PB-PG-0101-12240 - NIHR Research for Patient Benefit Programme - Final Report Project title: Determination of the ideal medication characteristics for the safe and effective administration of medications via enteral feeding tubes Authors: Miss Rebecca White - Oxford Radcliffe Hospitals NHS Trust Professor Duncan Craig - University of East Anglia Mr John Wood - University of East Anglia Professor David Wright - University of East Anglia Plain language summary Background Many patients are unable to take nutrition by mouth and therefore enteral feeding tubes (EFTs) have to be inserted directly into the stomach either via the nose or straight through the abdomen. Over 37,000 patients in the UK use these tubes long term. Medicines given by this route are unlicensed and therefore patients and carers have no guidance available to them to decide how best to prepare and administer medicines for delivery via this route. GPs prescribing for these patients in the community are unsupported as technical information on this route of administration in primary care is limited. A survey of practice amongst nutrition nurses, dietitians, nursing homes and patients was undertaken to determine what methods were used for medication administration and which medication were associated with problems. Laboratory work was undertaken to find out if the liquid medicines associated with problems had similar properties and if the methods used for tablet administration, dispersion or crushing, delivered an accurate dose. Findings The methods and flushing volumes used to administer medication via EFTs are varied. Tablet crushing is common and obtaining a liquid formulation can be difficult. Administration practices advocated by nutrition nurses and dietitians are not routinely applied by healthcare staff and patients in primary care. Tablet dispersion did not affect the dose delivered however, the crushing methods used lead to a significant reduction in the dose Liquid medications are associated with administration problems if they have a high viscosity or granular properties. Non-granular viscous liquids can be diluted to make administration easier. Conclusions Clearer guidance on enteral tube drug administration is required for patients and carers. Not all liquid formulations are suitable for EFT administration however tablet crushing should be strongly discouraged. Benefit to patients Freely accessible information for General Practitioners and nursing homes on safe administration of medication via enteral feeding tubes for the most commonly prescribed medication and improved signposting for further information should improve the quality and safety of prescribing for patients with enteral feeding tubes. Publicising this information via patient support groups should also empower patients to encourage their GPs to seek further information. Keywords Enteral tube, Medication, Administration, Tablet crushing Summary of research findings Background The increase in awareness of the importance of adequate nutritional intake has increased the use of enteral feeding tubes (EFT) in all areas of healthcare. An EFT provides a means of maintaining nutritional intake when there is limited access to the gastrointestinal tract. The British Artificial Nutrition Survey published data indicating that there are currently more than 37,000 patients in the community on home enteral feeding. Identifying a suitable drug formulation for administration to a patient with limited GI access or dysphagia is difficult. In these patients the enteral feeding tube is often the only means of enteral access and increasingly is being used as a route for drug administration. Administering drugs via an enteral feeding tube usually falls outside of the terms of the drugs product license, this has implications for the professionals responsible for prescribing, supplying and administering the drug as they become liable for any adverse event that the patient may experience. The pharmaceutical companies can provide very limited information on medication use outside of product license. The quality of data published relating to medication administration via EFTs is largely anecdotal and individual case report based. A robust method for assessing new medicine formulations for appropriateness for this route of administration is lacking and hence licensing for this route is exceptionally rare. The NPSA safety alert number 19, ‘promoting safer measurement and administration of liquid medicines via oral and other enteral routes’, further highlights the common use of this method of drug administration and mandates the inclusion of guidance in medicines policy for this route of administration. However, robust evidence to inform such policies and protocols is lacking. Tube blockage due to medication remains a significant problem. Marcuard and Stegall (1990) found that medication administered via narrow bore feeding tubes was the cause of tube occlusions in 63% of cases. A study by Benson et al (1990) found that even following an irrigation protocol, a significant relationship was observed between the number of medications administered through the tube and tube blockage, with the likelihood of tube blockage increasing in proportion to the number of medications administered. In two studies investigating administration by nurses through EFTs (seifert et al, 1995;belknap et al, 1997), those nurses who received assistance from the pharmacy were significantly more likely to administer liquid forms than those nurse who reported no pharmacy assistance and less likely to experience tube occlusion due to medications. Despite this evidence, the automatic selection of a liquid formulation may not be appropriate. Edes et al (1990) estimated the incidence of osmotic diarrhoea in tube fed patients directly due to the osmolality of the liquid medicines to be about 48%. Furthermore some liquid formulations are too thick or sticky to administer via EFTs. Although it is...