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. Author manuscript; available in PMC: 2023 Sep 19.
Published in final edited form as: JPEN J Parenter Enteral Nutr. 2023 Mar 22;47(4):519–540. doi: 10.1002/jpen.2490

Developing guidance for feeding tube administration of oral medications

Mark G Klang 1
PMCID: PMC10508335  NIHMSID: NIHMS1925249  PMID: 36847617

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.

Materials and 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 which 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 which 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 based on a composite of the documents cited, tests conducted, and author’s judgements based all the data collected. 36 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.

Keywords: Drug-nutrient interactions; Nutrition, Enteral nutrition; Nutrition, Administration; Nutrition Support Practice

Patients with a feeding tube for nutrition will require oral medications administered by the same route. Most oral medications have not been evaluated for feeding tube administration. To administer an oral medication through a feeding tube, the formulation must be in a liquid form. If a suitable liquid product is not available, a liquid can be extemporaneously compounded by opening the capsule or crushing the tablet before mixing in a suitable volume of water1. It should be noted, however crushing oral medications, and mixing in water may alter delivery of the active pharmaceutical ingredient (API).

Not all oral medications are suitable for being compounded into a liquid form. As an example extended or delayed release oral medications can yield adverse effects when crushed.2 Enteric coated products when crushed become exposed to gastric fluid and degrade prematurely. Information as to what medications may produce adverse outcomes when crushed are identified in the Institute for Safe Medical Practice’s Do Not Crush List (DNCL).3 The DNCL list advises not crushing hazardous drugs and those medication that produce unpleasant taste when crushed. However, a patient with a feeding tube may still receive these medications. The DNCL does not address issues the delivery of drug to the jejunum, tolerability/compatibility of the medication with the nutrition, or the potential for clogging the feeding tube.

Enterally fed patients are dependent on their tubes for delivery of nutrition. Clogs produced by undissolved medications will block delivery of nutrients to these patients. Clogs can also be formed by interactions between medication and the nutrient delivered.4,5 To date, there is no comprehensive guide on which drugs are appropriate for feeding tube administration, their potential for forming clogs and instructions for administration by the feeding tube route.

Nutrition support is therapeutically linked to optimal patient outcome.6 Enteral nutrition is the preferred route as parenteral nutrition often fails to regenerate endogenous protein mass and at times, exposes the patient to higher infection risks.7,8 This means that the medications and nutrition compete for the limited access afforded by the feeding tube. In evaluating medications for feeding tube administration, one must be aware of the physical dynamics of the feeding tube route. Feeding tubes are placed to have their distal tips residing in generally either in stomach, or in jejunum. Delivery of a drug into the stomach allows exposure to acidic content, dissolution in the gastric fluids and in some cases, activation to final form. Most drugs are absorbed in the jejunum.9 Many drugs require exposure to the gastric contents to dissolve, ionize or metabolize to the active form for absorption in jejunum.

Recently, the FDA has released guidance for evaluating oral medication for the feeding tube route10. This guidance does not require liquid medications to be tested, perhaps falsely implying that there are no issues with liquid medications and feeding tubes. General feeding tube guidelines recommend using the liquid formulations for the ease of administration11,12, 13. since crushed medication are the most frequent cause of obstructed feeding tubes14. Oral liquid medications have high osmolalities because they are formulated with thickening and sweetening agents to improve palatability.15 High osmolar liquids are poorly tolerated in feeding tube patients and in one study, was responsible for 40% of the incidence of diarrhea.16 The jejunum contents has an osmolality of 285 mOsm/kg17. It is acutely sensitive to the effect of fluids with high osmolarity as there is no diluting capacity as occurs with gastric administration. Pharmacies which compound extemporaneous suspensions often use vehicles with high osmolality and contain sorbitol18 which is a potent cathartic.19 As an example, Ora-Sweet® is one such vehicle used in Pharmacy compounding; it contains sorbitol and has an osmolality of 3240 mOsm/kg20.

This paper documents the efforts of the Research Pharmacy Core Laboratory at a Cancer Hospital, to examine and document the suitability of all non-narcotic oral formulary medications for feeding tube administration This project arose from challenges generated using the feeding tube route for medications. Initially, the computer order entry system did not allow for a feeding tube route in the directions for use. All oral medications were listed as “PO” as the route and but allowed special instructions in the open text section of the prescription. In most cases, the pharmacist was unaware if the patient was receiving medication via a feeding tube. An internal audit medication administration identified that 90% of the medications being administered by nurses through the feeding tube were listed on the medication order as “oral”. The information system programmers requested a specific delineation for which medications are appropriate for each feeding tube route to address this disparity.

Also, at the time, all legacy feeding tube connections were in the process of being replaced by EnFit® connectors which limit access by non-EnFit enabled devices. Generally, when a liquid medication was prescribed, the pharmacy prepared the dose using an oral syringe. Oral syringes are compatible with legacy type feeding tubes, but not with EnFit. As a result, it became imperative that the order-entry system distinguish the liquid medication order to specify either an oral or feeding tube route.

Methods

The primary goal of this study was to develop guidance for the extemporaneous compounding of dosage forms appropriate for passage through a feeding tube. There was no effort to compound products that could be used for multiple doses, as such would require stability-indicating assays in accordance with the latest USP <795> recommendations.21 Since this project involved only in-patient orders, the project focused on only extemporaneously compounded solutions.

This study does not cover food-drug interactions, since the author assumes all drugs will be administered separately, mixed with water, and rinsed before and after in accordance with ASPEN Enteral guidance22. This study did not evaluate the issues concerning the withholding of tube feeding to avoid drug-nutrient interaction (DNI). This issue was extensively reviewed by the DNI Task-Force and presented at the 2015 ASPEN Clinical Nutrition Week program in Long Beach CA. They found that the only interaction that clinically benefits from withholding tube-feedings was levodopa.23

The Drug Administration through Feeding Tubes (DAFT) project was undertaken to examine each non-narcotic oral dosage form on the hospital formulary. Each formulary drug was identified. In some cases, where the formulation differed between strength, other dose quantities were examined. E.g., acyclovir. 24 The literature was reviewed both for each specific dosage form as well as the active pharmaceutical ingredient (API), the structure, excipients, and pH dependent solubility. The package insert proved an invaluable reference noting precautions in crushing, or special instructions regarding feeding tube administration.

The most comprehensive document resourced was “Handbook on Drug Administration via Enteral Feeding Tubes” by R White and V Bradnam.25 This is an excellent textbook, documenting all oral drugs identified by the British Pharmaceutical Nutrition Group (BPNG). The textbook served as a guide to the issues with each medication25. PubMed® was also used as a resource for those medications which have been documented for administration through feeding tubes. PubChem® was used for the chemical structure, pKa, and optimal solubility where the package insert lacked this information. The results documented in this study reflect the data collected through analysis and not a function of a literature search.

