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Adminstering Medication vai a nasogastric tube

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					                                        Contents
Acknowledgments                                                     2
Introduction                                                        3
Review process for patients on medication who have had a            4
feeding tube fitted
General guidelines for formulations administered through            5
feeding tubes
Directions for administration of tablets, liquids, and capsules     6-8
Problem solving                                                      9
Complications of drug administration via enteral feeding tube        10
Reasons for unpredictable serum concentrations                       11
Drug monographs                                                    12-109
References                                                        110-114




Produced by          Brenda Murphy, Pharmacist                          1
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                             Acknowledgments

This guide is a compilation of theoretical, practical and anecdotal information from a variety
of sources. Many thanks to everyone who has contributed, particularly those people who
have provided practical information to supplement previously theoretical guides. I would
particularly like to mention the following sources, which have made significant contributions
to this edition.


        Whipps Cross Hospital’s Tube Feeding Drug Administration Guide.40

        Derriford Hospital Pharmacy enteral feeding guide.41

        Queen Victoria Hospital's Drug Adminstration via Enteral Feeding Tubes guide,
        March 2001.94

        Southern General Hospital, South Glasgow University Hospitals NHS Trust’s A to Z
        guide to administration of drugs via nasogastric/PEG tube. Updated June 2001.95

        County Durham and Darlington Acute Hospitals NHS Trust’s Guidelines for the
        administration of Drugs through Enteral Feeding Tubes, 2nd edition. July 2003.104

        Stockport NHS Trust’s Drugs via Enteral Feeding Tubes Guide (draft).105




Produced by          Brenda Murphy, Pharmacist                                               2
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                               Introduction

Drug administration via enteral feeding tubes is an unlicensed method of administration,
therefore in all cases where a patient with an enteral feeding tube fitted requires oral
medication, alternative (licensed) routes of administration should be sought.

When drug administration via enteral feeding tubes is necessary, the prescriber takes
responsibility for the off-license use of the drug concerned. This booklet is intended as a
guide to such administration. The information contained in this guide is mostly anecdotal, as
there is very little information on drug administration via enteral feeding tubes in product
literature provided by drug manufacturers.

Patient response to drugs administered via enteral feeding tubes can be unpredictable. Drugs
may have a greater or lesser therapeutic effect than when given by the oral route. The onset
and duration of effect may be affected. Side effects, particularly those involving the
gastrointestinal system, are likely to be exacerbated. The side effects of drugs which have
been given by an unlicensed route are also the responsibility of the prescriber.


Drugs should only be put down a feeding tube as a last resort because of the
implications for drug therapy and nutritional status.


If putting medication down an enteral feeding tube is unavoidable then it is sensible to keep
drug therapy to a minimum.

If problems do arise, please contact your ward pharmacist who is in an ideal position to
advise on the formulation, timing and route of administration of drugs.


Every reasonable attempt has been made to ensure that the information is accurate and
up to date at the time of printing.




Nursing staff should contact their ward pharmacist when a patient who was previously on
oral medication has had an enteral feeding tube fitted and is likely to have medication
administered via this route.




Produced by          Brenda Murphy, Pharmacist                                                  3
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
    Review process for patients on oral medication
     who have had an enteral feeding tube fitted.
Special care is needed if a patient becomes ‘NIL BY MOUTH’.
Medication designed for a specific route and method of administration will produce a more
predictable response when given by that route than when given via an enteral feeding tube.1

                                           Step one

   Can the current oral medication be administered by an alternative route?

                        Other methods of administration
RECTAL                                           eg. Aspirin, diclofenac, and paracetamol
                                                 suppositories
PARENTERAL                                       eg. Intravenous, intramuscular and
                                                 subcutaneous injections
TRANSDERMAL                                      eg. Hyoscine, GTN, and HRT patches
SUBLINGUAL/BUCCAL TABLETS                        eg. Prochlorperazine 3mg tablets


                                           Step two

   Can the current oral medication be changed to another other medication which has
    a more suitable method of administration?

    E.g. mefenamic acid tablets changed to diclofenac suppositories.

                                          Step three

   Does the drug come as a liquid or as a dispersible/soluble tablet, which is the
    preferred formulation for administering through the enteral feeding tube?

    Many sugar–free liquids contain sorbitol, an artificial sweetener, which is a laxative and
    can result in abdominal cramping and diarrhoea. Sorbitol has an accumulative effect and
    it is therefore important to minimise the intake of sorbitol where possible. Cost
    implications occur when the drug is only available in paediatric preparations and large
    volumes will be required.

                                           Step four

   When changing from solid to liquid dosage forms should any dose changes be made?

    If changing from slow release tablets/capsules to liquid it may to necessary to decrease
    the dose and increase the frequency of administration. Some drugs have a different
    bioavailability when being changed from a tablet to a liquid, e.g. digoxin. Other drugs
    contain a different salt of the drug in the liquid and tablet form, e.g. phenytoin.
Produced by          Brenda Murphy, Pharmacist                                                   4
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
           General guidelines for formulations
            which may be administered with
              care through feeding tubes
 Standard tablets
Crushing should be avoided. If crushing is the only option then the tablets should be crushed
well enough to prevent clogging of the tube. Care should be taken when crushing drugs
which have a high incidence of allergic reactions e.g. antibiotics and chlorpromazine.

