Ms Sarah Low Senior Clinical Pharmacist Khoo Teck Puat Hospital

1. GeriCare
Tele-Continuing
Professional Education
Topic: Medication Administration through Enteral Feeding Tubes
Date: 12 October 2020
Speaker: Ms Sarah Low
Senior Clinical Pharmacist
Khoo Teck Puat Hospital

2. Administrative matters
GeriCare
 Send your attendance and any feedback to:
- Ms Yu Chin Hui at yu.chin.hui@ktph.com.sg by 16 Oct 2020
- Registration of CPE points (for those with SNB no.)
 Next Tele-CPE session will be:
- Topic: Review of TeleGeriatrics Assessment Form
- Date: 14 Dec 2020 at 2.00 -3.00 pm
- Target audience: All TeleG trained staff

3. Medication Administration
through Enteral Feeding
Tubes
GeriCare 12th October 2020 by Sarah Low
Senior Clinical Pharmacist
Khoo Teck Puat Hospital
3

4. Learning Objectives for Nurses
1. Identify reason(s) why an enteral feeding tube is placed.
2. To be able to identify medications that cannot be administered
through enteral feeding tubes (EFT)
3. To understand the significance of administration timing of
medications
4. Apply this knowledge in nursing home patients
4

5. Purpose of Enteral feeding tube (EFT)
• Maintain nutritional intake
-when oral intake is inadequate
-when there is restricted access to the gastrointestinal tract (GIT)
eg obstruction
5

6. Medication management
in EFT administration
1) Review patient’s current medication list to
determine what medication can be crushed
2) If there is any medication that can be given in other
formulations eg patch, rectal, orodispersible tablets
6

7. Identify Medications that cannot
be administered through EFT
To reduce tube blockage
To reduce their potential toxicity
To increase efficacy of medications
7

8. Flushing of enteral feeding tubes
(EFT)
• EFT require regular, effective flushing to prevent tube blockages and
extend life of the tube
• Tube blockages may occur owing to
-small internal diameter of the tubes
-inappropriately prepared medications
-Poor flushing techniques
-Bacterial colonization within the feeding tube
8

9. To crush or not to crush:
References
9

10. Preparation: Can crush or Not?
Common medications that cannot be crushed
Choice of medication formulation
10

11. Common Medications that should not be
crushed
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1. Modified release preparation
:SR/XR/XL/PR/MR
3. Medication that can be irritating
Carbamazepine CR
Nifedipine LA 30mg
Madopar HBS 125mg capsules
Alendronate An irritant
2. Enteric Coated (EC) 4. Medications that can be teratogenic/and or
carcinogenic
Bisacodyl 5mg EC tablet
Sodium Valoprate 200mg EC
Omeprazole EC
Letrozole
Hydroxyurea
Dutasteride
(Avodart
capsules)
May release teratogenic and/or
carcinogenic particulars in the air
when crushed

12. Implications of Modified release
preparations
Do not crush any of the named preparations
• Slow release: SR
• Extended Release or XL
• Long Acting or LA
• Prolonged release or PR
• Modified Release or MR
• HBS Hydrodynamic Balanced System (controlled release)
12

13. Examples of modified-release
preparations
Slow release: SR
Potassium Chloride 600mg SR tablets
Extended Release or XL
Alfuzosin XL 10mg tablets
Long Acting or LA
Nifedipine LA 30mg or 60mg tablets
Prolonged release or PR
Tamsulosin 400mcg PR tablets
Modified release
Gliclazide MR (Diamicron MR)
13

14. Common Medications that should not be
crushed
14
1. Modified Preparations SR/XR/PR 3. Medication that can be irritating
Carbamazepine CR
Nifedipine LA 30mg
Madopar HBS 125mg capsules
Alendronate An irritant
2. Enteric Coated (EC) 4. Medications that can be teratogenic/and or
carcinogenic
Bisacodyl 5mg EC tablet
Sodium Valoprate 200mg EC
Omeprazole EC
Hydroxycarba
mide
(Hydroxyurea)
Dutasteride
May release teratogenic and/or
carcinogenic particulars in the air
when crushed