Each dose of formulary medication was tested in triplicate. The tests were designed to replicate the process taken by the medication administration staff to crush and prepare medication for feeding tube administration. All data collected was included in a worksheet. (See Blank Worksheet)

Each worksheet documented the following:

  1. Identification Data: Drug name, strength, manufacturer, NDC (National Drug Code), Lot number, and expiration date of each drug. Any available resources from the PubMed search were recorded. including structure, pKa, relevant references, solubility of the Active Pharmaceutical Ingredient (API), presence of film coating and solubility issues associated with pH.

  2. Crushing: The issue of crushing medications was approached differently for chemotherapy and non-chemotherapy medications.

    1. For non-chemotherapy agents, tablets were placed in crusher bags and crushed using the Quiet Crusher® device. To measure the effort needed to crush the tablets, the number of blows with the device’s hammer were recorded on the worksheet. Capsules were opened and the contents sprinkled into 10–15 mL of purified water and placed into labeled 50 mL sterile centrifuge tubes. In most cases, each drug was examined and tested in triplicate. The results were reported as the average of the three tests.

    2. For chemotherapy agents, in accordance with ASPEN and USP <800> recommendations1,26, the drugs were evaluated in two ways within the confines of a vertical flow, externally vented Biological Safety Cabinet:

      1. Dissolve in a syringe27. This allows the drug to be contained. This worked for many chemotherapy tablets.

      2. Use of the Rx Crush®28. This device has a pouch that keeps the medication contained while providing a mechanism to safely crush and prepare a suspension for feeding tube delivery. This device was used for all capsules and poorly soluble oral agents.

  3. Disintegration: The preparer measured length of time the solid particles would make a smooth slurry. Initially, 10ml of purified water was added to a pouch along with drug powder. Documentation included how the powder interacted with the water, size of particles, color of the liquid, extent of settling, and difficulty of dissolving. Any physical manipulation used to dissolve powder or particles in the water was recorded. An additional 10–20 ml of water could be added to improve dissolution. For capsules, water was added directly to the centrifuge tube and the same procedure as for the tablets was followed. The time was recorded. If the time exceeded 20 minutes, the recommendation recorded was to not administer through feeding tube.

  4. pH meter: After dissolution the pH value was collected using a pH meter (AB-15™, Accumet Basic, Fisher Scientific). The pH meter was calibrated with reference buffers of values 4, 7 and 10 (Fisher, Fair Lawn NJ). The pH value of the mixture was measured in triplicate. After each measurement, the probe was washed with purified water and dried with a low residue wipe. A reference standard (pH 4) was verified between measurements of samples to ensure accuracy of value recorded. Results were reported as the mean.

  5. Clogging Test: A 100 μm nylon mesh strainer was seated at the top of empty 50 mL centrifuge tube. The disintegrated drug was poured through the strainer and observed. If the entire fluid does not pass an additional 10–20 mL of purified water is added and recorded in the notes. A picture of the cell strainer adjacent to the labeled pouch used for crushing is recorded. If the mixture still did not pass through the strainer, the observation is noted, and the drug was labeled as having a high potential for clogging a feeding tube and a recommendation for extra rinsing was added, up to 30 mL.

  6. Osmometer: A 10 μL sample was removed from the effluent after the strainer. Osmolality was measured by the freezing point depression method using the Precision Systems 5010 Osmette II™. The osmometer was calibrated using osmometry reference standards of 100, 300, and 500 mOsm/kg at initiation and completion of tests. Dilutions were performed for medications that measured beyond the instrument’s calibration range of 0 to 500 mOsm/kg. The osmolality of all medications was measured in triplicate and the mean was reported in mOsm/kg.

The above tests were designed to evaluate the suitability of the crushed drug for feeding tube administration. All oral liquid formulations have high osmolarities (>1000 mOsm/kg)4,13. This study determined if the extemporaneously prepared suspension would have a lower value.

Purified water (USP definition) was used for dissolving drugs, rinsing feeding tubes and compounding. Sterile Water (USP) was recommended in the first Enteral Nutrition recommendations from ASPEN29. using USP 795 Pharmaceutical Compounding – Nonsterile as the reference to support this selection. The USP Chapter 795 advises to use Purified Water for compounding26. The water used for administration of medications through a feeding is not required to be sterile30.

Results:

The Feeding Tube Medication Summary Table (See Table) was assembled from the data collected on the individual worksheets. The data for liquids was collected from an earlier published study4. The table consists of 9 columns. Column 1 lists the medication that was evaluated. Column 2 lists the dosage forms that were examined, and notes, in red print, those formulations deemed inappropriate for feeding tube administration. Column 3 lists the recommendations for feeding tube administration as well as rationale used in making that determination. These recommendations are based on a composite of the physical and chemical properties and the results of the experiments conducted. Where a more detailed review is required, a number is added for the discussion point that corresponds to the issue. Columns 4 list the average pH value recorded after three tests in dissolving the medication in water. Where the entry is blank, no measurement was made. Columns 5 and 6 each list the recommendation if the selected drug is approved for feeding tubes with distal ports in either stomach, or in jejunum. Column 7 indicates the volume of water need to be added to the solid dosage form to enable forming a slurry suitable for feeding tube administration. This column also includes recommendations to use the liquid formulation of the drug, when deemed appropriate. Column 8 notes the amount of time needed to mix the solid dosage form into a suspension that should pass through a feeding tube without forming a clog. The Column 9 indicates the volume of water needed to effectively rinse the medication through the feeding tube. The expectation is that for all medications and nutrition products must be preceded with a flush solution of 15–30 mLs water to avoid interactions22.