 Dispersible and effervescent formulations
These are low in osmolality and will not cause diarrhoea. Most dispersible and effervescent
formulations contain sodium, which may need to be taken into account in sodium restricted
patients.

 Enteric coated tablets – do not crush
Designated as e/c in the BNF.
The enteric coating is designed to prevent drug dissolution in the stomach and to promote
absorption in the small intestine. If the tablet is crushed and passed down the enteral feeding
tube, undesirable side effects may occur. Side effects could include irritancy on the stomach
or a decrease in drug effectiveness. When crushed, the tablet will break into small chunks
that bind together when moistened and subsequently clog enteral feeding tubes.4

 Buccal and sublingual tablets – do not crush
Drugs formulated in these dosage forms such as prochloperazine (Buccastem) or GTN are
designed not to pass through the stomach and so avoid the first pass metabolism effects via
the liver. If these tablets are passed down the enteral feeding tube decreased drug absorption
will occur. Buccal and sublingual tablets are suitable to be used as normal in most cases even
if a patient becomes nil by mouth, provided that the patient is still producing normal
quantities of saliva.

 Sustained release and controlled release tablets – do not
  crush
The sustained release coating allows the drug to be released gradually over time. If the tablet
is crushed and passed down the enteral feeding tube an increase in the expected peak plasma
level may occur. The patient will be initially exposed to 2-3 times the normal dosage which
will increase the chance of side effects, and then later the drug will not last the full dosage
interval resulting in a lower trough in drug plasma concentration.

 Cytotoxic tablets – do not crush
All staff should avoid contact with cytotoxic drugs. Seek advice from pharmacy.

 Chewable tablets – do not crush
e.g. Tegretol Retard Chewtabs are formulated such that they are partially absorbed in the
mouth.5
If the tablet is crushed decreased drug absorption will occur.
Produced by          Brenda Murphy, Pharmacist                                                    5
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
             Directions for administration of tablets

   Crushing tablets

        1. Crush the tablet in a pestle and mortar or between two metal spoons.
        2. Add 15-30ml of distilled water to the mortar and mix with the powder.
        3. Draw up the solution in an oral syringe or a bladder syringe.
        4. Administer the solution through the enteral feeding tube.
        5. Rinse out the mortar with distilled water and add the remaining solution to the
           tube.
        6. Flush the tube post dose with 15-30ml of sterile water.


   Dispersible/disintegrating tablets
Tablets may disintegrate in water without crushing. If this is the case the tablet should be
prepared as follows:

        1.   Place intact tablet into the barrel of an oral or bladder syringe.
        2.   Replace the plunger and draw up 10-15ml of sterile water.
        3.   Replace cap, allow tablet to dissolve.
        4.   Shake well and administer dose down the enteral feeding tube .
        5.   Flush the tube post dose with 15-30ml of water.


   Effervescent tablets
Tablets will effervesce and disperse when placed in water. The resulting gases need to be
allowed to escape.

        1.   Pour 50ml sterile water into a beaker.
        2.   Add the tablet to the water.
        3.   Wait for the effervescent reaction to finish.
        4.   Swirl the solution and draw it all up into a 50ml oral/bladder syringe.
        5.   Administer the dose down the enteral feeding tube.
        6.   Flush the tube post dose with 15-30ml of water.



                                        Don’t

   Crush the tablet in a plastic container as the drug may adhere to the
    plastic.
   Use boiling water to dissolve tablets as it may affect bioavailability.
   Leave oral medicines unattended in syringes.
   Administer any medicine via any route that you have not prepared
    yourself.


Produced by           Brenda Murphy, Pharmacist                                                6
Updated by            Jen Smyth, Pharmacist
Checked by            Sue Lord, Pharmacist
Date of Production     January 2004
         Directions for administration of liquids

   Liquids
Liquids are the preferred formulation for administration via the enteral feeding tubes, when
available. It is usually not necessary to dilute liquid preparations with sterile water.

Flush with tube post dose with 15-30ml sterile water.



   Syrups
Syrups have viscous and hyperosmolar properties. It is best to dilute the syrup with the same
volume of sterile water.

If the syrup is one of several drugs to be administered it is preferable to administer the syrup
last.

Flush the tube post dose with 15-30ml of sterile water.



   Suspensions
The majority of suspensions are suitable for administration via the enteral feeding tube,
however some e.g. lansoprazole suspension may block the tube. See individual monographs
for advice

Flush the tube post dose with 15-30ml sterile water.




Liquid formulations made up specially by pharmacy on request by ward staff will most likely
contain Keltrol suspension. All suspensions containing Ketrol are to be diluted with the same
volume of water and flushed post dose with 30ml of sterile water. Sorbitol is not to be used
as a diluent as it will cause hyperosmolar diarrhoea.




