Midwinter Meeting February 29, 2020 Untangling Medication - PowerPoint PPT Presentation

Midwinter Meeting February 29, 2020

Untangling Medication Administration in Patients with Feeding Tubes Lilian F. Ooi, PharmD, BCPS, BCCCP Advanced Clinical Pharmacist Intermountain McKay-Dee Hospital

Disclosure I have no conflicts of interest to disclose. Off-label uses of drugs will be discussed.

Learning Objectives At the conclusion of this activity, pharmacists should be able to successfully: 1. Recognize the methods of enteral feeding 2. Describe considerations for medication administration through a feeding tube 3. Evaluate factors to safely prepare and administer medications through a feeding tube 4. Formulate an approach to dosage form selection and drug administration methods in patients with enteral feeding tubes

Learning Objectives At the conclusion of this activity, pharmacy technicians should be able to successfully: 1. Recognize the methods of enteral feeding 2. Recall issues with medication administration through a feeding tube 3. Evaluate factors to safely prepare, deliver, and store medication to be given through an enteral access device

Enteral Access Sites Classified by • Site of insertion • Location of distal tip of the feeding tube Selection based on • Short-term usage • Long-term usage • Disease state • Patient-specific factors 1 Williams NT. AJHP 2008. 2 White R. Pharmaceutical Press 2015.

Enteral Feeding Delivery Methods Continuous • Most common in hospital setting • Slow, continuous rate over 24 ‐ hour period Cyclic • Continuous feeding over a specific period • Generally overnight Bolus • Mimic usual eating patterns • 4 ‐ 6 times per day 1 Williams NT. AJHP 2008. 3 Boullata JI. ASPEN 2019.

Feeding Tube Size • Outer lumen tube diameter measured in French (Fr) units • 1 Fr = 0.33 mm • Small-bore tubes • 5-12 Fr • Gastrostomy, NG, NJ • Large-bore tubes • ≥ 14 Fr • PEG NG = Nasogastric; NJ = Nasojejunal; PEG = Percutaneous Endoscopic Gastrostomy . 1 Williams NT. AJHP 2008. 4 Image from https://www.compactcath.com/blog/catheter ‐ types ‐ and ‐ sizes.

Complications • Occlusions • Particle obstruction • Inadequately crushed tablets • Coating • Precipitate formation • Drug-feed interaction • Drug-drug interaction • Adverse events • Decreased efficacy • Increased systemic effects • Death 1 Williams NT. AJHP 2008. 5 McIntyre CM, Monk HM. AJHP 2014. 6 Schallom M. Am Nurse Today 2016. 7 Logrippo S et al. Clin Interv Aging 2017.

Safe Practice Recommendations Determine Establish drug Utilize proper route and dosage administration Report issues suitability form suitability techniques 1 Williams NT. AJHP 2008. 8 Boulllata JI. JPEN 2017.

Drug Route Suitability • Determine location of distal end of feeding tube • Most medications absorbed in small intestine • Feeding tube may bypass site of absorption • Antacids, sucralfate, bismuth • Require gastric acid for absorption • Ferrous sulfate, aspirin • Bypass first-pass hepatic metabolism • Opioids, tricyclic antidepressants, ß-blockers 1 Williams NT. AJHP 2008. 5 McIntyre CM. AJHP 2014.

Drug and Dosage Form Suitability • Use only immediate-release liquid or solid dosage forms • Be cognizant of osmolality and excipients • Avoid enteric-coated and film-coated products • Prepare hazardous drugs in central pharmacy • Recommend alternative routes of administration 1 Williams NT. AJHP 2008. 8 Boullata J. JPEN 2017. 9 Beckwith MC. Hosp Pharm 2004. 10 Grissinger M. P&T 2013. 11 Lippincott Procedures 2019.

