medication-tube feeding interactions 6 formula-related factors high-protein content – case reports...

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MEDICATION-TUBE FEEDING INTERACTIONS

Wannisa DongtaiPGY2 Critical Care/Nutrition Support Pharmacy Resident

College of Pharmacy University of ArizonaBanner-University Medical Center Tucson

Disclosure■ I have nothing to disclose concerning possible financial or

personal relationship with commercial entities that may have a direct or indirect interest in the subject matter of this presentation

Learning Objectives■ List 4 medications for which therapeutic levels are

affected by tube feeding.

■ Discuss options for managing administration of a specific medication with tube feeding to minimize effects on the medication’s efficacy and safety.

■ Identify potential drug-tube feeding interactions and treatment options in a given patient scenario.

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“Can I give this drug through the feeding tube?”

Medication-Tube Feeding Interactions

■ Physical and chemical effects of tube feeding on a drug that result in altered drug concentrations andresponse to the therapy

■ May lead to treatment failure and adverse reactions

Adapt from: Boullata JI. Handbook of drug-nutrient interactions. 2010Chan LN. J Parenter Enteral Nutr. 2013

Type and Location of the Feeding Tube

Williams NT. Am J Health-Syst Pharm. 2008

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Site of Feeding

Gastric

■ Easier placement

■ More physiologic feeding

■ Potential for drug-tube feeding interactions

Post-pyloric

■ Better for patients with gastric dysfunction, pancreatitis, and post-operative feeding

■ May reduce the risk of aspiration

■ Potential for drug-tube feeding interactions

Boullata JI. Handbook of Drug-Nutrient Interactions. 2010

Category of Interactions

■ Physical - precipitation

■ Pharmaceutical – extended release

■ Pharmacologic – vitamin K and warfarin

■ Physiologic – drugs cause feeding intolerance

■ Pharmacokinetic – absorptive environment

■ Pathophysiologic - unintended responses and disease state


Factors Contributing to Medication -Tube Feeding Interactions

■ Administration-related factors

■ Drug-related factors

■ Formula-related factors


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Administration-Related Factors■ Feeding tube size

– Long and smaller-bore tubes have a greater risk of occlusion

1. Williams NT. Am J Health-Syst Pharm. 2008 2. Boullata JI. Handbook of Drug-Nutrient Interactions. 20103. Heldt T, Loss SH. Rev Bras Ter Intensiva. 2013

1 French unit = 0.33 mm)

Figure:www.researchgate.net

Patient Case■ A 54 years-old male who admitted to the ICU with cirrhosis.

There is a concern of GI bleeding and a physician orders sucralfate via the enteral route in addition to pantoprazole.

■ Patient is intubated and receives continuous enteral nutrition via Dobhoff tube (DHT).

■ Chest X-ray shows DHT with the tip in the third portion of the duodenum.

■ What is a major medication-tube feeding interaction in this case?

Administration-Related Factors

■ Site of feeding: Gastric vs. Post-pyloric– Drugs intended for a local effect

o Antacids, sucralfate, bismuth

– Absorptive environmento Ketoconazole, itraconazole and tetracycline require

acidic environment (gastric PH) for absorptiono Digoxin is acid labile and hydrolyzed in acidic

environment

1. Williams NT. Am J Health-Syst Pharm. 2008 2. Boullata JI. Handbook of Drug-Nutrient Interactions. 20103. Heldt T, Loss SH. Rev Bras Ter Intensiva. 2013

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Patient Case (continued)

■ What is a major medication-tube feeding interaction in this case?– DHT tip is post-pyloric– Sucralfate will not present pharmacological effects– Sucralfate interacts with pantoprazole– Management:

■ Reposition DHT to the gastric if sucralfate will be continued

■ Discontinue sucralfate

Drug-Related FactorsDosage forms: liquid vs. solid dosage forms

■ Liquid preparations– Generally preferred– Factors need to be considered

o Volumeo Sorbitol content - causes GI intoleranceo Hypertonic medication - causes osmotic diarrheao Viscosity – cause tube occlusiono Formulations – microgranular, modified-release

1. Williams NT. Am J Health-Syst Pharm. 2008 2. Boullata JI. Handbook of Drug-Nutrient Interactions. 20103. Bankhead R et al. J Parenter Enteral Nutr. 2009