Feeding Tube Medication Summary Table

Medication Form <Not for FT> Recommendations / Rationale pH Gastric FT Jejunal FT Vol to Mix Time (Min) Vol to rinse
Abacavir <solution>, tablet Thick brown coating that is very hard to crush. But has lower osmolality than solution 3.2 ok ok 10 1 20
Acarbose Tablet Poorly soluble, requires extra rinsing as ppt quickly 6.4 ok ok 20 10 30
Acetaminophen <Tablet, suppository, chewable>, solution Solution preferred, as tablet does not dissolve well 5.9 ok ok use solution
Acetazolamide Tablet Tablet crushes easily, poorly dissolves. Extra rinse 6.0 ok ok 10 2 15
Acyclovir24 capsule, <tablet, suspension> Use capsule for FT, tablets poor solubility, suspension thick. See Discussion 1 7.2 ok ok 10 1 10
Alendronate <Tablet> Do not crush no no not for FT
Allopurinol Tablet Dissolves well, leaves residue that ppt quickly 6.5 ok ok 10 1 20
Aluminum Hydroxide suspension, <tablet> Tablet does not dissolve 7.2 ok no use solution 30
Amantadine <syrup>, capsule Syrup is thick, open powder-filled capsules 5.3 ok ok 10 10 20
Aminocaproic Acid Syrup Compatible with nutrition dilute 3X 6.1 ok ok use syrup
Amiodarone34 Tablet Unpredictable absorption adheres to plastic. See Discussion 5 3.8 no no not for FT
Amitriptyline Tablet Dissolves quickly, but ppt out quickly 5.3 ok ok 10 1 20
Amlodipine Tablet Dissolves well, leaves residue that ppt quickly 6.4 ok ok 10 1 20
Amoxicillin <capsule>, suspension Use suspension form, capsule does not dissolve well. 4.4 ok ok use suspension 10
Amoxicillin / clavulanate <tablet>, suspension Use suspension form, tablet does not dissolve well 5.3 ok ok use suspension 10
Ampicillin <capsule>, suspension Capsule forms clumps - use suspension 4.5 ok ok use suspension 10
Anagrelide Capsule Dissolves quickly 5.0 ok ok 10 1 10
Anastrozole Tablet Dissolves quickly 6.6 ok ok 10 1 10
Aprepitant <capsule>, suspension Use suspension, capsule difficult to administer. ok ok use suspension
Aripiprazole Tablet Dissolves quickly 6.2 ok ok 10 2 10
Ascorbic Acid tablet Dissolves quickly 2.6 ok ok 10 2 10
Aspirin tablet, <delayed release, EC tablet> Does not dissolve well, use immediately as drug degrades in solution 2.7 ok ok 10 1 10
Atazanavir Capsule Contains co-precipitate, mix in syringe and extra rinse. See Discussion 2 2.0 ok ok 10 2 20
Atenolol tablet Contains co-precipitate, mix in syringe and extra rinse See Discussion 2 10.3 ok ok 10 2 20
Atorvastatin tablet Forms clogs easily - use 30 ml water to rinse 9.7 ok ok 10 2 30
Atovaquone suspension Caution: clogs with nutrition formulas.4 extra rinse advised 5.9 ok ok use suspension 30
Axitinib tablet Dissolves quickly 6.6 ok ok 10 1 10
Azathioprine tablet Some generics dissolve slowly 5.0 ok ok 10 20 20
Azithromycin tablet, <suspension> Tablet dissolved readily, suspension 3950 mOsm/kg.4 9.5 ok ok 10 1 10
Baclofen tablet Disintegrates quickly, but foams and may form clogs - rinse well 7.0 ok ok 10 1 20
Benzonatate <pearls> Does not dissolve no no not for FT
Benztropine tablet Dissolves quickly 7.2 ok ok 10 1 10
Bethanechol tablet Dissolves quickly 6.9 ok ok 10 1 10
Bexarotene capsule Contains co-precipitate, mix in syringe and extra rinse. See Discussion 2 4.2 ok ok 15 20 30
Bicalutamide 51 tablet Dissolves quickly. Requires dissolution in Gastric pH. See Discussion 3. 8.0 ok no 10 1 10
Bisacodyl <suppository>, tablet EC Drug is enteric coated - but can be crushed 5.5 ok ok 10 1 10
Bromocriptine tablet Contains co-precipitate, mix in syringe and extra rinse. See Discussion 2 2.6 ok ok 10 2 10
Budesonide <capsule EC> Does not dissolve even after crushing - not for FT. See Discussion 16 no no not for FT
Bumetanide tablet Dissolves quickly 5.7 ok ok 10 2 10
Bupropion tablet Contains co-precipitate, mix in syringe and extra rinse. See Discussion 2 3.4 ok ok 10 2 20
Buspirone tablet Dissolves quickly 6.6 ok ok 10 1 10
Busulfan tablet Dissolves slowly, rinse well. Chemotherapy. Dissolve in syringe 6.6 ok ok 10 15 10
Cabergoline52 tablet Slow to dissolve. Requires dissolution in gastric fluid. See Discussion 3. 8.1 ok no 10 3 10
Calcitriol <capsule>, oral solution Capsule cannot be opened. Liquid has high osmolality, dilute 3X with water.4 7.8 ok ok use liquid 10
Calcium - Vitamin D Tablet Difficult to crush, require extra rinsing 7.9 ok ok 20 10 30
Calcium Acetate Capsule Open capsule, contents dissolve quickly 7.4 ok ok 15 1 20
Calcium Carbonate <suspension, tablet, tablet chewable> Difficult to crush, suspension thick - Use Calcium Acetate 8.7 no no not for FT
Calcium Carbonate (Oyster shell) <tablet> Forms clog, not for FT. Use Calcium Acetate 8.7 no no not for FT
Calcium Carbonate (Tums) <tablet> Forms clog, not for FT. Use Calcium Acetate 6.0 no no not for FT
Canagliflozin53 tablet Slow to dissolve. Requires acid to dissolve. See Discussion 3. 8.3 ok no 10 5 20
Candesartan tablet Dissolves quickly 5.5 ok ok 10 2 10
Capecitabine tablet Dissolved slowly, but completely 7.0 ok ok 20 20 20
Captopril tablet Dissolves quickly 2.7 ok ok 10 1 20
Carbamazepine suspension, <tablet> Use suspension, high osmolality 4225 mOsm/kg dilute 3X4 3.7 ok ok use suspension 30
Carbidopa-Levodopa Tablet Dissolves quickly 5.7 ok ok 10 1 20
Carvedilol Tablet Contains co-precipitate, mix in syringe and extra rinse. Ppt out quickly See Discussion 2 6.4 ok ok 10 1 20
Cefadroxil Capsule Dissolves quickly. Leaves a residue. Use extra rinse 5.6 ok ok 10 1 20
Cefixime capsules Dissolves quickly. Leaves a residue. Use extra rinse 3.5 ok ok 10 1 20
Cefuroxime <tablet>, suspension Tablet does not dissolve, use suspension 6.0 ok ok use suspension 10
Celecoxib capsule Contains co-precipitate, mix in syringe and extra rinse. See Discussion 2 7.5 ok ok 10 1 20
Cephalexin <capsule>, suspension Capsule Does not dissolve, use suspension ok ok use suspension 20
Cetirizine tablet Dissolves quickly 2.5 ok ok 10 1 10
Cevimeline capsules Slow to dissolve 6.8 ok ok 10 1 10
Chlorpheniramine tablet Dissolves quickly 6.2 ok ok 10 1 10
Chlorpromazine tablet Slow to dissolve 6.4 ok ok 10 2 10
Cholecalciferol tablet Dissolves quickly, extra rinse needed 7.3 ok ok 10 1 20
Cilostazol tablet Dissolves quickly 5.5 ok ok 10 1 10
Ciprofloxacin54 tablet, <suspension> Slow dissolution, rinse well, do not use suspension. See Discussion 10 4.2 ok ok 20 2 60
Citalopram tablet Dissolves quickly 6.0 ok ok 10 2 10
Clindamycin capsule Dissolves quickly 5.5 ok ok 10 1 10
Clonidine Tablet Dissolved slowly, but completely 7.1 ok ok 10 2 20
Clopidogrel55 Tablet Dissolves, requires gastric administration. See Discussion 3 2.0 ok no 10 2 20
Clotrimazole <Tablet> Oral lozenges. Do not administer through FT no no not for FT
Clozapine Tablet Dissolves quickly, requires extra rinse 6.5 ok ok 10 1 20
Colchicine Tablet Dissolves quickly 7.1 ok ok 10 1 10
Colesevelam <Tablet> Tablet Does not dissolve. Not for FT. See Discussion 16 no no not for FT
Conjugated estrogens Tablet Difficult to crush, rinse well 6.2 ok ok 20 3 20
