Special medical need in

residential care home

HAS4943 Lecture 5
 Learning objectives
• Dysphagia
• Feeding tube
• Usage of different dosage forms

2
 Dysphagia
• Dysphagia (swallowing difficulty) is common among elderly patients
• Stroke, head injury
• Esophageal cancer
• Reflux disease (GERD)
• Depending on the severity, the patient may require:
1. Minced diet (爛飯碎餐)
2. Pureed diet (糊餐) + thickener (凝固粉)
3. Tube feeding (管飼)
• Oral tablets and capsules may have to be crushed too

3
4
 Feeding Tube
A feeding tube is a medical device that
delivers nutrients to patients who cannot
eat on their own. This device can be
used in children as well as adults.

5
 Types of Feeding Tubes
PEG tube - percutaneous endoscopic gastrostomy tube,
placed from skin directly through the abdomen and
into the stomach, long term usage, done surgically
⿐胃管
NG tube - nasogastric tube, placed from nose to the D
stomach (gastric area), short term usage, not
surgically placed
Ryle
'
s Tube

ND tube - nasoduodenal tube, placed from nose to

the duodenum (first portion of the intestines), can
be for short term or long term usage, not surgically
placed

NJ tube - nasojejunal tube, placed from nose to the

jejunum (second portion of the small intestines), can
be for short term or long term usage, not surgically
placed

6
Types of Feeding Tubes

7
 Characteristics and diameter
• External diameter expressed using French (Fr) unit
• Each Fr = 0.33mm
• Compositions:
✓ Polyvinylchloride (PVC)
✓ Polyurethane (PUR) – Preferred option
Silicone
Softer and more flexible than PUR → need thicker walls →
smaller diameter
Latex 8
 somedug
塞喉( 奶塊疑固 cy (n not availableforc
Issues
• Use of enteral feeding tubes for drug administration is increasing but size of
tubes are decreasing (for patient comfort and acceptability) → Occlusion
• Crushing medications for enteral administration is considered “off-label”.
Some medications are NOT suitable for crushing.
• Drug Interactions / Drug-Food Interaction

Image credit: Irasutoya いらすとや

 What causes tube occlusion?
▪ Feed precipitation

▪ Feed contamination → easier precipitation

▪ Stagnant (滯) feed in the tube
▪ Incorrect drug administration
▪ Feeding tube properties
10
 Common causes…
• Creon (Pancreatic Lipases)
• Pellets become sticky in fluid
• may stick to fine bore tubes

• Recommendations:
• Use granule formulation (smaller pellets)
• Suitable for >10 French tubes
• Acidic fluids such as ‘honey-like’ fruit juices reduce pellet clumping
11
 Common causes…
• Proton Pump Inhibitors (PPIs) - Crushing inactivates PPIs
• Give granule formulation; or
• Switch to PPIs that are designed as “pellets within tablets” (can dissolve in water before feeding)
• Omeprazole (Losec)
Aailab • Lansoprazole (Takepron) xPantoprarole
• Recommendations:
• Granules to be used in 16 French or larger
• Granules have reduced absorption with food/feeds
• Wait 30 mins post dose before restarting feeds
• Use compatible tablets 12
 “Do not crush” references
• Check reference when you are uncertain
• ISMP “Do not crush” checklist
https://www.ismp.org/recommendations/do-not-crush
• Product insert
• Example from Pradaxa (dabigatran)

13
 SoluTion

Tackling the issues – Occlusion

• Ensure sufficient amount of water is flushed into the feeding tube
• Flushing of tubes should occur:
• Before and after each intermittent feed
• Every 4-6 hours during continuous feeding
• Before and after each drug administration

• To help prevent interactions between the feed and drug administered.

• To prevent occlusion
14

。
 How to flush meds
1. Appropriate drug formulation
2. Flush before & after each drug administration (15-30 ml of water)
3. Flush with warm water ; 中洗容器
4. Rinse tablet crusher/containers, and/or draw up water into the syringe used and flush this down
tube
5. One medication at a time
6. If more than one medicine is to be administered – flush between drugs with at least 10ml of water to
ensure that the drug is cleared from the tube
7. Restart feed unless a specific time interval is needed
8. Document water flushes if applicable
15
 Tackling the issues – Interactions
• Drug-tube interactions

• Drug-nutrient interaction (if no break in feed)

• Drug-drug interactions (if > 1 drug given at a time)

16
 Drug-feed interactions
• Chemical interaction
• drugs and feeds can bind
• e.g. Ca vs ciprofloxacin, doxycycline
• Physiological interaction
• Feeds can affect the absorption mechanism of drugs
• Physical interaction
• Interaction between drug and feed can cause change in feed consistency leading to blockage
of feeding tube

17
 Ciprofloxacin
• Interaction well established: absorption reduced by 50%
with enteral feeds
• Ciprofloxacin binds to divalent ions in feeds (Fe, Ca, Mg)

• Recommendation:
• Adjust feeding times – Intermittent feeding
• Monitor outcome closely, recommended upper end of dosing to
be used
18

