2.

9 HOURS

Continuing Education

By Joseph I. Boullata, PharmD, RPh, BCNSP

Drug Administration
Through an Enteral Feeding Tube
The rationale behind the guidelines.

OVERVIEW: Guidelines for the safe administration of drugs
through an enteral feeding tube are available, but research
shows that often nurses don’t adhere to them. This can lead
to medication error and tube obstruction, reduced drug effec-
tiveness, and an increased risk of toxicity. This article de-
scribes the factors to consider before administering a drug
through a feeding tube, examines the gap between recom-
mended and common practice, and discusses what the most
recent guidelines recommend and why.
I
t’s common knowledge among nurses that
before adding drugs to a patient’s IV bag or
syringe, the nurse must first check the drugs’
stability and compatibility. Yet a surprising num-
ber of nurses fail to follow similar precautions when
preparing drugs for administration through an enteral
feeding tube. This can lead to tube obstruction, reduced
drug effectiveness, and an increased risk of toxicity. In
fact, medication errors overall remain quite common,1
despite a decade-long movement to reduce them,
prompted largely by the Institute of Medicine’s 2000
report To Err Is Human: Building A Safer Health
System.2
Practice recommendations for administering med-
ication through an enteral feeding tube have been
available for many years.3-7 Most recently, the American
Society for Parenteral and Enteral Nutrition (ASPEN)
developed evidence-based guidelines for safe medica-
tion administration (I served on the task force); these
are outlined in Table 1.8 Despite all of these resources,
surveys of nurses working in various settings reveal that
the use of inappropriate technique is widespread.9-15
According to survey responses, one reason for the
use of inappropriate technique could be that many
nurses rely chiefly on their own experience and that
of coworkers for information, rather than on institu-
tional protocols or pharmacists.9, 14 Limited science
content in the curricula of some nursing schools may
also play a role.

THE LINK BETWEEN DRUG ADMINISTRATION AND EFFECTS

In pharmaceutics—the science of drug preparation
and administration—the physical and chemical prop-
erties of drug molecules are considered in the design
of appropriate dosage forms. A drug’s release from an

34 AJN ▼ October 2009 ▼ Vol. 109, No. 10 ajnonline.com

oral form and its subsequent absorption are controlled
by these properties and by the conditions within
the patient’s gastrointestinal (GI) tract. (Editor’s note:
The terms formulation, form, and formula aren’t
synonymous. Drug formulation refers to the devel-
opment and engineering of drug products. Dosage
form refers to the type of completed preparation;
forms mentioned in this article include solid imme-
diate- and sustained-release tablets and capsules, as
well as liquid solutions, suspensions, and emulsions.
Formula refers to enteral nutrition formula. Also,
because drug formulations can vary greatly among
manufacturers, even when the dosage form is the
same, brand names aren’t given unless a specific
product is meant or was named by researchers.)
Drug absorption through the GI tract depends
largely on two factors: the degree to which a drug
is soluble and the degree to which it can permeate
the intestinal mucosa. A drug’s solubility depends
on its ability to dissolve—to change “from a solid to
a dispersed form by immersion” in a solvent, accord-
ing to Stedman’s Online Medical Dictionary. Limited
dissolution is one of the most common reasons for
ineffective drug absorption.16 Dissolution depends
on many factors, including the surface area of the
drug particles and their diffusivity and solubility in
a solvent.16 Moreover, a drug’s solubility in water
doesn’t necessarily indicate its solubility in GI con-
tents, which is affected by, among other things, the
pH of those contents and the drug’s solubility in
fat.16, 17
Many drugs are formulated for oral administra-
tion. Administering an oral drug by any route other
than the mouth might alter its bioavailability (the
availability of active drug at the intended site) and
thus its therapeutic effect, perhaps even causing
toxicity. The U.S. Food and Drug Administration
approves a drug specifically for both its formula-
tion and its intended route of administration. Giving
an oral drug through a feeding tube goes beyond
those limits, and it’s unclear what the manufac-
turer’s liability would be if adverse effects occurred.
Further complicating matters is the fact that the
design of oral dosage forms and drug delivery sys-
tems is becoming increasingly sophisticated.18-21 For
example, although still in development, so-called
emulsions within emulsions may allow “incompatible
substances” to be delivered together.21
Before administering a drug through a feeding
tube, a clinician must consider the possible effect of
the feeding formula on drug absorption, according
to the ASPEN guidelines,8 as well as the length of the
patient’s functional bowel, the internal diameter and
length of the tube, the composition of the tube, the
routine flushing regimen, the location of the distal
end of the feeding tube relative to the site of drug
absorption, the size of the distal opening(s), the need
to keep a drug separate from a tube feeding formula,
ajn@wolterskluwer.com
Guidelines for Administering Medication
TABLE 1.
Through an Enteral Feeding Tube
• Do not add medication directly to an enteral feeding
formula.
• Administer each medication separately through an
appropriate access site.
• Liquid dosage forms should be used when available
and if appropriate.
• Only immediate-release solid dosage forms may be