Produced by          Brenda Murphy, Pharmacist                                                     7
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
     Directions for administration of capsules

    Hard Gelatin Capsules e.g. Ramipril

     1.   Gently ease open the capsule to release the powder.
     2.   Add the powder to the pestle.
     3.   Mix the powder with 15-30ml of sterile water.
     4.   Draw up the solution in an oral or bladder syringe.
     5.   Administer the solution through the enteral feeding tube.
     6.   Rinse out the mortar and add the remaining solution through the enteral feeding tube.


    Modified Release Capsules e.g. Propranolol SR

Ask ward pharmacist for advice. It may be necessary to change to another preparation.
See details on modified release tablets enclosed.


 Soft gelatin capsules e.g. nifedipine


Method one

1.   Pinprick one end of the capsule.
2.   Drain out the contents with a syringe.
3.   Administer through the feeding tube.
4.   Flush the tube post dose with 15-30ml of sterile water.


NB some of the drug may adhere to the soft gelatin capsule and the result may be
subtherapeutic levels of the drug.


Method two

1.   Dissolve capsule in 15-30ml of warm water.
2.   Remove undissolved gelatine.
3.   Draw up the solution in an oral or bladder syringe.
4.   Administer the solution through the feeding tube.
5.   Flush the tube post dose with 15-30ml of sterile water.


                  DO NOT MICROWAVE
 The extreme temperatures will affect the stability and
  bioavailability of the capsule.
Produced by           Brenda Murphy, Pharmacist                                                   8
Updated by            Jen Smyth, Pharmacist
Checked by            Sue Lord, Pharmacist
Date of Production     January 2004
                               Problem Solving

 What do you do if giving several medications?


Do not mix various drugs together in the pestle and mortar because if the tube becomes
blocked it may be difficult to determine how much of the drug has been given.

Administer each drug separately.


 How should you flush an enteral feeding tube?


Flush the feeding tube with 5ml of sterile water or saline for adults between medications to
prevent drug-drug interactions.

When all the medication have been administered, flush the tube with 15-30ml of sterile water
or saline for adults.

This procedure reduces the risk of tube blockage and helps with the delivery of the drug to
the stomach. 1

If the patient is fluid restricted, consult with the ward pharmacist or the doctor.


 What can be done if the tube becomes blocked?


Try flushing the feeding tube with lemonade, sodium bicarbonate, cola or soda water. The
combination of the acidity of these drinks, the effervescence due to carbonation and the
flushing action may dislodge the blockage.


 Are injectable drugs suitable to be used down the tube?


Some injectable drugs are suitable for oral administration and can be given via the enteral
tube for example Vancomycin and Hyoscine. See individual drug monographs for advice.


   Is it possible to add medication to the feed?


No, don’t ever add medication to feeds. There is a risk of microbiological contamination of
the feed and there are difficulties in predicting the effect the medication has on the physical
characteristics and stability of the feed and vice versa.


Produced by          Brenda Murphy, Pharmacist                                                    9
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
     Complications of drug administration via
              enteral feeding tubes

There are two main consequences for absorption via the stomach when an enteral feeding
tube is in place.1


1. The delivery of drugs directly into the stomach bypasses the normal enteral route where
   saliva may assist degradation of the drug.


2. The residence time in the stomach is reduced. Absorption of drug will be impaired if
   prolonged contact with the acid environment of the stomach is required for drug
   dissolution. When a jejunostomy tube is used the acid environment of the stomach is
   bypassed altogether. Problems can occur for example with Ketoconazole.2 Ketoconazole
   will either not be absorbed or will only be partially absorbed when administered directly
   to the jejunum through a NJ or a jejunostomy tube.




Refer to dietician booklet for a brief summary of types of tubes.




Produced by          Brenda Murphy, Pharmacist                                               10
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
               Reasons for unpredictable serum
                       concentrations
Nasogastric and naso-jejunal tubes deliver feeds and drugs to the stomach and jejunum
respectively. These tubes are long fine bore tubes with a large surface area for potential drug
absorption and may block easily due to their small bore.

PEG (Percutaneous Endoscopic Gastrostomy) and jejunostomy tubes are short tubes with a
wider bore.



                                       Reason one
Drugs may bind to the enteral feeding tube and reduce absorption and bioavailability of the
drug.

        Examples:

     Lansoprazole suspension.
     Carbamazepine Suspension.
     Phenytoin Suspension.



                                      Reason two
Nutrients in the enteral feeding solution may increase or decrease absorption of the drug from
the stomach. This will consequently affect the drug levels in the body.

     Highly protein bound drugs such as theophylline may interact with the protein content
      of the feed. This may result in decreased effects.
     Some drugs may be required to be taken on an empty stomach eg. flucloxacillin and
      tetracyclines. Tetracyclines may bind to some components of the feed and cause a
      decrease in the bioavailability of the drug.
     Digoxin interacts with enteral feeds, which are high in fibre such as Jevity feed.



