Medication administer through the colostomy?

Nurses General Nursing

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Can medication be administered via the colostomy? Pt had rectal Ca. & is not swallowing. Thanks for you information in advance.

Specializes in Home Care, Hospice, OB.

as for a hospital medical director knowing which meds could be absorbed through a colostomy

the word was hospice, not hospital!:uhoh3:

and almost all palliative meds can be given at any end or opening in the alimentary canal, sir.

patricia brown, rn, bsn, chpn, ccm,cohc, dhcs

the word was hospice, not hospital!:uhoh3:

and almost all palliative meds can be given at any end or opening in the alimentary canal, sir.

patricia brown, rn, bsn, chpn, ccm,cohc, dhcs

fixed it for you.

as for your second statement i would ask for a source. take a common drug that is used in hospice - oxycontin. to crush it and put it into jel-caps would be very dangerous as outlined in the pi:

"oxycontin tablets are to be swallowed whole and are not to be

broken, chewed, or crushed. taking broken, chewed, or crushed oxycontin tablets leads to rapid release and absorption of a potentially fatal dose of oxycodone."

to put it into the rectum would be similarly unwise. from the pi:

"oxycontin® is not indicated for rectal administration. data from a study involving 21 normal volunteers show that oxycontin tablets administered per rectum resulted in an auc 39% greater and a cmax 9% higher than tablets administered by mouth.

therefore, there is an increased risk of adverse events with rectal administration."

this would apply to almost any time released medicine. on the other hand medicines such as percocet have the same onset whether administered rectally or orally. other pain medications with nsaids such as percodan or vicoprofen may cause rectal ulcers because of the nsaid component with prolonged use. this just looks at pain meds.

when you look at other medications commonly used in palliative care you find that no studies have been done or that the medications need significant dose adjustment. for example the parenteral form of dilantin is not absorbed rectally and the base dose of the rectal formulation is 2-3 times the parenteral dose. neurontin, commonly used for pain is not absorbed rectally. i'm not exactly an expert on this but these are a few examples.

having hung around nurses for some time, i seem to recall something called the five r's. one of these r's is route. to make a blanket statement that almost all palliative care meds can be given through either end of the alimentary canal seems overbroad.

the other issue that you did not really address is the utility of giving medications through an ostomy. in the case of most colon cancer patients these are diverting ostomies with the cut made proximal to the tumor. there is no rectal vault or anal sphincter, which are both necessary for the absorption of rectal meds. in addition to the colonic mucosa being different, there is no mechanism to hold the medication in. most of the medication will end up back in the ostomy bag within a short time frame. in the event that it is a loop ostomy you may get less or more uptake from the depending on construction.

so look at the possible consequences of what my original answer was. you take meds, crush them, and put them into gel-caps then put these into the ostomy. so first you have to make sure you can crush them. thats relatively easy. most nurses stations have a crush/don't crush chart. as far as putting them into gel caps, i'm not sure why you would do this except for ease of handling, you get the same effect (or better) just putting the powder directly into the ostomy. so you have three possibilities.

1. good absorption - same as the pill

2. poor to no absorption - the patient does not get an adequate dose of the medication.

3. extra absorption - the patient gets more of the medication than intended.

basically one of the three scenarios is going to be what you want. without looking at each of the drugs in detail its going to be hard to tell what's going to happen. even then given the poor understanding of ostomy absorption i would still have my doubts.

without knowing the particulars of the medications i'm not even going to say the poster above is right or wrong. there simply isn't enough information. however, given what i know about ostomies and colonic throughput, i doubt the medications had much effect.

a final thought. taking a med, crushing it up and putting it into gel-caps has a name. its called compounding. i can't speak for all states but here it has to be done by a licensed pharmacist with a valid prescription for the particular patient.

david carpenter, pa-c

Specializes in Home Care, Hospice, OB.
fixed it for you.

as for your second statement i would ask for a source. take a common drug that is used in hospice - oxycontin. to crush it and put it into jel-caps would be very dangerous --that's why oxyir in a bioequivalent dose is used, if duragesic or another route isn't possible or tolerated.

this would apply to almost any time released medicine. --yes, it would

your requested source "symptom control in hospice and palliative care", peter kaye, p. 185

btw---it is not compounding to carry out a legal md order. i'm very impressed with your academic prowess, but please stay away from me and mine if we are terminal and uncomfortable--which, you will note, is the only instance i speak to. a good palliative care team treats the dying patient, not the pdr.:angryfire maybe you missed class when they were discussing compassion in end of life care.

an experienced hospice/palliative care doctor is worth their wt in gold.

we are often forced to get very creative w/med administration, which entails very close monitoring and dosage readjustments.

any med administered rectally, or that requires mucosa as its method of absorption, it's going to be variable- always.

until you have worked besides one of these experts, you will never appreciate the new and improved indications for many different meds, mostly opioids, benzos, antiemetics.

and i'm very familiar with contraindications, adverse events.

i also learned not to crush er, la meds in pharm 101, thank you.

give us some credit?

leslie

Specializes in Spinal Cord injuries, Emergency+EMS.

it appears that mr carpenter through alakco fknowledge doesn't seem to think Registered Nurses as in depdent ,accountable Healthcare Professionals have any madicines management knowledge ...

i'm also a littleconcerned aobut some of the statements he makes regarding the anatomy of ostomates .... someone with a terminal ileostomy or a colostomy has pretty much all of their small bowel , it's just how much large bowel is removed or defunctioned

btw---it is not compounding to carry out a legal md order. i'm very impressed with your academic prowess, but please stay away from me and mine if we are terminal and uncomfortable--which, you will note, is the only instance i speak to. a good palliative care team treats the dying patient, not the pdr.:angryfire maybe you missed class when they were discussing compassion in end of life care.