Grind simple compressed tablets to a fine powder
substituted.

Open hard gelatin capsules and mix the powder with
and mix with sterile water.
sterile water.
• Avoid mixing together medications intended for admin-
istration through an enteral feeding tube, given the
risks of physical and chemical incompatibilities, tube
obstruction, and altered drug responses.
• Before administering medication, stop feeding and
flush the tube with at least 15 mL of sterile water.
• Dilute the solid or liquid medication as appropriate and
administer using a clean oral syringe that’s 30 mL or
larger.
• Flush the tube again with at least 15 mL of sterile
water, taking into account the patient’s volume status.
• Repeat the previous three steps before administering
the next medication.
• After all medications have been administered, flush
the tube one final time with at least 15 mL of sterile
water.
• Restart feeding in a timely manner to avoid compro-
mising the patient’s nutritional status. Feeding may be
delayed for 30 minutes or longer, when appropriate, to
avoid altering the bioavailability of the drug.
• Consult with a pharmacist as needed.
Adapted from Bankhead R, et al., and the American Society for Parenteral and Enteral
Nutrition (ASPEN) board of directors. Enteral nutrition practice recommendations. JPEN J
Parenter Enteral Nutr 2009;33:1-46. Reprinted with permission from ASPEN. ASPEN does
not endorse the use of this material in any form other than its entirety.
and the size of the oral syringe for both accurate drug
dosing and safe intraluminal pressures.
All of these factors must be taken into account to
minimize the likelihood of complications. As the
ASPEN guidelines note, tube obstruction “is both
time- and resource-intensive to address, and there-
fore is best prevented.”8 Unexpected responses to drug
therapy can prove injurious or even fatal to patients
and increase the burden of care on clinicians and
AJN ▼ October 2009 ▼ Vol. 109, No. 10 35
 caregivers. Moreover, complications that result from
inappropriate drug administration through an enteral
feeding tube aren’t typically captured in adverse drug
event rates.8 It’s possible that such complications are
both underrecognized and underreported. A review
of medication error research concluded that obser-
vation was the most accurate method for detecting
such errors.22
WHAT SURVEYS OF PRACTICE TELL US
Several surveys have shown that some common
practices in enteral drug administration can inter-
fere with drug delivery.9-14 Overall, there is a lack
of consistency in practice among and even within
facilities. A 1988 survey of pediatric nurses at hospi-
tals in eight states revealed that enteral drug admin-
istration techniques varied significantly—yet 97%
of the respondents were confident that their tech-
niques were appropriate and effective.11 The authors
attributed the variability to a lack of standardized
protocols. In a more recent nationwide survey of crit-
ical care nurses, Belknap and colleagues found that
a majority of respondents used one to three inap-
propriate techniques for administering medication
through an enteral feeding tube.9 Indeed, within my
hospital, a survey conducted before implementation
of a drug administration protocol revealed that our
practices for drug administration through feeding
tubes weren’t uniform.10
Several common inappropriate techniques have
been identified. Belknap and colleagues found that
when multiple drugs were to be given at the same
time, 68% of respondents administered them together
instead of separately.9 And dosage forms were altered:
25% and 15% of respondents reported routinely
crushing enteric-coated and sustained-release tablets,
respectively, before administering them through a
feeding tube. Also, 57% didn’t routinely flush the
tube before administering a drug, and 19% didn’t
consult the pharmacist about the availability of liq-
uid dosage forms. When a liquid dosage form was
given through a tube, only 60% diluted it first. In
another survey of acute care nurses at 11 Rhode
Island hospitals, 53% indicated that even when a
liquid dosage form was available, they didn’t order
it.13 And a survey of nurses at a midwestern medical
center found that just 38% flushed the tube between
drugs when more than one was given.12
These practices aren’t unique to acute care. A