                                     Reason three
Diarrhoea can be a problem in post-pyloric feeding. This is partly because the jejunum lacks
the reservoir effect provided by the gastric fluids in the stomach and partly because the
protective action of the pylorus in the regulation of delivery of nutrients into the intestine is
bypassed.3 Many liquid medications are hyperosmolar or hypertonic, and when administered
directly into the jejunum osmotic diarrhoea and nausea will occur.


Produced by          Brenda Murphy, Pharmacist                                                 11
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                 Drug
              Monographs




Produced by          Brenda Murphy, Pharmacist   12
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Acebutolol

Presentation
100mg and 200mg capsules.
400mg film-coated tablets.

Method of administration
The capsules can be opened, and the contents dispersed in water for administration.41,105

                                        Aceclofenac

Presentation
100mg tablets.

Method of administration
Consider switching to an alternative drug which has a dispersible, liquid, or rectal form, e.g.
diclofenac, ibuprofen. If no alternative is suitable, the tablet can be crushed and mixed with
water for administration.41 Follow the directions on page 6.

Clinical guidance
For short term use only as aceclofenac is more irritant to the gastrointestinal tract after being
crushed.

                                      Acetazolamide

Presentation
250mg tablets.
250mg and 500mg slow release capsules.
500mg injection.

Method of administration
The standard tablets disperse with a fine sediment.7,40,41 The injection has been used
orally.104
The slow release capsules are not suitable for use. Contact Pharmacy for advice.

                                      Acetylcysteine

Presentation
600mg effervescent tablets.
200mg/ml injection.

Method of administration
Use the effervescent tablets. Alternatively the injection can be diluted 1:4 in orange juice. It
has a bitter taste.40



Produced by          Brenda Murphy, Pharmacist                                                  13
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                           Aciclovir

Presentation
200mg, 400mg, and 800mg tablets.
200mg, 400mg, and 800mg dispersible tablets.
200mg/5ml suspension.
250mg, 500mg, and 1g infusion.

Method of administration
Use the liquid or the dispersible tablets.104

                                           Acitretin

Presentation
10mg and 25mg capsules.

Method of administration
The capsule contents are poorly soluble, and are therefore not suitable to be used via enteral
feeding tubes as they may cause blockage.105 For patients with swallowing difficulties, the
capsules can be opened and their contents sprinkled onto soft food.105

                                        Albendazole

Clinical guidance
Do not crush.41 Contact Pharmacy for advice.

                                        Alendronate

Presentation
5mg, 10mg, and 70mg tablets.

Clinical guidance
The tablets are not suitable for crushing due to the risk of oesophageal damage.50

                                         Alfacalcidol

Presentation
0.25mcg, 0.5mcg, and 1mcg capsules.
2mcg/ml oral drops.
2mcg/ml injection.

Method of administration
Use the oral drops, and give immediately as they are light sensitive.41,104

                1 drop                equivalent to             100nanograms106

Produced by          Brenda Murphy, Pharmacist                                                   14
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                          Alfuzosin

Presentation
2.5mg film coated tablets.
5mg and 10mg modified release tablets.

Method of administration
The standard tablets can be crushed and administered via an enteral feeding tube.42 Follow
the directions on page 6.
The modified release tablets should not be used.

                                        Allopurinol

Presentation
100mg and 300mg tablets.

Method of administration
The tablets can be crushed and mixed with water for administration.8 Follow the directions
on page 6.

Clinical guidance
Give after feed.35

                                     Alverine citrate

Presentation
60mg and 120mg capsules.

Method of administration
The capsules can be opened, and the contents dispersed in water for administration.105

Clinical guidance
The capsule contents have an anaesthetic effect.105

                                        Amantadine

Presentation
100mg capsules.
50mg/5ml syrup.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41,104




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Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Amiloride

Presentation
5mg tablet.
5mg/5ml oral solution.

Method of administration
Use the oral solution and flush post dose with 15-30ml of sterile water.

                                      Aminophylline

Presentation
100mg tablets and m/r tablets of various strengths.

Clinical guidance
Patients could be changed to equivalent does of Theophylline liquid. Seek advice from
pharmacy.

                                        Amiodarone

Presentation
100mg and 200mg tablets.

Method of administration
The tablets can be crushed and mixed with water for administration.42 Follow directions on
page 6 and give immediately.7,8 During working hours a suspension can be prepared by
Pharmacy.

                                       Amitriptyline

Presentation
10mg, 25mg, and 50mg tablets.
25mg/5ml and 50mg/5ml oral solution.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104

                                        Amlodipine

Presentation
5mg and 10mg tablets.

Method of administration
There is no liquid formulation available. The tablets will disperse readily in water.7,37 Follow
instructions on page 6 and give immediately.

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Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Amoxycillin

Presentation
250mg and 500mg capsules.
125mg/5ml and 250mg/5ml suspension.
3g sachets.
250mg, 500mg, and 1g injection.