first, i will admit i was incorrect on one part. a physician can also compound drugs according to the us code. so if the physician did the compounding then according to this they are probably ok:

http://www4.law.cornell.edu/uscode/21/usc_sec_21_00000353---a000-.html

it also varies by state. colorado did not allow it. georgia probably does.

anyone else that does this that is not a pharmacist is probably falling outside us law (in my non-lawyer opinion). for example if you crush the medication it is usually because either the pi or some other reference states that it can be crushed and given po. however, if you think that there is a pi that says crush, put in a gelatin capsule and give through an ostomy then you are mistaken. you have not only changed the form here but also the route. the fda probably has bigger fish to fry but i wouldn't risk my license on that. and no just because an md said its ok doesn't make it a legal order.

as far as compassion and end of life, yeah i did go to that class and thats why i work closely with the palliative care team. here that includes a physician, an np, a social worker and a pharmacist. our team works with the palliative care team to ensure the optimum course for the patient. frequently its discussion between myself, the np and both pharmacists to find the best combination of medications that will benefit the patient and (frequently) be within the guidelines for hospice. its a lot more than the pdr, but my responsibilities don't end when i call the palliative care team.

david carpenter, pa-c

it appears that mr carpenter through alakco fknowledge doesn't seem to think Registered Nurses as in depdent ,accountable Healthcare Professionals have any madicines management knowledge ...

i'm also a littleconcerned aobut some of the statements he makes regarding the anatomy of ostomates .... someone with a terminal ileostomy or a colostomy has pretty much all of their small bowel , it's just how much large bowel is removed or defunctioned

I think that RNs are plenty accountable. Thats why I am concerned about blanket statements regarding changing the route of the med. Even if an MD did give an order, any bad outcomes are going to come back on the nurse that followed that order.

As far as the anatomy, yes these people have small bowel. No you are not accessing it. Look at this picture:

http://www.nlm.nih.gov/medlineplus/ency/presentations/100011_4.htm

Lets say that you put a percocet into the ostomy opening. The natural flow of the small and large bowel contents is out of the ostomy opening. So anything that you put in comes right back out. In order for there to be small bowel absorption the pill would have to travel retrograde through the remaining length of colon and into the small bowel.

If this was an ileostomy:

http://www.cancer.org/docroot/CRI/content/CRI_2_6x_Ileostomy.asp

(look at Brooke ileostomy digram)

The medication might be absorbed by the ileum (although anectdotally I've had bad luck with pouch ileostomies and absorption). More likely you have to get the medication into the jejunum to get any decent absorption. Once again needing retrograde travel of the medication.

That is my anatomical argument to using an ostomy. Not that small bowel doesn't exist. Its that you can't get the medicine in contact with it.

David Carpenter, PA-C

How to choose the best route for an opioid.

brief blurb on stomal administration.

http://www.findarticles.com/p/articles/mi_qa3689/js_200012/ai_n8906000/pg_5

leslie

How to choose the best route for an opioid.

brief blurb on stomal administration.

www.findarticles.com/p/articles/mi_qa3689/js_200012/ai_n8906000/pg_5

leslie

Interesting article, realistically it confirms what I've been taught. Its been done but no one really knows how well it works. If I'm treating pain, I would rather go with the surest thing.

If the hospice allows it we try to send patients out with PICC lines. Generally if we have an NPO hospice patient (or one with N/V) we look at the same items if the patient is not a hospice patient.

1. Is the medication necessary. In our patient population especially they can end up on medications they don't need any more.

2. Is there another route for the drug. If they have a PICC can they go home with that.

3. Is there another drug that we can use with a different route.

4. Do we need to compound something to get the same effect with a different route.

Usually we work with with pharmacy and palliative care to get the meds worked out.

David Carpenter, PA-C

Specializes in DOU.

EDIT: oops - never mind. :)

Interesting article, realistically it confirms what I've been taught. Its been done but no one really knows how well it works. If I'm treating pain, I would rather go with the surest thing.

David Carpenter, PA-C

we would all prefer to go w/the surest thing.

often, this is just not feasible.

i've been working w/the dying for 12 yrs.

more often than not, their veins are junk.

most reach a point where po is not an option.

we work with what is available- often w/wonderful results.

granted, the hard data is not readily available.

but anecdotally, we know what works.

there is so much to be learned when working alongside of an experienced hospice doctor.

they typically have to work with alternate routes, since pt's systems are systematically shutting down.

they're amazing....just amazing.

leslie

Hi all, I saw this thread and had to register to comment!

As far as an ileostomy goes, you cannot give meds through one, nor should you ever introduce anything into the stoma. First off, an ileostomy is formed from small bowel. So the transit time through the stoma and into the pouch is too fast for meds to absorb. It is unlike the colon in that stool passes through much more quickly, it does not absorb water and it always "working". That means that even if the patient has not been eating, stomach acids and juice will continue to flow from it.

2ndly and more importantly, introducing any object into the stoma poses a tremendous risk for perforation, damage and bleeding. Because there are no pain receptors there the patient would not be able to tell you if she/he were hurt. I spoke with several gastroenterologists who told me this and also said NEVER to put anything into a stoma even if it is ordered by a doc. The only thing going into the stoma of an ileostomy patient is the GI docs finger for examination, or the colonoscope and that's it. I am glad this subject came up. I don't think there is enough education for nurses or even docs for that matter, about ostomies.

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