nationwide survey by Seifert and Johnston of long-
term care nurses found that 49% of respondents said
that when multiple drugs were to be given at the same
time, they mixed the drugs together; 15% and 13%
reported routinely crushing enteric-coated and sus-
tained-release tablets, respectively.14 Although 92%
routinely consulted the pharmacist about liquid
dosage forms, when such forms were available
the nurses used them only 61% of the time. When
36 AJN ▼ October 2009 ▼ Vol. 109, No. 10
the nurses did use these forms, 36% didn’t routinely
dilute them first. Respondents who reported using
one inappropriate technique usually used others.
When critical care nurses were asked about their
sources of information on this topic, they cited clin-
ical experience (57%), coworkers (22%), and nurs-
ing school (13%).9 About a third of the nurses were
aware of printed guidelines at their institutions, but
only 5% ranked this as their primary source. Similarly,
long-term care nurses said their top-three main sources
of information were clinical experience (55%), nurs-
ing school (19%), and coworkers (17%).14 From
67% (rural nurses) to 75% (urban nurses) were aware
of printed guidelines, but just 17% cited these as a
main information source. Pharmacists were viewed
as key sources by only 6% and 12% of the critical
care and long-term care nurses, respectively.
Fortunately, awareness of how these issues affect
patient safety is growing, fostering greater collabo-
ration across disciplines.23, 24
WHAT THE ASPEN GUIDELINES RECOMMEND AND WHY
The following are the major recommendations in the
current guidelines, with rationales and examples.
Do not add medication directly to an enteral
feeding formula. When a patient receives both med-
ication and nutrition through a feeding tube, it can
be harmful to mix them before delivery, despite the
convenience of doing so. Mixing disrupts the steril-
ity of prepackaged enteral formula, as well as that
of the delivery system used in feeding. Mixing also
creates the potential for drug–formula interactions
leading to tube obstruction, altered drug or nutrient
bioavailability, altered GI function, or a combination
of these. Avoiding such interactions requires know-
ing whether the drug and the formula are compat-
ible and likely to remain stable after mixing.
With patients on parenteral nutrition, drugs are
not added to the formula unless compatibility and
stability data support doing so; the situation for
patients on enteral nutrition is analogous.8 (A sub-
stance is stable when it’s resistant to chemical or phys-
ical changes; two or more substances are compatible
when they can be combined without undergoing
chemical or physical changes that alter bioavailabil-
ity.) Any such information cannot be extrapolated
to different formulations of the same drug, to other
drugs in the same class, or to other feeding formu-
las. For example, in one study, the addition of liquid
morphine at a low concentration (2 mg/mL) to enteral
formula resulted in decreased pH and noticeable pre-
cipitate; the addition of the same drug at a higher
concentration (20 mg/mL) did not.25 An evaluation
of compatibility and stability must go beyond visual
examination and identify any physical or chemical
changes that occur upon mixing.
There is limited information on the compatibil-
ity and stability of a few common drug products
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 Esophagus
Liver

Stomach

Gallbladder

Duodenum
Colon
Pancreas

Jejunum

Ileum

Cecum

Appendix

FIGURE 1. An enteral feeding tube can terminate

and commercially available enteral formulas.25-30
Compatibility can be affected by formula-related
factors, including type and concentration of protein
and its fiber and mineral content, as well as by the
drug product’s pH, alcohol and mineral content, vis-
cosity, and osmolality (a property that encompasses
the concentration of and pressure exerted by parti-
cles in solution).26, 28 Two studies found that the con-
centrations of some drugs in various formulas fell
in the stomach, duodenum, or jejunum. When
administering oral medication through an enteral
feeding tube, it’s important to consider whether
the drug requires gastric acid, bile, pancreatic
secretions, or a combination of these, for ade-
quate dissolution, as well as where in the GI tract
most of the drug is absorbed.