Method of administration
For short term courses, consider using injection. Alternatively, use the liquid, and flush with
15-30ml of sterile water.104

                                       Amphotericin

Presentation
100mg tablets.
100mg/ml suspension.
10mg lozenges.
50mg infusion.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.40

                                        Anastrazole

Presentation
1mg film coated tablets.

Method of administration
Crush the tablets and mix with water for administration via enteral feeding tube.46 Follow the
directions on page 6.

                                          Arthrotec

Presentation
‘50’ and ‘75’ tablets.

Clinical guidance
Tablets are formed of a core of diclofenac surrounded by a mantle of misoprostol.
They are not suitable for crushing.51




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Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                       Ascorbic acid

Presentation
50mg, 100mg, 200mg, and 500mg tablets.
1g effervescent tablets.
100mg/ml injection.

Method of administration
Use the effervescent tablets if possible.94,104 Where lower doses are necessary, crush the
tablets and disperse in water for administration.104

                                           Aspirin

Presentation
75mg and 300mg dispersible tablets.
75mg and 300mg enteric coated tablets.
300mg suppositories.

Method of administration
Use the suppositories if possible. Alternatively use the dispersible tablets.104

Clinical guidance
Give with food.35 Do not crush enteric-coated tablets.

                                          Atenolol

Presentation
25mg, 50mg, 100mg film coated tablets.
25mg/5ml liquid .

Method of administration
Use liquid and protect from light.88 Follow directions on page 7 for liquids.

                                       Atorvastatin

Presentation
10mg, 20mg, 40mg, and 80mg film coated tablets.

Method of administration
Tablets can be crushed and mixed with water for administration.37 Follow the directions on
page 6.

Clinical guidance
Atorvastatin tablets are not very soluble and a residue may be left, with the potential to block
the enteral feeding tube. Flush well after dosing.37


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Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                       Azathioprine

Presentation
25mg and 50mg film coated tablets.
200mg/5ml suspension can be made by pharmacy.

Clinical guidance
The tablet is cytotoxic. Do not crush or dissolve the tablet. See page 5 and consult with
pharmacy.

                                       Azithromycin

Presentation
250mg capsules.
500mg film-coated tablets.
200mg/5ml suspension.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.105

                                          Baclofen

Presentation
5mg/5ml liquid.
10mg tablet.

Method of administration
Use liquid. If the liquid is unavailable the tablets are dispersible.38,39 Follow guidelines on
page 6.

                                        Balsalazide

Presentation
750mg capsules.

Method of administration
The capsules can be opened, and the contents dispersed in water for administration.104 The
manufacturer advises against this, however, as the contents of the capsules will stain badly.105

                     Bendrofluazide (Bendroflumethiazide)

Presentation
2.5mg and 5mg tablets.

Method of administration
Tablets will disperse readily in water.38,39,40,41 Follow directions on page 6.
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Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                           Benzhexol (Trihexyphenidyl)

Presentation
2mg and 5mg tablets.
5mg/5ml syrup.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41

                           Benztropine (Benzatropine)

Presentation
2mg tablets.
1mg/ml injection.

Method of administration
Tablets can be crushed and administered.41 Follow the directions on page 6. The injection
has also been administered orally.104

                                        Betahistine

Presentation
8mg and 16mg tablets.

Method of administration
The tablets will disperse in water.41 Follow the directions on page 6. Flush well after
administration.

                                     Betamethasone

Presentation
500mcg tablet.
500mcg soluble tablet.
4mg/ml injection.

Method of administration
Use the soluble tablets.41

                                       Bethanechol

Presentation
10mg and 25mg tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.

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Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Bezafibrate

Presentation
200mg tablets. 400mg modified release tablets.

Method of administration
The 200mg tablet will disperse in water over 1-2 minutes, or can be crushed.52 Flush well.
Follow the directions on page 6.

Clinical guidance
The modified release tablet is not suitable for administration via enteral feeding tubes.52

                                       Bicalutamide

Presentation
50mg and 150mg tablets.

Method of administration
Tablets are very insoluble but can be crushed finely and administered.46 Follow the
directions on page 6.

                                          Bisacodyl

Presentation
5mg e/c tablet.
10mg suppositories.

Method of administration
Use the suppositories.

Clinical guidance
The tablet has an enteric coating. Do not crush as it has an irritant effect on the stomach.41

                                         Bisoprolol

Presentation
1.25mg, 2.5mg, 5mg and 10mg film coated tablets.

Clinical guidance
Change to atenolol, which has a syrup formulation. See page 18 and page 7.

Alternatively the tablets can be crushed finely for administration via enteral feeding tube, but
there is a risk of blocking the tube. Flush well after the dose to minimise this.95




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Date of Production    January 2004
                                      Bromocriptine

Presentation
1mg and 2.5mg tablets.
5mg and 10mg capsules.