Cyanocobalamin <Tablet> Tablet Does not dissolve. See Discussion 16 no no not for FT
Cyclobenzaprine tablet, <XL tablet> Immediate use tablet dissolved readily, do not crush XL 6.4 ok ok 10 1 10
Cyclophosphamide <tablet>, injection Chemotherapy, use injection form 4.3 ok ok Use Injection
Cyclosporine <capsule> Do not administer through FT no no not for FT
Cyproheptadine Tablet Dissolves slowly 6.1 ok ok 10 5 20
Dabigatran <Tablet> Do not administer through FT no no not for FT
Dapsone Tablet Poorly soluble, require extra rinsing 6.8 ok ok 20 5 30
Darunavir suspension, <tablet> Tablet has poor dissolution, use suspension ok ok use suspension
Demeclocycline 56 Tablet Poorly soluble, requires extra rinsing. Requires gastric administration. See Discussion 3 2.2 ok no 20 5 30
Desmopressin <Spray>, tablet Poorly soluble, requires extra rinsing 6.8 ok ok 20 1 20
Dexamethasone <solution>, tablet Dissolves quickly, solution osmolality > 10,000 mOsm/kg4 - use tablet for FT 5.7 ok ok 10 1 10
Diclofenac EC <tablet> Will clog FT. See Discussion 16 no no not for FT
Dicloxacillin capsule Dissolved slowly, but completely 5.8 ok ok 10 1 10
Digoxin solution, <tablet> Use solution, dilute for osmolality 3X (5950 mOsm/kg) 4 6.5 ok ok use solution
Diltiazem Immediate Release tablet Easily clogs, use extra water for rinse 6.2 ok ok 10 2 30
Dimenhydrinate tablet Dissolves quickly 6.9 ok ok 10 1 10
Diphenhydramine capsule, <tablet>, solution capsule dissolves quickly, solution Osmolality 3975 mOsm/kg4 3.9 ok ok use solution
Divalproex <capsule> Extended/delayed release. Do not administer through FT no no not for FT
Docusate Sodium <capsule>, liquid Capsule does not dissolve, use liquid 6.5 ok ok use liquid
Donepezil Tablet Dissolves quickly 6.7 ok ok 10 1 20
Doxazosin Tablet Dissolves quickly 6.6 ok ok 10 1 20
Doxycycline Capsule Dissolves quickly, requires gastric acid dissolution 2.4 ok no 10 1 20
Duloxetine <Capsule> Capsule contains enteric coated pellets - not for FT no no not for FT
Efavirenz <Capsule> Does not dissolve- clogs tube 7.8 no no not for FT
Enalapril32 tablet Dissolves quickly, prodrug requiring acid dissolution. See Discussion 3 3.4 ok no 10 1 10
Eplerenone tablet Dissolves quickly 7.2 ok ok 10 1 10
Ergocalciferol (Vitamin D-2) <capsule>, liquid Capsule difficult to open, Liquid osmolality 16,100 mOsm/kg dilute 3X with water.4 ok ok use liquid
Erythromycin suspension, <tablet> Tablet Does not dissolve, use suspension ok ok use suspension
Escitalopram tablet Dissolves quickly 4.0 ok ok 10 1 10
Ethacrynic acid 57 tablet Dissolves quickly, need acid for dissolution 2.9 ok no 10 1 10
Ethambutol tablet Dissolves easily, but higher doses require more water 6.7 ok ok 15 1 20
Exemestane tablet Poorly soluble, requires extra rinsing. Chemotherapy, Use Rx-Crush 5.6 ok ok 10 2 20
Famciclovir tablet Dissolves slowly 7.4 ok ok 10 5 10
Famotidine <suspension>, tablet Tablet dissolves quickly. Suspension osmolarity 687 mOsm/L13 7.0 ok ok 10 1 10
Fenofibrate tablet Poorly soluble, requires extra rinsing 5.9 ok ok 20 5 30
Ferrous Gluconate <tablet> Do not administer through FT- use iron polysaccharide liquid58 no no not for FT
Ferrous Sulfate <liquid, tablet> Do not administer through FT- use iron polysaccharide liquid58 no no not for FT
Fexofenadine tablet Contains co-precipitate, poor dissolution, extra rinse. See Discussion 2 3.2 ok ok 10 1 30
Finasteride tablet Dissolves quickly 7.6 ok ok 10 1 10
Fluconazole <suspension>, tablet Osmolality liquid 2185 mOsm/kg4, use tablet 4.3 ok ok 10 1 30
Fludrocortisone Acetate tablet Slow dissolution, rinse well 7.5 ok ok 10 5 30
Fluoxetine capsule Dissolves quickly 5.2 ok ok 10 1 10
Flutamide capsule Poorly soluble, requires extra rinsing 7.1 ok ok 20 15 30
Folic Acid tablet Dissolves quickly, requires extra rinse 5.3 ok ok 10 1 20
Furosemide <solution>, tablet Tablet dissolves quickly, liquid osmolality 8975 mOsm/kg4 See Discussion 1 9.8 ok ok 10 1 20
Gabapentin Solution, <capsule> Osmolality 8275 mOsm/kg4, dilute 3X water See Discussion 13 6.3 ok ok use suspension
Gefitinib59 tablet Dissolves only in stomach acid. See Discussion 3 ok no 20 5 30
Gemfibrozil tablet Difficult to crush, but dissolves readily, need extra rinse 6.5 ok ok 10 1 20
Glimepiride tablet Dissolves quickly but falls out of solution quickly. Contains a co-precipitate. See Discussion 2 7.5 ok no 10 1 10
Glipizide tablet Dissolves quickly 5.8 ok ok 10 1 10
Glyburide tablet Poorly soluble, requires extra rinsing 7.3 ok ok 10 1 30
Glycopyrrolate tablet Contains co-precipitate, poor dissolution, extra rinse See Discussion 2 7.4 ok ok 10 2 20
Granisetron tablet, <liquid> Dissolved slowly, but completely 6.7 ok ok 10 4 10
Haloperidol60 solution, <tablet> Unreliable disintegration requires acid for dissolution, use solution. See Discussion 3 3.3 ok no use solution
Hydralazine tablet Much residual undissolved rinse well 5.2 ok ok 10 5 30
Hydrochlorothiazide Tablet, <capsule> Much residual undissolved rinse well 6.4 ok ok 10 1 20
Hydrochlorothiazide - triamterene tablet Much residual undissolved rinse well 8.3 ok ok 10 2 20
Hydrocortisone <enema>, tablet Much residual undissolved rinse well 8.5 ok ok 10 2 20
Hydroxyzine syrup, <tablet> Poor dissolution, mix and frequent rinse 3.2 ok ok use syrup
Ibuprofen suspension, <tablet> Use suspension, dilute 3X with water Osmolality 2350 mOsm/kg 4 3.9 ok no use suspension
Imatinib61 tablet Contains co-precipitate, poor dissolution, extra rinse. See Discussion 3 4.6 ok no 20 20 30
Indomethacin capsule, <suppository> Open capsule, contents dissolve quickly 5.7 ok ok 10 1 20
Irbesartan tablet Does not dissolve, extra rinse needed 6.9 ok ok 10 1 30
Iron polysaccharide <capsule>, liquid Use liquid, capsule beads form clogs ok no use liquid
Icosapent <Capsule> Liquid-filled capsules, not for FT no no not for FT
Isoniazid Tablet Dissolves quickly 6.8 ok ok 10 1 20
isosorbide mononitrate tablet Dissolves quickly 6.7 ok ok 10 1 10
Isradipine capsule Dissolves quickly, requires extra rinse 5.5 ok ok 10 1 20
Ivermectin tablet Dissolves quickly 7.1 ok ok 10 1 10
Ketoconazole 62 <cream>, tablet Poorly soluble, does not mix well for FT. need acid to dissolve. See Discussion 3 6.9 ok no 10 5 30
Labetalol tablet Poorly soluble, requires extra rinsing 5.6 ok ok 10 2 20
Lactobacillus Granule Dissolves quickly 5 ok ok 20 10 30
Lactulose Liquid Ok for gastric, but dilute for j-tube does to high osmolality 4180 mOsm/kg 4 4.8 ok ok use liquid
Lamotrigine 63 tablet, <chewable tablet> Dissolves quickly, but requires extra rinsing, need acid to dissolve. See Discussion 3 8.2 ok no 10 1 20
Lamivudine\ Zidovudine tablet Dissolves quickly, but requires extra rinse 6.8 ok ok 10 1 30
Lansoprazole36 capsule Beads clog with water use acidic juice, or make susp with bicarb ok no 30 10 30
Lansoprazole ODT64 tablet Disintegrating Mix with water ok no 10 5 20
Lansoprazole Oral Suspension36,37 suspension Compounded with NaHCO3 ok ok use liquid
Letrozole tablet Poorly soluble, requires extra rinsing 7.0 ok ok 10 5 20