15. Controlled release preparations
• The entire daily dose is administered as an immediate-release bolus and this can have fatal consequences.
15
DRUG NAME DRUG NAME (Alternatives) What happens if CR
preparations are crushed?
HBS Madopar (L-dopa
100mg/benserazide 25mg)
CAPSULES
Madopar (levodopa 200mg/
benserazide 50mg) TABLETS The less effective control
of tremors and other
Parkinson symptoms
Carbamazepine 200mg
(Tegretol) CR tab
Carbamazepine 200mg (Tegretol)
tab
Cause an immediate
release of the
medications causing more
side effects OR crushing
the medications may lead
to less effective control of
the seizures if used for
control of epilepsy
CR=Controlled Release
IR =Immediate release (CR means
longer acting, NOT THE SAME AS IR)
Tablets can be halved or quartered,
suitable for those on NGT

16. Using Appropriate Formulations of
Medications
• Switch of Controlled release medications to Immediate release medications
and titrate according to the response of the patient and disease
• To prevent dose dumping
• Prevent total daily dose of med given as bolus when CR preparation are crushed
• Maintain same total daily dose as much as possible and increasing
frequency
16
Pharmacotherapy Update May/June 2008
Decrease Toxicity of medications
Increase Efficacy of medications

17. Common Medications that should not be
crushed
17
2. Enteric Coated (EC) Purpose of
enteric
coated
What happens when they
are crushed? Removing of
enteric coating?
Bisacodyl 5mg EC tablet
Sodium Valoprate 200mg EC
Omeprazole EC
Design to
pass through
the stomach,
prevent
destruction
of drug in the
stomach and
release drug
in the
intestine
• Unpredictable drug
degradation in stomach 
Reduced effectiveness of drug
• Exposure of drug irritant to
mucosal lining Increase
Gastrointestinal irritation
• EC coating is hard to crush
successfully may break into
small pieces  increase risk of
blockage when admin thru EFT

18. When you have a patient on enteral
feeding tubes
• If patient is recently converted to NGT and his med list:
• bisacodyl EC tablets for constipation
• Sodium valoprate EC tablets for behavioural issues
• Omeprazole EC capsules for history of gastric reflux
• What do you do?
18

19. When you have a patient on enteral
feeding tubes
• If patient is recently converted to NGT and his med list:
• bisacodyl EC tablets for constipation
• Sodium valoprate EC tablets for behavioural issues
• Omeprazole EC capsules for history of gastric reflux
• What do you do?
• Flag to the Dr about the patient’s recent change of oral to NGT
• All the above medications are Enteric coated
• Not suitable for NGT
• Are there any other alternative formulations?
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20. What alternatives can we suggest?
Enteric coated (EC)
• Bisacodyl 5mg EC tablet
• Sodium valoprate 200mg EC
• Omeprazole EC 20mg capsules
Alternatives
• Bisacodyl suppositories or senna tablets
• Sodium valoprate liquid (Epilim 200mg/5ml)
• Esomeprazole tablets (dispersed in water)
20

21. Common Medications that should not be
crushed
21
1. Modified Preparation: SR/XR/PR 3. Medication that can be irritating
Carbamazepine CR
Nifedipine LA 30mg
Madopar HBS 125mg capsules
Alendronate An irritant
2. Enteric Coated (EC) 4. Medications that can be teratogenic/and or
carcinogenic
Bisacodyl 5mg EC tablet
Sodium Valoprate 200mg EC
Omeprazole EC
Hydroxycarba
mide
(Hydroxyurea)
Dutasteride
capsules
(Avodart)
May release teratogenic and/or
carcinogenic particulars in the air
when crushed

22. Common Medications that should not be
crushed
22
1. Modified preparations: SR/XR/PR 3. Medication that can be irritating
Carbamazepine CR
Nifedipine LA 30mg
Madopar HBS 125mg capsules
Alendronate An irritant
2. Enteric Coated (EC) 4. Medications that can be teratogenic/and or
carcinogenic
Bisacodyl 5mg EC tablet
Sodium Valoprate 200mg EC
Omeprazole EC
Hydroxycarba
mide
(Hydroxyurea)
Dutasteride
May release teratogenic and/or
carcinogenic particulars in the air
when crushed