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 significantly during the 12-hour and 24-hour study
periods.29, 30 Another study found that of 24 incom-
patible drug–formula mixtures, 23 (96%) resulted
in tube obstruction; of those, fewer than a third
could be cleared by flushing with water.26 Even when
compatibility and stability data support adding a
drug product to a formula, the clinician must evalu-
ate the therapeutic benefit. For example, will an
adequate amount of the drug be available at the
intended site?
Administer each medication separately through
an appropriate access site. This requires considera-
tion of the access site, the drug formulation, and its
preparation for administration.
Is the access site appropriate? Before administra-
tion, ask whether the drug requires gastric acid, bile,
pancreatic secretions, or a combination of these for
adequate dissolution, as well as where in the GI tract
most of the drug is absorbed. Many drugs must be
administered into the stomach or duodenum to
ensure proper dissolution and absorption, although
as the guidelines point out, “there are distinct and
occasionally unknown sites of absorption of spe-
cific drugs.”8 Administering a drug below the duode-
num risks bypassing the sites where these processes
best occur, and that, in turn, will affect both drug
bioavailability and effectiveness. For example, war-
farin appears to be absorbed high in the proximal
small bowel,31, 32 and iron given orally dissolves in the
stomach and is predominantly absorbed in the duo-
denum7; administration of either through a jejunos-
tomy tube risks poor bioavailability.
Drug classification systems may
help clinicians predict whether
administration via an enteral
feeding tube is appropriate.
Is the drug formulation appropriate? Drugs in-
tended for oral administration are designed for a
healthy GI tract. To deliver an oral drug through
a feeding tube is to destroy its carefully designed deliv-
ery mechanism—and quite possibly to alter how it
will perform in the GI tract.
Drug classification systems have been developed
to help clinicians predict a drug’s performance in
the body, based on measures such as solubility and
permeability.33, 34 It’s possible that such a system may
also help clinicians predict whether administration via
an enteral feeding tube is appropriate. The formula-
tion of drugs with high solubility and high permeabi-
lity (such as metronidazole) is usually uncomplicated;
38 AJN ▼ October 2009 ▼ Vol. 109, No. 10
these drugs are probably of least concern for admin-
istration through a feeding tube. But the formula-
tion of drugs with low solubility or low permeability
or both (such as the protease inhibitors) can be quite
complex; such drugs should probably not be altered
for administration through a feeding tube. Indeed,
according to Takagi and colleagues, of the 200 top-
selling immediate-release oral dosage forms, about
40% are considered “practically insoluble” in water.35
Yet these forms can deliver the intended dose of
active drug to the intended site, an indication of just
how sophisticated drug formulation has become.
Formulation issues can be drug product—or dos-
age form—specific. The presence of excipients—
nontherapeutic ingredients such as fillers, binders,
buffers, and preservatives—must also be consid-
ered. For example, quinapril (Accupril) tablets con-
tain magnesium carbonate. If a tablet were to be
crushed and dissolved in water, the carbonate would
raise the pH of the solution, causing the active drug to
degrade rapidly to a poorly absorbed metabolite.36
Different formulations of a drug may demonstrate
significant differences in stability or bioavailability.
For example, in one animal study, the equivalent
of 10 mg/kg of itraconazole was given as either a
solid-dispersion coating or as a semisolid emulsion.37
The latter formulation provided about twice the
bioavailability.
Enteric-coated and sustained-release dosage forms
should not be crushed for administration through
feeding tubes.3 Tablets with enteric coatings don’t
crush readily, and the resulting powder tends to
clump in water, increasing the likelihood of tube
obstruction. Crushing sustained-release dosage forms
destroys the protective coating, resulting in erratic
blood levels and potential toxicity. The results can
be disastrous, as in a case described by Schier and
colleagues38 of a 38-year-old woman hospitalized
with pneumonia. Upon stabilization, her medica-
tions were changed to oral forms of hydralazine,
labetalol, and extended-release nifedipine, which
were crushed and given through a nasogastric tube.
She developed bradycardia with hypotension, had an
asystolic cardiac arrest, and was resuscitated. The
next day the same drugs were given the same way,
and she died. The crushed nifedipine was deemed a
contributing factor.
Liquid-filled gelatin capsules can also cause prob-
lems; once the capsule is breached it’s difficult to
ensure that the full dose has been extracted. Although
