Quote from Julian Dodd
Thanks for your advice which will be taken and acted upon
New House best practice statement
RE: Administration of medication via PEG
Patient safety is enhanced when those administering medicines understand and apply the principles of pharmacology, (Jordan 2003).
If prescribed medications are to realize their therapeutic potential, healthcare professionals need to focus on the details of drug administration, (Jordan 2003).
This statement is confined to enteral administration
Some drugs, for example, warfarin, phenytoin, sucralfate and syrup formulations, are known to interact with enteral feeds and/or gastric acid and should be administered following a cessation of feeding of at least two hours. Drugs whose absorption is decreased by food should also be administered following a cessation of feeding of at least two hours.
(1) Nurses should be aware of any reactions and plan medication administration accordingly.
Enteral feeding tubes can sometimes block. This can be due to medications being incompletely crushed or forming clumps when exposed to moisture Opening a capsule or crushing a tablet before administration will (in the majority of cases) make its use 'unlicensed'. Under the Medicines Act 1968 only medical and dental practitioners can authorise the use of 'unlicensed' medicines in people. It is, therefore, strictly illegal to open a capsule or crush a tablet before administration without prescriber authorisation. Chewing medication before swallowing must also be carefully considered because this practice can have the same effect as crushing tablets or opening capsules.(Wright 2002 b)
(2) Nurses should ensure that, wherever possible, medicines are translated to liquid form. If, for any reason a liquid alternative is not available, authorisation for unlicensed medication administration (crushing of tablets or opening of capsules) should always be obtained from the prescriber in writing and not accepted verbally. If there is no alternative, crush tablet or open capsule and mix with 10-15ml of freshly boiled and cooled water Draw up into 50ml syringe flush tube with 30ml of water before drug administration, administer each drug separately, flushing the tube with 5ml of water in between each medication. The syringe should also be flushed between each administration, flush the tube with 30ml of water after administration is complete. There are certain medications which should never be crushed, Wright D (2002a) provides a list of medications that should never be crushed or opened. It is based on lists published in the United States and Canada (Glustein 1984, Mitchell and Pawlicki 1992) and acts as a useful guide for healthcare practitioners in the UK, as there is currently no official list here.
In many clinical areas, the margin for error in drug administration is now very narrow. Unless administration issues are addressed, the amount of drug entering the body can fluctuate, resulting in either therapeutic failure or serious adverse effects. It is extremely important that nurses consider any factors which may affect drug bioavailability and employ strategies to deal with any problems which could arise. Food may bind to drugs, keeping them in the intestines and decreasing absorption, to a varying degree. Examples include frusemide/furosemide, calcium antagonists, erythromycin stearate, tetracyclines and iron preparations. Antacids and guar gum bind in a similar way to many drugs, particularly enteric-coated preparations (Stockley 1999) Some foods and herbs can interfere with metabolism and increase or decrease the effects of certain drugs. Re-timing administration of medicines may not prevent these drug/food interactions. When medications have to be administered through PEG tubes, they should be in liquid form, diluted if appropriate. However, it is important to seek advice as not all oral liquids are suitable for PEG tube administration, for example, co-amoxiclav and lansoprazole suspensions may form clumps; and diazepam, and possibly carbamazepine, adhere to plastic tubes (Naysmith and Nicholson 1998).Due to the fact that any failure to consider the details of formulation variables, drug interactions or administration schedules may compromise the efficacy of therapeutic regimens and even patient safety, pharmacists, doctors, patients and, if appropriate, carers should be consulted by nursing staff regarding medication regimens The following is given as an example of best practice as far as administration of medication via peg is concerned.(see Jordan 2003).
Handwashing will reduce the risk of infection.
To reduce the risk of tube blockage:
Administer medicines when the patient is not receiving enteral feeding, if possible. Alternatively, stop the feed for 15-60 minutes before drug administration. This is easier if drugs are only administered once or twice per day.
Administer each medicine separately, flush tube with 30ml (10ml-30ml in some guidelines) sterile (*) or boiled water cooled to body temperature before and after administering medicine, and with at least 10ml between medicines. Use 50ml syringes to avoid pressure damage to the feeding tube and breakage.
If patient is on restricted fluids record water administered on the fluid balance chart.
Drugs should be administered as liquids formulated for oral administration, if at all possible. However, not all these are suitable It may be necessary to dilute viscous (thick) or concentrated liquids with at least an equal volume of sterile(*) water .