Method of administration
The tablets can be crushed and dispersed in water for administration.95 Follow the directions
on page 6. Give immediately. Protect from light.41

                                   Brompheniramine

Presentation
2mg/5ml syrup.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41

Clinical guidance
The liquid is not compatible with feeds, so flush well before and after each dose.41

                                        Budesonide

Presentation
3mg capsules.
3mg modified-release capsules.
2mg/100ml enema.

Method of administration
The capsules can be opened, and the granular contents dispersed in fruit juice for
administration.105 Do not open the modified release capsules.

                                        Bumetanide

Presentation
1mg/5ml sugar free liquid.
1mg and 5mg tablets.

Method of administration
Use liquid. If the liquid is unavailable the tablet will disperse in 5-10 minutes.38,39 Follow
guidelines on page 6.




Produced by          Brenda Murphy, Pharmacist                                                   22
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Buspirone

Presentation
5mg and 10mg tablets.

Method of administration
The tablets can be crushed and dispersed in water for administration.41 Follow the directions
on page 6.

                                        Cabergoline

Presentation
500mcg, 1mg, 2mg, and 4mg tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6. Give with
food.41

                                 Calcium supplements

                                     Calcium Carbonate

Presentation
500mg chewable tablets (Calcichew).
1.25g effervescent tablets (Cacit).

Method of administration
Use the effervescent tablets. The chewable tablets should not be used.94

                                     Calcium Gluconate

Presentation
600mg tablets (1.35mmol calcium).
1g effervescent tablets (2.25mmol calcium).

Method of administration
Use the effervescent tablets.40,41

                                      Calcium Sandoz

Presentation
2.7mmol/5ml syrup.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104

Produced by          Brenda Murphy, Pharmacist                                              23
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                    Calcium folinate

Presentation
15mg tablets.

Method of administration
The tablets can be crushed and mixed with water for administration.40 Follow the directions
on page 6.

                                   Calcium resonium

Presentation
Powder for oral administration.
Enemas.

Method of administration
Use the enemas.105

                                       Candesartan

Presentation
2mg, 4mg, 8mg, and 16mg tablets.

Method of administration
Tablets can be crushed and mixed with water for administration.53 Follow the directions on
page 6.

Clinical guidance
No information available on whether candesartan is likely to block enteral feeding tubes.53

                                          Captopril

Presentation
12.5mg, 25mg and 50mg tablets.
5mg/5ml liquid can be made by pharmacy.

Method of administration
Consult pharmacy for the preparation of the liquid. Captopril tablets will disperse in 5-10
minutes and can be used if the liquid formulation is unavailable.39,40 Follow guidelines on
page 6. Give on an empty stomach.




Produced by          Brenda Murphy, Pharmacist                                                24
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                     Carbamazepine

Presentation
100mg, 200mg and 400mg tablets. 100mg and 200mg chewtabs.
100mg/5ml liquid. 125mg and 250mg suppositories.
200mg and 400mg (retard) modified release tablets.

Method of administration
Use the liquid. Dilute with an equal volume of sterile water and flush post dose with 15-30ml
of sterile water. Suppositories are licensed for a maximum of seven days.35

Clinical guidance

                                           Absorption

Carbamazepine is slowly and irregularly absorbed from the GI tract.9 Care must be taken to
administer carbamazepine at the same time and in the same manner each day so that
variations in the extent of drug absorption are minimised. Stop enteral feed for at least two
hours before and two hours after dose to maximise drug absorption.

Carbamazepine is absorbed onto PVC feeding tubes. However it has been shown that when
the suspension is diluted with an equal volume of water, loss is negligible.10

                     Guideline for changing to the liquid preparation:

If changing from Retard formulations to liquid preparation give the same daily dose but
increase the frequency of administration.

Carbamazepine MR tablet               Equivalent to        Carbamazepine liquid
400mg twice a day                                          200mg four times a day
100mg tablet/liquid                   Equivalent to        125mg suppositories



                                       Carbimazole

Presentation
5mg and 20mg tablets.

Method of administration
The tablets can be crushed and dispersed in water for administation.95 Follow the directions
on page 6.




Produced by          Brenda Murphy, Pharmacist                                              25
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                      Carbocisteine

Presentation
375mg capsules.
125mg/5ml liquid.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41

                                         Carvedilol

Presentation
3.125mg, 6.25mg, 12.5mg, and 25mg tablets.

Method of administration
Tablets can be crushed, and will form a suspension in water.52 Follow the directions on page
6.

Clinical guidance
Use immediately.52

                                         Cefadroxil

Presentation
500mg capsules.
125mg/5ml, 250mg/5ml, and 500mg/5ml suspension.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.94

Clinical guidance
Cefadroxil is a restricted use antibiotic at WMH. Contact Pharmacy for advice.

                                          Cefixime

Presentation
200mg film-coated tablets.
100mg/5ml suspension.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41

Clinical guidance
Cefixime is a restricted use antibiotic at WMH. Contact Pharmacy for advice.