the guidelines recommend giving liquid dosage forms
(rather than solid ones) when possible, many com-
mercially available liquid dosage forms aren’t appro-
priate for administration via a feeding tube.39 Some
common excipients can increase osmolality and cause
diarrhea. And injectable dosage forms aren’t designed
for administration into the GI tract at all. (For more
on this, see the discussion of dilution below.)
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 Determine the best way to prepare a drug for
administration through a feeding tube. Most solid
immediate-release tablets should be crushed to a very
fine powder before being dissolved in sterile water.
(An immediate-release gelatin capsule containing
solid drug should first be opened and its contents
then treated the same way.) Crushing results in a small
particle size, which usually improves dissolution and
decreases the likelihood of tube obstruction; how-
ever, the resultant increase in particle surface area
can “accelerate changes in molecular structure” and
make interaction with other substances more likely.8
How well a given drug mixes
into solution must be taken into
account, or incomplete dosing
might result.
Any solid dosage form contains both active drug
and excipients, and these may behave differently
upon mixing in a solvent. (The physical and chemi-
cal properties of the solvent—usually but not always
water—also play a role; dilution is discussed in the
next section.) For example, consider how table sugar
and sand mix with warm water: the table sugar dis-
solves, but the sand does not, falling to the bot-
tom. Most drugs will behave somewhere along the
sugar–sand continuum. How well a given drug mixes
into solution must be taken into account, or incom-
plete dosing might result. For example, sedimentation
may be evident. To ensure that the patient receives the
intended dosage, the mortar and pestle, medicine
cup, or oral syringe (or any combination of these)
used in preparing the dose should be rinsed and the
rinse solution administered. Because a mortar and
pestle require thorough cleaning between uses to
avoid cross-contamination, the use of a medicine cup
for crushing is preferable. (If the drug being admin-
istered might be allergenic, cytotoxic, carcinogenic,
or teratogenic, it shouldn’t be crushed in a patient
care area at all, but rather by the pharmacist under
highly controlled conditions, and only when nec-
essary.)
Some immediate-release tablets, including those
designed to disintegrate in the mouth, might dis-
solve readily in water without prior crushing. But
some orally disintegrating tablets (such as lanso-
prazole [Prevacid SoluTabs]) must not be crushed,
because they contain enteric-coated microgranules.
And some capsules (such as doxycycline [Oracea])
contain both immediate- and delayed-release granules.
ajn@wolterskluwer.com
Dilute the solid or liquid medication as appropri-
ate and administer using a clean oral syringe. After
a solid dosage form is pulverized, the powder must
be diluted before administration through an enteral
feeding tube. Liquid dosage forms usually require
dilution as well.
Sterile water or saline are the preferred diluents
for most drug products.8 Ideally, the same mixture
of solvents used by the manufacturer is used to avoid
drug degradation, but in practice that is rarely pos-
sible. Sterile water meets United States Pharma-
copeia standards. Tap water should not be used; it
can and often does contain contaminants, including
pathogenic microorganisms, pesticides, pharmaceu-
ticals, and heavy metals8, 40 that might interact with
a drug and reduce its bioavailability. Only syringes
manufactured and intended for oral or enteral use
should be used to measure and administer a medica-
tion through a feeding tube.41 (To prevent inappro-
priate administration, the syringe tip should be too
large to fit Luer ports or other nonenteral access
devices.)
Many oral liquid drug products are formulated
for children; when giving an adult such a product,
a larger volume may be necessary even before dilu-
tion to achieve correct dosing. Liquid dosage forms
usually contain excipients (such as thickeners, sta-
bilizers, suspension agents, and sweeteners) that
increase the liquid’s viscosity and osmolality. The
volume of diluent required (and thus the amount of
diluent to be used) will be determined by the viscos-
ity and osmolality of the liquid dosage form, the
length of the feeding tube, its internal diameter, and
the location of the distal tip. The higher a drug prod-
uct’s viscosity or osmolality, the more diluted it should
be before administration through a tube. For a patient
on restricted fluid intake (such as one with heart
failure or kidney disease), the smallest possible amount
of diluent should be used.
Suspensions tend to have much higher viscosity
than solutions. Some suspensions may contain gran-
ules, including sustained-release granules. Highly
viscous or granular suspensions tend to resist flow-