Leucovorin tablet Dissolves quickly, but requires extra rinsing 5.7 ok ok 10 1 20
Levetiracetam oral solution, <tablet> Difficult to rinse tablet, use liquid but dilute 3x as osmolality 5075 mOsm/kg 4 6.0 ok ok use liquid
Levodopa and Carbidopa tablet Poorly soluble, requires extra rinsing 5.7 ok ok 10 1 30
Levofloxacin <tablet>, suspension Use suspension, dilute 3X volume. See Discussion 10 5.1 ok ok use suspension
Levothyroxine Sodium65 tablet Contains co-precipitate, mix in syringe and give immediately 7.3 ok ok 10 2 10
Linezolid suspension, <tablet> Tablet forms clogs, use suspension 7.0 ok ok use suspension
Liothyronine tablet Poorly soluble, requires extra rinsing 5.4 ok ok 10 3 30
Lisinopril tablet Poorly soluble, requires extra rinsing 6.6 ok ok 10 2 30
Lithium Carbonate 66 <capsule>, suspension Use suspension, dilute 3X with water. Need gastric administration. See Discussion 3 11.1 ok no use suspension
Loperamide <capsule>, liquid The liquid should be diluted with 3x volume as osmolality 6775 mOsm/kg 4 4.0 ok ok use liquid
Lopinavir/Ritonavir <tablet> Unable to prepare a suspension after 20 minutes of mixing. See Discussion 3 6.2 no no not for FT
Loratadine tablet, <syrup> Tablet better for FT, syrup too thick 7.1 ok ok 10 2 10
Losartan and hydrochlorothiazide tablet Slow to dissolve, requires extra rinsing 7.6 ok ok 10 4 30
Losartan tablet Slow to dissolve 7.8 ok ok 10 2 10
Magnesium amino acid chelate <tablet> Does not dissolve. See Discussion 12. 10.5 no no not for FT
Magnesium Hydroxide liquid Clings to FT, rinse with 30 mL See Discussion 4 9.4 ok no 30
Magnesium Oxide44 <tablet> Does not dissolve- not for FT. See Discussion 12 10 no no not for FT
Meclizine tablet Dissolves quickly 3.1 ok ok 10 2 10
Medroxyprogesterone tablet Dissolves quickly 6.2 ok ok 10 1 10
Megestrol suspension, tablet Low dose use tablet, for high dose suspension. Dilute suspension. Osmolality 3665 mOsm/kg.4 7.2
4.4		 ok ok 10 2 20
Mercaptopurine <Tablet> suspension Chemotherapy, use suspension dilute 3X water to avoid clogs 6.5 ok ok Use suspension
Memantine tablet Dissolves quickly 6.7 pk ok 10 2 10
Mesalamine <Extended-release capsule, enema> Extended-release formulation. Do not administer through FT no no not for FT
Mesna tablet Osmolarity 700 mOsm/kg, dilute with 30 mL and Rinse with 30 mL water to prevent clog 6.7 ok ok 30 2 30
Metformin tablet Osmolarity 800 mOsm/kg dilute with 30 mL Rinse with 30 mL water to prevent clog 6.4 ok ok 30 2 30
Methenamine tablet Osmolality 745 dilute with 30 mL and Rinse with 30 mL water to prevent clog 5.0 ok ok 30 2 30
Methimazole tablet Dissolves quickly 6.1 ok ok 10 1 10
Methotrexate <Tablet> Liquid Chemotherapy, use liquid ok ok Use liquid
Methylergonovine tablet Dissolves quickly 3.1 ok ok 10 2 20
Methylprednisolone tablet Dissolves quickly 7.8 ok ok 10 1 10
Metoclopramide <tablet>, solution Dilute solution 3x water, Osmolality 4660 mOsm/kg.4 7.6 ok ok use solution
Metolazone tablet Dissolves quickly 6.4 ok ok 10 1 10
Metoprolol Tartrate tablet, <extended release> Dissolves quickly 6.5 ok ok 10 1 10
Metronidazole tablet Dissolves quickly, but requires extra rinse 6.8 ok ok 10 1 20
Metyrapone capsule Capsule cannot be opened no no not for FT
Mexiletine capsule Dissolves quickly. Need extra rinse 5.8 ok ok 10 1 20
Midodrine tablet Dissolves quickly 6.3 ok ok 10 1 10
Mineral Oil 67 <enema, liquid> Not advised - can degrade material of FT no no not for FT
Minocycline capsule Dissolves quickly 3.6 ok ok 10 1 10
Mirtazapine tablet Dissolves quickly 7.6 ok ok 10 1 10
Misoprostol68 tablet Manufacturer recommends compound and give immediately 5.9 ok no 10 1 20
Montelukast tablet Produces foam - difficult to mix. Extra rinse needed 8.2 ok no 10 5 30
Multivitamins <tablet>, liquid Dilute liquid 3x with water, Osmolality 3655 mOsm/kg 4 3.4 ok ok use liquid
Mycophenolate Mofetil <capsule, tablet>, suspension Use suspension as tablet slow to dissolve 7.0 ok ok use suspension
Nadolol tablet Slow dissolution, rinse well - need acid for dissolution 10.3 ok no 15 1 20
Naloxegol tablet Tablet has a film coating, require extra rinse 5.1 ok ok 10 1 30
Naproxen tablet Slow dissolution, extra rinse needed 5.1 ok ok 10 2 20
Nefazodone tablet Slow dissolution, extra rinse needed 4.4 ok ok 10 2 30
Nelfinavir69 tablet, solution Slow dissolution, rinse well; need acid for dissolution 8.8 ok no 10 2 20
Nebivolol tablet Poorly soluble, requires extra rinsing 6.0 ok ok 10 5 20
Neomycin Sulfate tablet Dissolves quickly 6.2 ok ok 10 1 10
Nevirapine tablet Contains co-precipitate, poor dissolution, extra rinse needed 7.2 ok ok 15 2 30
Niacin tablet Slow dissolution, rinse well 4.5 ok ok 10 2 20
Niacinamide tablet Poorly soluble, requires extra rinsing 7.3 ok ok 10 4 30
Nifedipine <capsule> Difficult to reliably remove from capsule 5.8 no no not for FT
Nitrofurantoin <tablet>, suspension Tablet difficult to crush - use suspension 3.8 ok ok use suspension
Nitroglycerin <SL tablet> Not for FT no no not for FT
Norethindrone 70 tablet Dissolves quickly, prodrug requires gastric activation 7.5 ok no 10 1 10
Nortriptyline capsule Dissolves quickly 6.9 ok ok 10 1 10
Nystatin Oral <suspension, tablet> For oral rinse, not for FT 7.1 no no not for FT
Olanzapine71 ODT tablet, tablet ODT requires intact GI tract but less water than tablet. Gastric only 8.2 ok no 15 5 30
Olmesartan72 tablet Slow dissolution, rinse well- prodrug requires gastric administration. 7.0 ok no 10 2 20
Omeprazole38 capsule Beads clog with water use acidic juice, or make Bicarb susp ok no 15 5 30
Ondansetron73 <ODT tablet, Solution> tablet, Use tablet. Solution osmolality 2935 mOsm/kg.4 See Discussion 1 5.9 ok ok 10 1 10
Oseltamivir Phosphate74 capsule, <suspension> Prodrug, require gastric administration to activate. See Discussion 3. Suspension thick with sorbitol. Mix capsule with water 4.7 ok no 10 1 10
Oxcarbazepine 75 <suspension>, tablet Contains co-precipitate, poor dissolution, require gastric administration. Suspension thick with sorbitol 8.0 ok no 10 2 20
Oxybutynin tablet, <XL form> Dissolves quickly 6.1 ok ok 10 1 10
Pancrelipase tablet, <capsule> Use Viokace only. Gastric FT only ok no 10 1 10
Pantoprazole <tablet> Extended release, not for FT- lansoprazole suspension is preferred 9.0 no no not for FT
Paroxetine tablet Dissolves quickly 6.7 ok ok 10 1 10
Penicillin V K <tablet>, suspension use suspension 7.2 ok ok use suspension
Pentoxifylline2 tablet Controlled release, do not crush - make susp change dose/ frequency ok ok compound suspension
Phenazopyridine tablet Poorly soluble coated tablet, requires extra rinsing, stains 3.5 ok ok 10 5 30
Phenytoin15 <capsule, tablet>, suspension Use suspension, osmolality 3095 mOsm/kg dilute 3X. See discussion 14 7.1 ok ok use suspension
Phytonadione tablet Poorly soluble, requires extra rinsing 7.0 ok ok 20 6 30
Pilocarpine tablet Poorly soluble, requires extra rinsing 5.6 ok ok 10 2 20