Image credit: Irasutoya いらすとや

 Carbamazepine
• Enteral feeding may decrease absorption of carbamazepine liquid preparation
• Carbamazepine liquid may adhere (adsorb) to feeding tube
• Prevented by proper dilution
• May decrease serum drug levels → monitor
• Recommendation:
• Dilute with equal volume of water
• If administering greater that 400mg /day → divide into 4 equal doses
• Liquid contains sorbitol – beware of adverse effects such as diarrhoea 19
 Phenytoin
• Interaction with enteral feeds (Bauer et al 1982)
• Viscous suspension
• May decrease serum drug levels (70% reduction e.g. Ensure (milk))
• Separate enteral feeding from phenytoin administration by at least 2 hr
• Recommendation:
• Flush before & after dose administeration
• Liquid preparation is the preferred formulation
• Adjust dose according to the drug levels, may require higher doses

20
 Drug-nutrient interaction examples
• Levodopa: Absorption decreased by high protein diet
• Levodopa is transported across the lumen by the phenylalanine transporter
• Use Dispersible tablets if available
• Apomorphine infusion when no other alternative

21
 疑⾎指數 Warfarin
0
• Variable vitamin K content in enteral feed can result
in fluctuation of INR until dosing regimen is
stabilised
• Evidence of physiological interaction between enteral
feed and warfarin
• Recommendations:
• Monitor INR closely during and on discontinuation or
alteration of feed
• All tablets can be crushed or dispersed in water
• Administer prescribed dose via tube, rinse dosing
apparatus and give via tube
• When possible give during break in feed
22
Image credit: https://www.vecteezy.com/vector-art/
5391034-foods-high-in-vitamin-k-vector-illustration-with-healthy-foods-rich-in-vitamin-k-organic-food-collection
 for
Crushing 磨碎
Choosing medication formulations
YES NO

Solutions (most appropriate) Enteric coated products

Dispersible tablets Modified release preparations
(MR, SR ,XR ,LA, CR, etc)
Effervescent tablets Teratogenic or Cytotoxic drugs

Suspensions – granular and Hormone products, prostaglandin

non-granular products, steroids, antibiotics

Immediate release tablets Buccal & sublingual preparations

23
 Dilemma – K supplement
• Potassium (K) supplement is commonly prescribed together with diuretics (e.g. Lasix)
• K preparations available in HA:
• Tablets (Slow K)
• Oral solution 鉀⽔
• Slow K is NOT ideal for tube feeding, but…
• Trouble with oral solution
• Bulky! (3.6L bottle) → transport and storage issue
• Difficult to administer (need to use original 3.6L bottle)
• Nasty taste

24
 Alternative routes
• Transdermal e.g. GTN, HRT
• Parenteral/injectable – not always long term option
• Sublingual or buccal e.g. GTN, NRT
• Orodispersible tablets e.g. olanzapine, lansoprazole
• Rectal e.g. suppositories for pain relief (paracetamol), enemas (mesalazine)
• Intranasal e.g. sumatriptan for migraine

25
 Usage of different dosage forms
安老院舍藥物管理指南 2018:

26
 Teaching points
• Storage requirement
• Administration method
• Special dosage form
• Insulin pen
• Topical steroid
• Eye drops
• Others

27
 Insulin injection (key points)
• Insulin should be injected at a 90-degree
angle.

…
• The best sites for injection are the upper
…

∴ outer thighs, buttocks and abdomen.

轉位
.

• Rotate the injection sites to avoid the

development of fatty lumps
(lipohypertrophy) which will delay insulin
absorption.

28
 Insulin injection (key points)
• Keep unopened insulin pens in refrigerator
• Once opened: keep in room temperature
• Replace the pen needle at each injection
• Real-life scenario in RCH:
• Actually, consumables (e.g. insulin pen needles) are charged to the family
• Price: $5 @
• Some family members feel too expensive and ask if there are alternative cheaper ways to inject insulin
• Sometimes the insulin is withdrawn from the pen cartridge using syringe

29
DON’T DO THIS

30
Fingertip Units for Topical Steroids
• One fingertip unit (FTU) is the
amount of topical steroid that is
squeezed out from a standard tube
along an adult’s fingertip. (This
assumes the tube has a standard 5
mm nozzle.)

• One FTU is enough to treat an area

of skin twice the size of the flat of an
adult's hand with the fingers together.
31
Fingertip Units for Topical Steroids (for adult)

32
 FTU

Image credit: https://www.researchgate.net/figure/

Application-of-topical-creams-and-emollients-guidance-on-quantities-for-application_fig5_236251284
33
34
 Eye drops
• Which eye drops should be kept in refrigerator?
• Ans: only few certain eye drops
• Xalatan (latanoprost)
• Chloramphenicol

• Common misconception: every eye drops should be kept in refrigerator

35
36
 Special instruction
• E.g. Prednisolone tablets as a mouthwash

• Remember to check reference when uncertain

Link: https://mft.nhs.uk/app/uploads/sites/3/2018/09/UDH-135.pdf 37
 Special instruction
• E.g. Prednisolone tablets as a mouthwash

• Remember to check reference when uncertain

Link: https://mft.nhs.uk/app/uploads/sites/3/2018/09/UDH-135.pdf 37