ing through a tube; dilution helps to overcome this
but may not be sufficient, especially if the tube is
narrow. It’s difficult to know what volume of dilu-
ent is needed in such cases. But studies have shown
that dilution of a liquid drug product before admin-
istration is associated with improved delivery of the
drug dose to the distal end of the tube.42, 43
The higher the osmolality of a drug product, espe-
cially when administered directly into the small intes-
tine, the more likely are GI intolerance and diarrhea.6
Some liquid drug products have high osmolality (above
600 mOsm/kg can be considered high); for example,
that of one commonly used acetaminophen elixir
exceeds 5,000 mOsm/kg and that of diphenoxylate
liquid exceeds 8,000 mOsm/kg.6 A single dose of such
AJN ▼ October 2009 ▼ Vol. 109, No. 10 39
 products will require significant dilution (150 to
250 mL of diluent) before administration. Products
containing electrolytes, such as liquid potassium chlo-
ride, also tend to have high osmolality. (One hand-
book reports that, depending on the brand, the pH
of potassium chloride varies from 2.4 to 6.2; pH is
another factor that must be taken into account be-
cause the formula’s pH can affect a drug’s stability.44)
Avoid mixing medications intended for administra-
tion through an enteral feeding tube. Most clinicians
know they shouldn’t mix different drugs in the same
IV bag or syringe without first ensuring the drugs’ sta-
bility and compatibility; the same rule applies here
for both solid and liquid dosage forms. It’s hard
enough to predict stability for any one drug prod-
uct altered for administration through a feeding tube;
when more than one drug is administered at the same
time, predicting stability and compatibility becomes
even more difficult. Thus, when more than one drug
is scheduled for administration, they must be given
separately.
Nurses don’t have to navigate
the ASPEN guidelines alone.
The potential for drug–drug interactions (as well
as for those involving excipients) increases when
two or more dosage forms are crushed together.
Crushing involves applying significant force to a
drug product, and it increases the amount of par-
ticulate surface area available for interaction. Either
can accelerate changes to molecular structure and
result in altered physical and chemical properties;
such risks increase exponentially when more than
one drug, with its excipients, is crushed.
When a drug product is altered, its stability can
be compromised. Indeed, one study found that when
two nonsteroidal antiinflammatory drugs with simi-
lar molecular structures were similarly prepared as
solid dispersions, they exhibited very different solu-
bility.45 Mixing two or more dosage forms creates a
new entity; it’s unknown how each drug would be
released.
The same kinds of concerns pertain to mixing
two or more liquid dosage forms. Their stability after
mixing and their compatibility with each other and
with any solvents used would have to be considered,
as would their likely miscibility (the ability to mix
in any ratio and remain mixed). Because such data
aren’t readily available, every new mixture must be
studied before predictions can be made. Mixing one
liquid drug product with another may also alter vis-
cosity and affect how the mixture flows through a
tube. It’s also often unknown how a particular mix-
ture of liquid dosage forms might behave in the body.
40 AJN ▼ October 2009 ▼ Vol. 109, No. 10
Stop the feeding and flush the tube with at least
15 mL sterile water before and after administering
each medication. Flushing the tube has been shown
to decrease the incidence of tube obstruction.46 As
with dilution, only sterile water or saline should be
used.
It’s impossible to know what quantities of enteral
formula, active drug, excipients, and other products
are left in the residue inside the feeding tube. For
example, when researchers crushed losartan tablets
(Cozaar) and diluted the resulting powder in water,
they knew that some drug would precipitate; they
also found “unknown degradation products,” which
decayed more rapidly when exposed to light and
oxygen.47
Flush the tube one final time with at least 15 mL
sterile water to ensure delivery of the total dose and
reduce residue within the lumen.
Restart the feeding in a timely manner to avoid
compromising nutritional status. For most medica-
tions, stopping enteral feeding and flushing the tube
before and after drug administration is sufficient to
separate feeding from drug administration; feeding
can resume after the final flush. But for a few drugs—
including the fluoroquinolones, penicillin, carba-
mazepine, phenytoin, voriconazole, and warfarin—
a longer nutrient-free interval may be necessary.
There are reports of significantly reduced drug effi-
cacy when such drugs are given too close in time to
an enteral feeding.6 The ASPEN guidelines recom-
mend a separation time of at least 30 minutes,8 but
some drugs may require longer periods. Delaying a