Drug-Related Factors

■ Solid dosage forms–Compressed, immediate-release tablets can be crushed–Capsules that contain powder, or beads or pellets that are

an immediate release form–Liquid-filled soft gelatin capsule

Williams NT. Am J Health-Syst Pharm. 2008 Boullata JI. Handbook of Drug-Nutrient Interactions. 2010

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Formula-Related Factors■ High-protein content– Case reports of interaction between levodopa and protein in

enteral feeding o Caused levodopa withdrawal and neuroleptic-like syndromeo Amino acid from enteral feeding may compete with levodopa

for absorptiono Suggested management:

• Separate feeding time and drug administration: bolus or cyclic feeding

• Limit total daily protein intake – may cause malnutrition• Increase dose of levodopa

1. Heldt T, Loss SH. Rev Bras Ter Intensiva. 2013. 2. Bonnici A et al. Ann Pharmacother. 2010. 3. Cooper M et al. Ann Pharmacother. 2008 4. Withman et al. J Pharm Pract. 2016

Specific Drug-Tube Feeding Interactions

■ Carbamazepine

■ Fluoroquinolones

■ Phenytoin

■ Warfarin

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Carbamazepine■ Limited data

■ Enteral feeding may decrease carbamazepine absorption

■ Carbamazepine may bind to the feeding tube

■ Post-pyloric feeding may cause clinically significant effects


Bass J et al. Epilepsia. 1989

• Oral vs. NG feeding administration• No significant differences in

pharmacokinetic parameters• Cmax was lower with NG feeding (p =

0.052)• Strong correlation between CBZ dose

and Cmax after oral administration, but not NG feeding

*NG=nasogastric; CBZ = Carbamazepine

Loss of Carbamazepine Suspension through Nasogastric Feeding Tube

Adrianne L et al. Am J Hosp Pharm. 1990

■ Compared 12 methods of administrating CBZ suspension via NG tube– NG tube size, with/without diluent, type of diluent, and type of

flush solution

■ For methods with diluent, diluted CBZ 10 mL (200 mg) with 10 mL of diluent

■ Significant loss of CBZ in undiluted suspension methods

■ Significant losses were associated with diluents and flush solution

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Carbamazepine■ Management:

–Dilute CBZ suspension with an equal volume of sterile water

–Consider holding the feeding for 2 hours before and after drug administration

–Monitor drug level–Consider alternative therapy


Fluoroquinolones

■ Drug dependent

■ Available studies are small and have limitations

■ Possible mechanisms– Bind to cations in enteral feeding– Bind to the feeding tube– Differences in hydrophilicity


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Figure 1. Time course of serum concentrations of moxifloxacin after the administration of a single moxifloxacin 400mg dose as - An intact tablet (regimen A)- A crushed tablet administered through

a nasogastric tube with water (regimen B)

- A crushed tablet administered through a nasogastric tube with concurrent enteral feeding (regimen C)

Value are expressed as geometric means (n=12).

Burkhardt O et al. Clin Pharmacokinet. 2005

Fluoroquinolones■ Management

– Consider holding enteral formula for 1 hour or more and 2 hours after the dose, especially with ciprofloxacin

– Switch to IV formula if possible– Consider alternative antibiotics


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Phenytoin■ A systemic review found that decreased serum phenytoin

concentrations associated with enteral feeding

■ The exact mechanism is unknown–Phenytoin binds to feeding tube –Phenytoin binds to enteral formula

Au Yeung SC et al. Ann Pharmacother 2000

JPEN J Parenter Enteral Nutr. 1993

Phenytoin■ Management

– Dilute phenytoin suspension with an equal volume of sterile water

– Switch to IV route if possible– May consider holding formula for 1-2 hours before and

after drug administration– Monitor phenytoin level– Consider alternative therapy

Au Yeung SC et al. Ann Pharmacother 2000Boullata JI. Handbook of Drug-Nutrient Interactions. 2010

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Warfarin

■ Warfarin interacts with vitamin K content in enteral formulas– Most of enteral formulas were reformulated to reduce the vitamin K content

■ Feeding tube may compromise the amount of warfarin reaching the patient

Williams NT. Am J Health-Syst Pharm. 2008 Boullata JI. Handbook of Drug-Nutrient Interactions. 2010Klang M et al. J Parenter Enteral Nutr. 2010

Warfarin

Management

■ Adjust warfarin dose

■ Consider holding formula for 1 hour before and after drug administration

■ Monitor INR closely

■ Consider alternative anticoagulants


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Patient Case■ A 74 years old female with atrial fibrillation who has been on

warfarin 5 mg daily at home.