Resources • Tertiary references • Guidebooks, online drug databases • ISMP “Do Not Crush” list • NIOSH list of antineoplastic and other hazardous drugs • Institutional policies and procedures • Primary literature ISMP = Institute of Safe Medication Practices; NIOSH = National Institute for Occupational Safety and Health2019. 2 White R. 2015. 8 Boullata J. JPEN 2017. 12 ISMP 2019. 13 NIOSH 2016.

Proper Administration Techniques Administer each Stop enteral Restart medication feeding feeding separately Prepare each Flush well medication •15 ‐ 30 mL purified separately water •Flush in between •Open capsules each administration •Crush solid dosage forms to fine powder •Dilute medication 1 Williams NT. AJHP 2008. 2 White R. 2015. 3 Boullata JI. ASPEN 2019. 8 Boullata J. JPEN 2017. 9 Beckwith MC. Hosp Pharm 2004. 11 Lippincott Procedures 2019.

Test Question-Pharmacists and Technicians NM is a 76-year-old male with acute cardioembolic stroke secondary to atrial fibrillation. He failed his swallow evaluation and consented to nasogastric (NG) tube placement. Apixaban Docusate 5 mg tab PO BID 100 mg cap PO BID Medications: Atorvastatin Pantoprazole enteric ‐ coated (EC) 80 mg tab PO QHS 40 mg tab PO daily Metoprolol extended ‐ release (XL) Tamsulosin 50 mg tab PO Daily 0.4 mg cap PO daily What recommendations would you discuss with the physician or communicate to the bedside nurse? Choose all the correct statements. A. Apixaban and atorvastatin can be crushed and given via NG tube B. Change metoprolol XL to immediate-release formulation given twice daily C. Crush tamsulosin, dilute with purified water, and give via NG tube D. Hold pantoprazole EC tab

References 1. Williams NT. Medication administration through enteral feeding tubes. Am J Health-Syst Pharm. 2008; 65:2347-57. White R, Bradnam V. Handbook of Drug Administration via Enteral Feeding Tubes. 3 rd ed. London, UK: Pharmaceutical Press; 2015. 2. 3. Boullata JI. Guidebook on Enteral Medication Administration . Silver Spring, MD: American Society for Parenteral and Enteral Nutrition; 2019. 4. French Cather Scale. CompactCath. https://www.compactcath.com/blog/catheter-types-and-sizes. Accessed January 20, 2020. 5. McIntyre CM, Monk HM. Medication absorption considerations in patients with postpyloric enteral feeding tubes. Am J Health-Syst Pharm 2014; 71:549-56. 6. Schallom M. How to recognize, prevent, and troubleshoot mechanical complications of enteral feeding tubes. Am Nurse Today 2016; 11(2):1-8. 7. Logrippo S, Ricci G, Sestili M et al. Oral drug therapy in elderly with dysphagia: between a rock and a hard place! Clin Interv Aging . 2017; 12:241-251. 8. Boullata JI, Carrera AL, Harvey L, et al. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter Enteral Nutr . 2017;41:15-103. 9. Beckwith MC, Feddema SS, Barton RG, Graves C. A Guide to Drug Therapy in Patients with Enteral Feeding Tubes: Dosage Form Selection and Administration Methods. Hosp Pharm 2004; 39:225-237. 10. Grissinger M. Preventing Errors When Drugs Are Given Via Enteral Feeding Tubes. P&T 2013; 28(10)575-576. 11. Enteral tube drug instillation. (2019). In Lippincott procedures. Retrieved from http://procedures.lww.com. 12. Oral Dosage Forms That Should Not Be Crushed. Institute for Safe Medication Practices. Updated November 1, 2018. https://www.ismp.org/recommendations/do-not-crush. Accessed January 20, 2020. 13. NIOSH List of Antineoplastic and Other Hazardous Drugs in Healthcare Settings. Updated September 2016. https://www.cdc.gov/niosh/docs/2016- 161/pdfs/2016-161.pdf. Accessed January 20, 2020.