Pioglitazone tablet Poorly soluble, requires extra rinsing 2.5 ok ok 10 3 30
Posaconazole76 suspension, <tablet> Administer with enteral nutrition (rinse before and after) 4.5 ok no use suspension 20
Potassium Chloride <solution, tablet>, powder packet Use powder packet dilute to 8 oz. See Discussion 11. 3.3 ok ok use powder packet
Potassium Phosp/Na Phosphate powder, <tablet> Use powder and dilute 7.0 ok ok use powder capsule
Pramipexole tablet Dissolves quickly 6.8 Ok Ok 10 1 10
Pravastatin 77 tablet Poorly soluble, require extra rinsing, need acid for dissolution. See Discussion 3 8.8 ok no 10 2 20
Prednisolone solution Safe for FT Osmolality 2995 mOsm/kg4 6.9 ok ok use solution
Prednisone <solution>, tablet Tablet dissolves quickly, don’t use elixir, Prednisolone is better tolerated 6.8 ok ok 10 1 10
Pregabalin78 <capsule>, suspension Use liquid- safe undiluted ok ok Use Liquid
Primaquine tablet Dissolves quickly 2.8 ok ok 10 2 10
Primidone tablet Tendency to foam and require extra rinse 7.6 ok ok 10 2 20
Probenecid tablet Poorly soluble, requires extra rinsing 5.8 ok ok 10 1 20
Prochlorperazine <suppository>, tablet Poorly soluble, requires extra rinsing 4.6 ok ok 10 1 20
Promethazine tablet, Dissolves quickly 6.0 ok ok 10 2 10
Propranolol tablet Poorly soluble, requires extra rinsing 6.4 ok ok 10 1 20
Pseudoephedrine tablet EC Dissolves quickly, despite coating 6.8 ok ok 10 1 10
Pyrazinamide tablet Poorly soluble, requires extra rinsing 6.1 ok ok 10 5 30
Pyridostigmine tablet, <syrup> Dissolves quickly, do not use syrup 4.0 ok ok 10 1 10
Pyridoxine (Vitamin B-6) tablet Poorly soluble, requires extra rinsing 5.4 ok ok 10 4 30
Quetiapine tablet Poorly soluble, requires extra rinsing 5.8 ok ok 15 4 30
Quinapril79 tablet poorly soluble, requires extra rinsing, need acid for dissolution. See Discussion 3 9.6 ok no 10 1 30
Quinine <capsule> Does not dissolve. See Discussion 16 6.8 no no not for FT
Raloxifene tablet Dissolves quickly 5.8 ok ok 10 3 20
Raltegravir <tablet> Does not dissolve. See Discussion 16 no no not for FT
Ramelteon tablet slow dissolve 5.7 ok ok 10 4 20
Ramipril capsule Poorly soluble, requires extra rinsing 5.2 ok ok 20 2 30
Repaglinide80 tablet poorly soluble, requires extra rinsing, need acid for dissolution. See Discussion 3 9.5 ok no 10 1 20
Ribavirin <capsule>, suspension use suspension, avoid compounding hazardous 3 7.0 ok ok use suspension
Rifabutin <capsule> Does not dissolve. See Discussion 16 9.2 no no not for FT
Rifampin <capsule> Does not dissolve- See Discussion 16 6.9 no no Not for FT
Rifapentine tablet Poorly soluble, requires extra rinsing 6.9 ok ok 10 2 30
Rifaximin tablet Poorly soluble, requires extra rinsing 7.2 ok no 20 1 30
Risperidone 81 solution, tablet requires acid for delivery. See Discussion 3 8.1 ok no 10 1 10
Ritonavir <tablet>, suspension do not crush tablet, use suspension ok no use suspension
Rosuvastatin tablet Dissolves quickly 5.8 ok ok 10 1 10
Senna syrup, <tablet> use syrup 5.2 ok ok use syrup
Sertraline <concentrate>, tablet Poorly soluble, requires extra rinsing 6.1 ok ok 10 1 20
Sildenafil tablet slow to dissolve, extra rinse 4.3 ok ok 10 2 20
Simethicone <tablet>, liquid use liquid 4.9 ok no use liquid
Sirolimus <Liquid> not for FT, clogs tube 5.4 no no not for FT
Simvastatin tablet slow to dissolve, extra rinse 3.1 ok ok 10 2 20
Sitagliptin tablet slow to dissolve, extra rinse 5.6 ok ok 10 2 20
Sodium Bicarbonate tablet slowly dissolving, high osmolality. See Discussion 4 8.2 ok no 10 2 20
Sodium Chloride tablet Difficult to crush, slow to dissolve 5.1 ok ok 10 5 10
Sotalol tablet Dissolves quickly 5.8 ok ok 10 1 10
Spironolactone tablet slow to dissolve, extra rinse 5.8 ok ok 10 2 20
Sucralfate suspension, <tablet> use suspension. See Discussion 4 3.5 ok no use suspension
Sulfamethoxazole/Trimethoprim 400 mg-80 mg <tablet>, suspension Use suspension, extra rinse needed, Osmolality 5560 mOsm/kg4 5.6 ok ok use suspension
Sumatriptan tablet Dissolves quickly 5.5 ok ok 10 1 10
Tacrolimus <capsule>, suspension use suspension ok ok use suspension
Tamoxifen <tablet>, suspension use suspension 7.1 ok ok use suspension
Tamsulosin <bead filled capsules> not for FT no no not for FT
Telmisartan tablet slow to dissolve, require gastric administration ok no 10 5 10
Tenofovir Alafenamide tablet Dissolves slowly but completely 4.3 ok ok 10 2 10
Tenofovir Disoproxil Fumarate82 tablet Does not dissolve well. Prodrug require acidic dissolution. See Discussion 3 3.1 ok no 10 2 30
Terazosin capsule Dissolves quickly 5.4 ok ok 10 1 10
Tetracycline capsule dissolves quick, need extra rinse 1.6 ok ok 10 1 20
Thiamine tablet dissolves quick, need extra rinse 4.6 ok ok 10 2 20
Thioridazine tablet dissolves quick, need extra rinse 4.9 ok ok 10 2 20
Thyroid tablet dissolves slowly 7.2 ok ok 10 3 10
Tizanidine tablet dissolves quick, need extra rinse 5.1 ok ok 10 1 20
Tolterodine tablet dissolves quick, need extra rinse 6.6 ok ok 10 2 20
Tolvaptan tablet dissolves quick, need extra rinse 5.5 ok ok 10 1 20
Topiramate tablet dissolves quick, need extra rinse 7.2 ok ok 10 1 30
Tranexamic Acid 83 tablet poorly soluble, does not mix well for FT. need acid to dissolve 7.3 ok no 20 5 30
Trazodone tablet dissolves quick, need extra rinse 5.2 ok ok 10 1 20
Triamterene capsule dissolves quick, need extra rinse 6.1 ok ok 10 1 30
Triprolidine and Pseudoephedrine tablet Dissolves quickly 5.2 ok ok 10 2 10
Ursodiol capsule Poorly soluble, requires extra rinsing 6.4 ok ok 10 2 30
Ursodiol tablet Poorly soluble, requires extra rinsing 7.0 ok ok 20 1 30
Valproic Acid <capsule, syrup>, solution use solution. Osmolality 2010 mOsm/kg4 4.2 ok ok use solution
Valsartan Tablet Poorly soluble, requires extra rinsing 4.3 ok ok 10 1 20
Vancomycin <capsule>, suspension Capsule contains a tablet. use suspension 4.1 ok ok use suspension
Varenicline tablet Dissolves quickly 5.3 ok ok 10 1 20
Venlafaxine tablet Dissolves quickly 6.3 ok ok 10 3 10
Verapamil tablet Dissolves quickly 5.7 ok ok 10 1 20
Vitamin B Complex With Zinc tablet Does not dissolve well. Require extra rinse 3.5 ok ok 20 5 30
Vitamin E <capsule>, liquid Liquid-filled capsule. use liquid ok ok use liquid
Vitamins, Multiple Adult liquid, <tablet> use liquid. Osmolality 3655 mOsm/kg4 dilute 3X 3.4 ok ok use liquid
Vitamins, Multiple Pediatric liquid, <tablet chewable> Liquid drops. Osmolality 1450 mOsm/kg 13 ok no 20 3 10
Voriconazole suspension, <tablet> use suspension, Osmolality 2010 mOsm/kg4 4.2 ok ok use suspension
Warfarin35 <tablet> Not for FT admin- clings to FT. See discussion 5 no no not for FT
Zidovudine capsule, <syrup> Syrup too thick. Capsule dissolves quickly 6.5 ok ok 10 1 10
Zinc Sulfate capsule Does not dissolve well. Rinse with 30 mL water to prevent clog 5.5 ok ok 20 1 30
Ziprasidone capsule Does not dissolve well. Rinse with 30 mL water to prevent clog 4.8 ok ok 10 1 30
Zonisamide capsule difficult to open, does not completely dissolve 4.9 ok ok 10 1 20
Open in a new tab