Produced by          Brenda Murphy, Pharmacist                                            26
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Cefuroxime

Presentation
125mg and 250mg film-coated tablets.
125mg/5ml suspension.
125mg sachets.
250mg, 750mg, and 1.5g injection.

Method of administration
Consider whether to use the injection. Alternatively, use the liquid, and flush with 15-30ml
of sterile water.41

Clinical guidance
Cefuroxime oral is not usually used at WMH. Contact Pharmacy for advice.

                                         Celecoxib

Presentation
100mg and 200mg capsules.

Clinical guidance
The capsule should not be opened as it provides some stability to the medication.54
Rofecoxib is available as a liquid, and may be an alternative. Contact ward pharmacist.

                                          Celiprolol

Presentation
200mg and 400mg tablets.

Method of administration
Tablets can be crushed, and will disperse in water.55 Follow the directions on page 6.

Clinical guidance
Tablet is film coated, so crush finely or the coating may block the enteral feeding tube.55

                               Cephalexin (Cefalexin)

Presentation
250mg and 500mg capsules.
250mg and 500mg tablets.
125mg/5ml, 250mg/5ml, and 500mg/5ml suspension.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104



Produced by          Brenda Murphy, Pharmacist                                                 27
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                               Cephradine (Cefradine)

Presentation
250mg and 500mg capsules.
250mg/5ml suspension.
500mg and 1g injection.

Method of administration
Consider whether to use the injection. Alternatively, use the liquid, and flush with 15-30ml
of sterile water.41

Clinical guidance
Cephradine is a restricted use antibiotic at WMH. Contact Pharmacy for advice.

                                          Cetirizine

Presentation
10mg tablets.
5mg/5ml solution.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.94,104

                                       Chloral hydrate

Presentation
707mg chloral betaine (414mg chloral hydrate) tablets.
143.3mg/5ml elixir.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41,104 The liquid is light sensitive, so
give immediately.41


            Liquid dosage          =       15-45ml with water or milk at bedtime.106



                        Chlormethiazole (Clomethiazole)

Presentation
192mg capsule.
250mg/5ml syrup.

Clinical guidance
The syrup interacts with enteral feeding tubes, and should not be used.41 Contact Pharmacy
for advice on alternatives.
Produced by          Brenda Murphy, Pharmacist                                                     28
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Chloroquine

Presentation
250mg chloroquine phosphate (155mg chloroquine base) tablets.
200mg chloroquine sulphate (150mg chloroquine base) film-coated tablets.
68mg/5ml chloroquine sulphate (50mg/5ml chloroquine base) syrup.
54.5mg/ml chloroquine sulphate (40mg/ml chloroquine base) injection.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41 Alternatively the tablets can be
crushed.105

Clinical guidance
The liquid should not be given at the same time as antacids. Protect from light.41

                                      Chlorothiazide

Presentation
500mg tablets.
250mg/5ml suspension.

Method of administration
Use the suspension. The tablet can be crushed if necessary.7,40

                     Chlorpheniramine (Chlorphenamine)

Presentation
4mg tablets.
2mg/5ml syrup.
10mg/ml injection.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.40,94,104 Protect from light.41

                                     Chlorpromazine

Presentation
10mg, 25mg, 50mg, and 100mg coated tablets.
25mg/5ml and 100mg/5ml solution.
25mg/ml injection.
100mg suppositories (unlicensed).

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.94,104



Produced by          Brenda Murphy, Pharmacist                                                29
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                         Chlorthalidone (Chlortalidone)

Presentation
50mg and 100mg tablets.

Method of administration
The tablets will disperse in water.7,40 Follow the directions on page 6.

                        Cholestyramine (Colestyramine)

Presentation
4g sachets.

Method of administration
Use the sachets.

Clinical guidance
Cholestyramine affects the absorption of other medicines, so give all other medicines at least
one hour before or four-six hours after a dose of cholestyramine. Flush the feeding tube well
after each dose.41

                                          Cilazapril

Presentation
500mcg, 1mg, 2.5mg, and 5mg film-coated tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.

                                         Cimetidine

Presentation
200mg, 400mg and 800mg tablets.
200mg/5ml syrup.
200mg/2ml injection.

Method of administration
The syrup is incompatible with feeds so allow a time gap of one hour before and after feed.41
Dilute the syrup with the same volume of sterile water and flush post dose with 15-30ml of
sterile water. The injection is suitable to be given orally.40




Produced by          Brenda Murphy, Pharmacist                                              30
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Cinnarizine

Presentation
15mg tablets.
75mg capsules.

Method of administration
The tablets can be crushed and dispersed in water for administration.41,95 Follow the
directions on page 6.

                                        Ciprofibrate

Presentation
100mg tablets.

Method of administration
Tablets can be crushed and administered.104,105 Follow the directions on page 6.

                                       Ciprofloxacin

Presentation
250mg and 500mg tablets.
2mg/ml IV infusion.
250mg/5ml suspension.