feeding is less disruptive for patients on an inter-
mittent feeding regimen than for those on a contin-
uous regimen. Even when the evidence on a drug
isn’t conclusive—as in one systematic review of more
than 30 years of research into the possible interaction
between phenytoin and enteral formula48—it’s recom-
mended that the patient care plan consider the sched-
uling of drug administration and feeding and that
patients be closely monitored.
COLLABORATION BETWEEN NURSES AND PHARMACISTS
Nurses don’t have to navigate these guidelines alone.
Pharmacists are responsible for giving others on the
care team pharmacologic information, including
the physical and chemical properties of specific
drugs and their various formulations and dosage
forms, as well as an interpretation of the published
stability and compatibility data. In one Dutch study,
a multidisciplinary program reduced the number of
tube obstructions and medication errors by promot-
ing practice guidelines, holding training sessions
for nurses, establishing a database of oral dosage
forms, and having pharmacists offer patient-specific
recommendations.49
The pharmacist can also address whether it’s
appropriate to administer a particular drug through a
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feeding tube, its likely bioavailability when given by
that route, and what the potential complications
might be, including drug–nutrient interactions. The
pharmacist will be able to recommend ways to sim-
plify a patient’s drug regimen. These might include
temporarily discontinuing any drugs that aren’t imme-
diately essential; adjusting the dosing schedule to min-
imize the number of drugs given at the same time;
using liquid or immediate-release dosage forms when
available; and, if a drug isn’t well suited to adminis-
tration through a feeding tube, using another route of
administration or switching to a similar product that
can be given via a tube. Institutional protocol may
even allow the pharmacist to prepare the prescribed
drug for administration through a feeding tube before
dispensing it, when appropriate. Specific preparations
intended for tube administration that have been stud-
ied may be found in pharmacy reference manuals and
in the literature.44, 50 Study data should indicate that a
particular preparation will be stable over time and
that the full intended dosage will be delivered to the
distal end of the tube. ▼
For 24 additional continuing nursing education
articles related to the topic of drug therapy, go
to www.nursingcenter.com/ce.
Joseph I. Boullata is an associate professor of pharmacology
and therapeutics in the School of Nursing at the University of
Pennsylvania and a pharmacy specialist in nutrition support
at the Hospital of the University of Pennsylvania, both in
Philadelphia. Contact author: boullata@nursing.upenn.edu.
The author of this article has no significant ties, financial or
otherwise, to any company that might have an interest in the
publication of this educational activity.
REFERENCES
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42 AJN ▼ October 2009 ▼ Vol. 109, No. 10
2.9 HOURS
Continuing Education
EARN CE CREDIT ONLINE
Go to www.nursingcenter.com/ce/ajn and receive a certificate within minutes.
GENERAL PURPOSE: To provide registered profession-
al nurses with information on the factors to consider
before administering a drug through an enteral feed-
ing tube, the gap between recommended and com-
mon practice, and the most recent guidelines.
LEARNING OBJECTIVES: After reading this article and
taking the test on the next page, you will be able to
• summarize the studies presented here on the issues
surrounding drug administration through an enteral
feeding tube.
• list the factors that influence the effectiveness and
safety of drug administration through an enteral
feeding tube.
• outline how to best administer drugs through an
enteral feeding tube.
TEST INSTRUCTIONS
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To use the form provided in this issue,
• record your answers in the test answer section of the
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question has only one correct answer. You may make
copies of the form.
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evaluation. Mail the completed enrollment form and
registration fee of $24.95 to Lippincott Williams and
Wilkins CE Group, 2710 Yorktowne Blvd., Brick, NJ
08723, by October 31, 2011. You will receive your
certificate in four to six weeks. For faster service, include
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two business days of receiving your enrollment form.
You will receive your CE certificate of earned contact
hours and an answer key to review your results. There
is no minimum passing grade.
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This activity is also provider approved by the California
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TEST CODE: AJN1009A
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