Soluble/dispersible tablets thoroughly dissolved in sterile (*) water may be an alternative.
In consultation with doctors and pharmacists, it may be possible to use injectable forms of medication, short term, but doses will need to be adjusted. Some intravenous medicines, for example, diazepam, adhere to plastic tubes.
If it can be demonstrated that all professionals agree that there is no alternative (for example, warfarin), tablets should be finely crushed and administered as a dilute solution with sterile (*) water. Wear gloves to reduce exposure.
Enteric-coated, sustained release, modified release, sublingual, chewable tablets, nitrates, cytotoxics, hormones, steroids, prostaglandins and pancreatic enzymes should never be crushed.
Avoid bulk-forming laxatives as these will expand on contact with moisture and block the feeding tube.
Avoid antacids, as these may interact with the feed and block the tube.
Many medicines are incompatible with enteral feeds. Interactions can occur, which could block the feeding tube. Avoid co-administration, unless this has been approved by the manufacturer or pharmacist. No drugs should be administered with Fresenius Kabi feeds
To minimise adverse drug reactions:
Be aware that concentrated (hyperosmolar) medicines, particularly those containing sorbitol (in some sugar-free preparations) can cause diarrhoea when administered enterally.
Consider the emetic potential of all medications. PEG feeding, particularly if administered rapidly, can cause nausea. Co-administration of a medication that has nausea as a side effect is likely to exacerbate these problems
Constipation is a common problem in this client group. This is exacerbated by drugs which inhibit colonic motility, for example, tricyclic antidepressants and opioids.
Due to changes in bioavailability caused by change in route of drug administration, change from tablet to liquid formulation or possible interaction with the enteral feed, it is important to monitor patients for both adverse effects of medication and therapeutic failure.
(*) Some authorities consider boiled water cooled to body temperature an adequate substitute for sterile water in these circumstances. Manufacturers of the giving sets advise against use of tap water (Fresenius Kabi 2000). A few medicines, for example, ciprofloxacin suspension, interact with the ions in tap water and must be administered with sterile water (Thomson et al 2000). (BAPEN 2003, Chadwick and Forbes 1996, Fresenius Kabi 2000, Nutricia 1996, Nutricia clinical care team (2002), Pine 1999, Whitney et al 2001)
1. BAPEN (2003), British Association for Parenteral and Enteral Nutrition Administering Drugs via Enteral Feeding Tubes: A Practical Guide. London, BAPEN.
2. Chadwick C, Forbes A (1996) Pharmaceutical problems for the nutrition team pharmacist. The Hospital Pharmacist. 3, 6, 139-143.
3. Fresenius Kabi (2000) Gastrostomy Aftercare Booklet for Patients and Carers. Runcorn, Fresenius Kabi.
4. Glustein J (1984) To crush or not to crush: administering solid medication to the elderly patient. Perspectives. Winter, 12-14.
5. Mitchell J, Pawlicki K (1992) Oral dosage forms that should not be crushed. Hospital Pharmacy. 27, 690-699.
6. Howell 2000
7. Jordan S et al (2003) Administration of medicines part 2: pharmacology. Nursing Standard. 18, 3, 45-54.
8. The Medicines Act 1968 (Commencement No. 8) Order 1989, ISBN 0110961927. Medicines Act 1968. London HMSO
9. Naysmith M, Nicholson J (1998) Naso-gastric drug administration. Professional Nurse. 13, 7, 424-451
10. Nutricia (1996) The Flocare Gastrostomy range. Trowbridge, Nutricia Clinical Care.
11. Nutricia clinical care team (2002) Unpublished Personal communication. cited in Jordan S et al (2003)
12. Pine M (1999) Home enteral nutrition. In Van Way C (Ed) Nutrition Secrets. Philadelphia, Hanley & Belfus
13. Stockley I (1999) Drug Interactions. Fifth edition. Oxford, Blackwell Science.
14. Thomson F et al (2000) Managing drug therapy in patients receiving enteral and parenteral nutrition. Hospital Pharmacist. 7, 6, 155-
15. Thomson F et al (2000) Managing drug therapy in patients receiving enteral and parenteral nutrition. Hospital Pharmacist. 7, 6, 155-164
16. Wright D (2002a) Medication administration in nursing homes. Nursing Standard. 16, 42, 33-38.
17. Wright D (2002) Swallowing difficulties protocol: medication administration. Nursing Standard. 17, 14-15, 43-45.