Abbreviations: EC, enteric-coated; FT, feeding tube GI, gastro-intestinal; XL, extended release; ppt, precipitate

The results of this review are summarized in a table based on a composite of the literature collected, tests conducted, and author’s judgements based all the data collected. 36 medications were identified as inappropriate for feeding tube administration and an additional 46 medications were identified as only inappropriate for direct jejunal administration

The measured osmolality of solid dosage forms mixed in water all showed safe values (<400 mOsm/kg). Only calcium acetate, methenamine, metformin and mesna exceeded 500 mOsm/kg. The recommendation in the table was that additional fluid should be given to reduce gastrointestinal adverse effects when compounding those medications.

Discussion:

Some of the recommendations in Column 3 were based on the following issues:

  1. For liquid medications with measured osmolality of greater than 1000, and an alternative solid dosage form was available that could be crushed and mixed with water for safe administration, the recommendation was to not administer the liquid through feeding tube and use the compounded solid dosage form. Furosemide is an example of this issue. Furosemide liquid has an measured osmolality of 8975 mOsm/kg4, whereas crushing and mixing the tablet with water yields a much better tolerated osmolality of 3 mOsm/kg.

  2. Some drugs contain a coprecipitate as a component of their formulation Coprecipitates allow for a temporary solubilization, which may allow the API to precipitate out after a period. The recommendation was to mix these drugs in a syringe. This will allow a slurry to form and be administered immediately. An example of this is illustrated with Acyclovir. The suspension form is very thick, and the tablet formulations contain a coprecipitate, povidone which may allow the drug to fall out of solution. The capsule formulation does not contain povidone and can be opened and mixed with water24.

