at Chicago, Chicago, IL, USA
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Yu M, Chen J, Zheng S, Wang H, He X. Reduce medication errors in tube feeding administration by establishing administration standards and standardizing operation procedures. DRUGS & THERAPY PERSPECTIVES 2020. [DOI: 10.1007/s40267-019-00698-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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47
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Silva MRMD, Dysars LP, Santos EPD, Ricci Júnior E. Preparation of extemporaneous oral liquid in the hospital pharmacy. BRAZ J PHARM SCI 2020. [DOI: 10.1590/s2175-97902019000418358] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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San C, Lê MP, Matheron S, Mourvillier B, Caseris M, Timsit JF, Wolff M, Yazdanpanah Y, Descamps D, Peytavin G. Management of oral antiretroviral administration in patients with swallowing disorders or with an enteral feeding tube. Med Mal Infect 2019; 50:537-544. [PMID: 31722864 DOI: 10.1016/j.medmal.2019.10.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 12/14/2018] [Accepted: 10/18/2019] [Indexed: 02/07/2023]
Abstract
HIV infection has evolved into a chronic disease with comorbidities since the combination antiretroviral therapy era. Complications still occur and patients may need to be admitted to an intensive care unit. Acute respiratory failure is the first cause of these admissions, questioning the administration of solid oral dosage formulations. This issue is also observed in geriatric units where the prevalence of dysphagia is high and underestimated. The problem of antiretroviral administration is critical: altered solid oral dosage formulations and/or administration via enteral feeding tubes are sometimes the only option. The aim is to help manage antiretroviral treatment in unconscious or intubated patients and those with swallowing disorders who are hospitalized in intensive care units or geriatric units. This review provides information on the main antiretroviral regimens and on practical and legal aspects of manipulating solid oral dosage formulations and administration via enteral feeding tubes. Alternatives to the solid formulation are available for most of the 27 oral antiretrovirals available, or manufacturers provide recommendations for patients who are unable to swallow. Manipulation of solid oral dosage formulations such as crushing tablets or opening capsules and administration via feeding tubes are frequently reported but should be the last option for safety and liability issues. Before any off-label administration of a drug, physicians should consider alternatives to the solid oral dosage formulation and check whether the drug can be altered. Therapeutic monitoring is important in this particular setting as the pharmacokinetic profile of drugs is difficult to predict.
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Affiliation(s)
- Carine San
- Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M P Lê
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France.
| | - S Matheron
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - B Mourvillier
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Caseris
- Service de pédiatrie, AP-HP, Hôpital Robert Debré, 75019 Paris, France
| | - J-F Timsit
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - M Wolff
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Réanimation médicale et infectieuse, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - Y Yazdanpanah
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Service de maladies infectieuses et tropicales, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - D Descamps
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de virologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
| | - G Peytavin
- Université Paris Diderot Sorbonne Cité, IAME, Inserm UMR 1137, F-75018 Paris, France; Laboratoire de pharmacologie-toxicologie, AP-HP, Hôpital Bichat-Claude-Bernard, 75018 Paris, France
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Causes of nasoenteral tube obstruction in tertiary hospital patients. Eur J Clin Nutr 2019; 74:261-267. [PMID: 31363174 DOI: 10.1038/s41430-019-0475-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 06/03/2019] [Accepted: 07/12/2019] [Indexed: 01/03/2023]
Abstract
BACKGROUND/OBJECTIVES Obstruction of the nasoenteral tube is one of the complications of enteral nutrition therapy, and its causes and frequency of occurrence are not well understood. To evaluate the causes of enteral nutrition feeding tube obstruction. To study the time elapsed between the beginning of the nutrition therapy and the obstruction of the tube. SUBJECTS/METHODS This was a retrospective cohort study of 1170 patients aged 18 years or older who were hospitalized at Sírio-Libanês Hospital between January 2015 and October 2017, and who were undergoing enteral nutrition therapy delivered using an infusion pump through a nasogastric or nasoenteral tube. The study population included 683 (58%) men and 487 (42%) women. The median age was 79 years. Of these, 1084 patients received enteral nutrition and medication through the feeding tube, and 86 received medication alone. Variables investigated as causes of feeding tube obstruction were the administration of medication through the tube, type of diet, and use of symbiotics. RESULTS Obstruction rates were 4% for up to 40 days of observation and 8% for the total observation time. The time for obstruction of 10% of the tubes in patients receiving rivaroxaban, linagliptin, metformin, and nystatin was 16, 19, 20, and 28 days, respectively. CONCLUSIONS The main cause of nasoenteral tube obstruction (odds ratio) was the combination of metformin (2.0), nystatin (3.1), linagliptin (4.3), rivaroxaban (2.4), and a high-protein diet (1.9). Overall, proper tube care and strict compliance with tubal drug delivery guidelines can result in low tube obstruction rates.
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50
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Logrippo S, Sestili M, Ganzetti R, Bonacucina G, Marziali A, Fattoretti P, Busco S, Caraffa A, Polidori C, Palmieri GF. Potassium canrenoate compounding for administration via enteral feeding tubes: a physical and microbiological stability study. Eur J Hosp Pharm 2019; 25:e120-e125. [PMID: 31157081 DOI: 10.1136/ejhpharm-2017-001276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 06/24/2017] [Accepted: 07/03/2017] [Indexed: 11/04/2022] Open
Abstract
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.
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Affiliation(s)
- Serena Logrippo
- School of Advanced Studies, University of Camerino, Camerino, Italy.,School of Pharmacy, University of Camerino, Camerino, Italy
| | - Matteo Sestili
- Italian National Research Centers on Ageing (INRCA), Ancona, Italy
| | - Roberta Ganzetti
- Italian National Research Centers on Ageing (INRCA), Ancona, Italy
| | | | | | | | - Silvia Busco
- School of Pharmacy, University of Camerino, Camerino, Italy
| | | | - Carlo Polidori
- School of Pharmacy, University of Camerino, Camerino, Italy
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