23. Administration Techniques
23

24. Administration techniques
24
Grind tablets
into fine
powder and
mix with
water
Open hard
gelatin
capsules and
mix powder
with water
DO NOT mix
feeds with
medicines
When multiple
medications are
scheduled for
administration at
the same time, each
should be given
separately, with
flushing of 5-10ml of
water in between
To avoid potential interactions and incompatibilities
Dilute
thick/viscous
liquids with
10 to 30ml of
water
Lactulose need to be
diluted with 2-3
times the volume of
water immediately
prior to
administration

25. Administration Timing of Medications
• Medications to be taken on an empty stomach for better absorption
• Bisphosphonates (administer first, then 30 minutes restart feed) 1
• Thyroxine eg 6am
• Interactions with milk feed
• Phenytoin: absorption reduced by 70%
• Space apart from feeds for 1 to 2 hours, appropriate irrigation
• Fluoroquinolones (ciprofloxacin absorption is decreased by 50%) 1
• Milk feeds should be withheld 1 hour before administering medicine and 2 hours after
• Warfarin
• Dependent on the vitamin K in the feed
26
1: handbook of Enteral feeding
Increase the Efficacy of medications

26. Case 2: Patient on NGT
• Med list :
• Tamsulosin PR for Benign Prostate Hypertrophy (BPH)
• Isosorbide mononitrate SR (Imdur SR) for heart/angina
• Nifedipine LA 30mg or 60mg for high blood pressure
• Ciprofloxacin 500mg bd x 5 days (8am, 6pm)
• Enteral feed given 5 times a day at 6am, 10am,2pm, 6pm, 10pm
• Do you have any concerns? What do you do?
27

27. Case 2: Patient on NGT
28
1: handbook of Enteral feeding
• What should you do?
• You should flag to the Dr about
• the patient’s recent change of oral to NGT
• 3 medications are sustained/controlled release preparations

28. Case 1 Scenerio 1
29
1: handbook of Enteral feeding
• If the Dr decided to change the med list to :
• Terazosin 1mg on (For BPH)
• Isosorbide dinitrate 10mg tds (Angina/heart)
• Amlodipine 5mg om or 10mg om
• Ciprofloxacin 500mg bd x 5 days (8am, 6pm)
• Enteral feed given 5 times a day at 6am, 10am,2pm, 6pm, 10pm
Do you have any other concerns?

29. Administration Timing of Medications
Interactions with milk feeds
• Fluoroquinones (ciprofloxacin absorption is decreased by 50%)1
• Milk feeds should be withheld 1 hour before administering medicines and 2 hours
after
Ciprofloxacin 500mg bd x 5 days (8am, 6pm)
Enteral feed given 5 times a day at 6am, 10am, 2pm, 6pm & 10pm
• Ciprofloxacin should be served at ____ and ______
30
1: handbook of Enteral feeding

30. Administration Timing of Medications
Interactions with milk feeds
• Fluoroquinones (ciprofloxacin absorption is decreased by 50%)1
• Milk feeds should be withheld 1 hour before administering medicines and 2 hours
after
Ciprofloxacin 500mg bd x 5 days (8am, 6pm)
Enteral feed given 5 times a day at 6am, 10am, 2pm, 6pm & 10pm
• Ciprofloxacin should be served at 8am and 8pm
31
1: handbook of Enteral feeding

31. Case 1: Scenario 2
32
1: handbook of Enteral feeding
• Patient is on
• Terazosin 1mg on (For BPH)
• Isosorbide dinitrate 10mg tds (Angina/heart)
• Amlodipine 5mg om or 10mg om
• Warfarin 2mg on at 6pm (stable INR at 2) for AF
• Enteral feed given 5 times a day at 6am, 10am,2pm, 6pm, 10pm
• Do you have any concerns?

32. Take Home Message
33
Identify medications that cannot be
administered through EFT
• 4 types: Modified preparations, EC, Irritants, Carcinogenic/Teratogenic
Administration timing of medications
• To increase the efficacy of the medications

33. Group Photo