  3. For any drug which is a prodrug, requiring activation or dissolution in gastric fluid was designated as not recommended for jejunal administration. While it is possible to dissolve these drugs in an acidic fluid and then give into the jejunum, acidic fruit juices all have high osmolalities and would also not be tolerated in the jejunum. An example of this is Enalapril which requires gastric activation from the prodrug to be absorbed31,32. In most cases the solubility information is found in the package insert.

  4. Drugs that act locally in the stomach, such as sucralfate and buffering antacids should not be given into the jejunum. 33.

  5. Drugs that adhere to the plastic of the feeding tube, such as amiodarone34 and warfarin35 have unpredictable absorption. Accordingly, this table advises not to administer through feeding tubes.

  6. If the product required more than 50 mL of water for dilution, it was not recommended for feeding tube administration. As an example, Sirolimus liquid, which is a very thick suspension, was marked in the table as not recommended for the feeding tube route, since an adult dose required more than 50 mL dilution to allow feeding tube passage.

  7. Enteric coated beads are sensitive to pH and will form clogs when mixed with water12. In some cases, the drug can be given with an acidic juice to allow passage for gastric administration. Tamsulosin and lansoprazole were marked as not recommended for feeding tube administration. While there is a study that recommends Lansoprazole capsules be mixed with 120 mL of apple juice (acidic) and given through gastric feeding tube36, apple juice is hyperosmolar4 which limits this product to gastric administration. Another report cites the Orally Disintegrating Tablet (ODT) can be mixed in water for gastric administration37. As an alternative, mixing lansoprazole capsule beads with sodium bicarbonate and forming a suspension allows for administration to both gastric and jejunal routes38. The table recommendation is to use the compounded suspension for all lansoprazole (and other Proton Pump Inhibitors) feeding tube orders.

  8. If the liquid is an acidic syrup and the tablet can be crushed easily (e.g., Zidovudine), the recommendation was to crush the tablet, rather than risking a clog formed by reaction of acidic medication and intact protein nutrition product.

  9. If the FDA has specifically noted that the formulation should not be administered through a feeding tube, as with Ciprofloxacin suspension, the recommendation in this table would be consistant with that comment39.

  10. Fluroquinolones have potential food drug interactions leading to recommendations of withholding nutrition for 2 hours before and after administration of the antibiotic11. This recommendation was based on a controversial in-vitro study that combined the drug directly with enteral nutrition, instead of mixing with water.40 Drugs should only be mixed with water before administration through feeding tubes22. In that study the Fluroquinolones was directly mixed with divalent cationic salts and demonstrated no interaction. Mixing the drug with water optimizes dissolution and delivery41, and is the recommendation in this table.

  11. For potassium chloride medication orders, it would be easiest to recommend using the liquid formulation, and to advise dilution to 8 oz as stipulated in the package insert. As a practical matter, given limitations of maximum syringe size (2 oz.) this may result in a concentrated product and if given undiluted, resulting in cramping from the hyperosmolar fluid. Another issue of potassium administration is, K-Dur® tablets dissolve in water, but there were reports of increased clogs using this formulation42. For these reasons, the recommendation is to use the powder packets that must be diluted before administration.

  12. Magnesium deficiency is common in oncology patients43. Magnesium salts, promoted as supplements have poor dissolution and deliver little magnesium for absorption44. These salts were not recommended for feeding tube administration due to lack of benefit and tendency to cause clogs.

  13. The recommendation for Gabapentin is not to compound a liquid using the tablet or capsule, but to use the suspension. Reports have suggested increased adverse effects when switching generic formulations of antiepileptic drugs, particularly with gabapentin.45

  14. Phenytoin has been documented in the literature as having a drug-nutrient interaction.46 It was stated that the drug binds to enteral nutrition, and that patients on enteral nutrition have faster transit times. This is inconsistent with clinical practice where enterally fed patients are more prone to constipation.47,48 A review of all the phenytoin studies found that this interaction did not occur in any of the randomized control studies.49 My own thesis showed that dilution the suspension improves dissolution, and eliminates the interaction.50 The recommendation in this chart is not to withhold nutrition, but to dilute the suspension three times the volume using water. It is recommended, however, to monitor phenytoin levels when it is administered through feeding tubes as absorption may be unpredictable.

  15. If the medication formulation is defined as orally disintegrating table, where the drug is absorbed through oral mucosa, or sub-lingual, where the drug is absorbed under the tongue, these dosage formulations would be labeled as not recommended for feeding tube administration.

  16. If the mixed drug required more than 20 minutes to mix into a suspension, it was assigned the recommendation “not to use for feeding tube” administration.

One of the limitations of this chart is that it is constrained by what formations and dosage forms that exits in the current formulary. Other formulations may exist that offer better administration for the feeding tube, but these were not tested here. The reader is welcome to use our worksheet for evaluation of their products to determine the ideal product for feeding tubes.

Conclusion:

The data collected in the table was used to create the recommendations for feeding tube administration. The administration of oral medications by the feeding tube route remains an unapproved use by the FDA for most drugs. The tests conducted only reveals the physical parameters of the drug delivery and does not evaluate what changes in absorption will occur when crushing or preparing a liquid formulation of a solid oral dosage form. These issues must be considered when administering oral medications by the feeding tube route.

This table will continue to grow. As new drugs are added to formulary, the methodologies discussed will be used to optimize drug delivery through feeding tubes. The next stage of this project is implementing the data collected and creating order entry pathways which include recommendations for clinical application.

Clinical Relevancy Statement.

Oral medications are not designed for feeding tube administration. Feeding tubes are often clogged by poorly dissolved drugs, eliminating a vital route of administration to nutrients and subsequent medications.

This document reflects a comprehensive review of all non-narcotic oral medications used at a cancer hospital for appropriateness for the feeding tube route. This paper combines the literature and physical assessments of oral medication to create a guidance on drug preparation, optimal route of administration and actions to reduce clogging the feeding tube.

This report will provide clinicians with a guide to optimal drug preparation for the feeding tube route. This report also identifies which medications are inappropriate for direct jejunal administration without gastric exposure.

This report also provides a mechanism to evaluate future oral medications for feeding tube administration, to reduce clogging and improve patient care.

Acknowledgements

The author wishes to thank the following students – who contributed to the data collected for this study:

Arnold and Marie Schwartz College of Health Sciences and Pharmacy: Alex Korik, Eugene Kolomiyets, Gila Schreier, Guozhou Wu, Jae Lim, Nadeem Abdin, Olga Mironova, Rachel Harooni, Richard Leong, Unnati Gandhi, William Yankovich, Carol Hanna, Matthew Andersen, Mariya Elterman, Merit Henen, Rebecca Massachi, Rachel Tedesco

St John’s College of Health Sciences and Pharmacy: Christine Chisari, Henry Huang, Jeffrey Macaluso, Marlene Almeida, Melissa Marlieb, Zachary Hopkins

Summer Interns: Ramey Boules, Patrick Hu, Alycia Hatashima, Sihem Ettaieb, Nicole Ng, Trisha Arriola, Jacob Chess, Lauren Burton, Keisha Lewars, Victoria Chann, Hannah Nguyen

Footnotes

Disclosures

Financial Disclosure: None declared

Conflicts of Interest: None declared

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