■ Patient is admitted in the ICU due to acute kidney injury.

■ DHT is placed and enteral feeding is initiated.

■ A physician would like to re-start home dose of warfarin.

■ What is the appropriate approach that you would like to do in this patient?

General Recommendations■ Administer drugs by the oral route when possible

■ Consider alternative routes if drugs are available (e.g. rectal, transdermal, IV, sublingual)

■ Liquid dosage forms are preferredo Check sorbitol content and osmolality (if possible)o Dilute hypertonic products with 10-30 mL of watero Dilute viscous products with 30-50 mL water (1:3

volume/volume)


General Recommendations■ If a solid dosage form is used, select appropriate dosage

forms

■ Do not mix drugs directly to the enteral feeding formula

■ Avoid mixing drugs together

■ Administer each drug separately


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General Recommendations■ Flush the tube with at least 15 mL water before and after

administering drugs

o Flush the tube with at least 5-10 mL water between drugs

■ Restart the feeding in a timely manner

■ Consider holding feedings before and after administering specific drugs


Acknowledgment

■ Carol J Rollins, MS, RD, CNSD, Pharm.D., BCNSP

References■ Adrianne L et al Loss of Carbamazepine Suspension through Nasogastric Feeding Tube. Am J Hosp Pharm. 1990;

47:2034-4

■ Au Yeung SC1, Ensom MH. Phenytoin and enteral feedings: does evidence support an interaction? Ann Pharmacother. 2000 Jul-Aug;34(7-8):896-905.

■ Bankhead R et al. Enteral Nutrition Practice Recommendations Task Force. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009 Mar-Apr;33(2):122-67.

■ Bass J et al. Effects of enteral tube feeding on the absorption and pharmacokinetic profile of carbamazepinesuspension. Epilepsia. 1989 May-Jun;30(3):364-9.

■ Bonnici A et al. An interaction between levodopa and enteral nutrition resulting in neuroleptic malignant-like syndromeand prolonged ICU stay. Ann Pharmacother. 2010 Sep;44(9):1504-7.

■ Burkhardt O et al. Effects of enteral feeding on the oral bioavailability of moxifloxacin in healthy volunteers. ClinPharmacokinet. 2005;44(9):969-76.

■ Chan LN. Drug-nutrient interactions. JPEN J Parenter Enteral Nutr. 2013 Jul;37(4):450-9.

■ Cooper MK, Brock DG, McDaniel CM. Interaction between levodopa and enteral nutrition. Ann Pharmacother. 2008 Mar;42(3):439-42.

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References■ Healy DP, Brodbeck MC, Clendening CE. Ciprofloxacin absorption is impaired in patients given enteral feedings orally

and via gastrostomy and jejunostomy tubes. Antimicrob Agents Chemother. 1996 Jan;40(1):6-10.

■ Heldt T, Loss SH. Drug-nutrient interactions in the intensive care unit: literature review and current recommendations. Rev Bras Ter Intensiva. 2013 Apr-Jun;25(2):162-7.

■ Klang M, Graham D, McLymont V. Warfarin bioavailability with feeding tubes and enteral formula. JPEN J Parenter Enteral Nutr. 2010 May-Jun;34(3):300-4

■ Rollins CJ. Drug–Nutrient Interactions in Patients Receiving Enteral Nutrition. In Boullata JI eds. Handbook of Drug-Nutrient Interactions. 2010: 367-410.

■ Seifert CF, McGoodwin PL, Allen LV Jr. Phenytoin recovery from percutaneous endoscopic gastrostomy Pezzer catheters after long-term in vitro administration. JPEN J Parenter Enteral Nutr. 1993 Jul-Aug;17(4):370-4.

■ Whitman CB et al. Levodopa Withdrawal Presenting as Fever in a Critically Ill Patient Receiving Concomitant Enteral Nutrition. J Pharm Pract. 2016 Dec;29(6):574-578.

■ Williams NT. Medication administration through enteral feeding tubes. Am J Health Syst Pharm. 2008 Dec 15;65(24):2347-57.

■ Wright DH et al. Decreased in vitro fluoroquinolone concentrations after admixture with an enteral feeding formulation. JPEN J Parenter Enteral Nutr. 2000 Jan-Feb;24(1):42-8.

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medication-tube feeding interactions 6 formula-related factors high-protein content – case reports...

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