Method of administration
Where possible ciprofloxacin should be administered intravenously however the tablets will
disperse,43 follow the directions on page 6. Flush with 65ml sterile water. The suspension is
not suitable to use, as it may block the tube.43

Crushed tablets have an extremely unpleasant taste so always use suspension for patients with
swallowing difficulties who do not have enteral tubes in situ.43

Clinical guidance
Tap water is not suitable to use, as minerals in the tap water may bind with ciprofloxacin and
decrease the amount of drug absorbed.36

                                         Affect of food

Ciprofloxacin interacts with enteral feeds to produce insoluble chelates11,12 and the absorption
of the drug is significantly reduced. A feeding break of one hour before and two hours after
the administration of ciprofloxacin is recommended.13 It has been shown that the absorption
is reduced by 28% when administered with Ensure and by 33% when administered with
Osmolite.14



Produced by          Brenda Murphy, Pharmacist                                                31
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                           Absorption

Ciprofloxacin is believed to be absorbed in the duodenum15 and not in the jejunum,
subsequently a dose increase should occur if administered through a NJ or jejunostomy tube.
Consult with ward pharmacist.

                                        Citalopram

Presentation
10mg and 20mg tablets.
40mg/ml drops.

Method of administration
Use the drops.

Clinical guidance
8mg (4 drops) of the oral drops is equivalent to a 10mg tablet.93

                                     Clarithromycin

Presentation
250mg and 500mg tablets.
125mg/5ml suspension.
500mg infusion.

Method of administration
The suspension is thick and may block the tube. Use of the infusion or switching to
erythromycin should be considered. If the suspension has to be used, dilute the dose with the
same volume of water immediately prior to administration.56

Clinical guidance
Do not dilute the suspension beyond manufacturer’s recommendations until administration,
as dilution of the preservative will occur, affecting the expiry of the product.56

                                       Clindamycin

Presentation
75mg and 150mg capsules.
150mg/ml injection.

Method of administration
Capsules can be opened and the contents dispersed in water.57 Follow the directions on page
8.

Clinical guidance
Give immediately. Capsule contents taste foul and may be unpalatable for oral
administration in patients with swallowing difficulties.57
Produced by          Brenda Murphy, Pharmacist                                             32
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Clobazam

Presentation
10mg tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.

                                      Clomipramine

Presentation
10mg, 25mg, and 50mg capsules.
75mg modified-release, film-coated tablets.
25mg/5ml liquid.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104 Alternatively the capsules can be
opened, and the contents dispersed in water for administration.104 Do not crush the modified
release tablets.

                                       Clonazepam

Presentation
500mcg and 2mg tablets.
2.5mg/ml oral drops (unlicensed).
500mcg/ml oral solution (unlicensed).
1mg/ml injection.

Method of administration
For patients with enteral feeding tubes, the tablets can be crushed and administered.7,40,94,104
Follow the directions on page 6.

The injection can also be given orally after dilution with 1ml water for injections.40

For patients with swallowing difficulties, use the oral drops or the solution.

Clinical guidance
Do not mix the drops or the solution with water as this will cause the drug to precipitate
out.105




Produced by          Brenda Murphy, Pharmacist                                                     33
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                          Clonidine

Presentation
25mcg and 100mcg tablets.
2.5mg and 5mg transdermal plasters.
150mcg/ml injection.

Method of administration
The injection can be administered orally/via enteral feeding tubes.100

Clinical guidance
There is no information on the use of tablets nasogastrically, so do not crush. The
transdermal plasters are indicated for the management of hypertension. However onset of
action takes 2-3 days, and so these are probably only suitable when the period for which the
patient needs them can be planned for.96

                                        Clopidogrel

Presentation
75mg tablet.

Method of administration
Tablets can be crushed and mixed with water for administration.42 Follow the directions on
page 6.

                                      Co-amilofruse

Presentation
2.5/20mg and 5/40mg tablets.

Method of administration
Give the components (frusemide and amiloride) separately as both are available as liquids.
Alternatively, the tablets can be crushed and mixed with water for administration,39,40 follow
the directions on page 6.

                                       Co-amilozide

Presentation
2.5/25 and 5/50 tablets (amiloride/hydrochlorothiazide).

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.




Produced by          Brenda Murphy, Pharmacist                                                 34
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                       Co-amoxiclav

Presentation
375mg (250/125) and 625mg (500/125) tablets (amoxycillin/clavulanic acid).
375mg (250/125) dispersible tablets.
125/31, 250/62, and 400/57 suspension.
600mg (500/100) and 1.2g (1000/200) injection.

Method of administration
Use the dispersible tablets or the liquid, and flush with 15-30ml of sterile water.94,104

                                        Co-codamol

Presentation
8/500, 15/500, and 30/500 tablets (codeine/paracetamol).
8/500 and 30/500 effervescent tablets.
8/500 and 30/500 capsules.
30/500 and 60/1000 sachets.

Method of administration
Use the effervescent tablets or the sachets.94,104

                                      Co-danthramer

Presentation
25/200 and 37.5/500 capsules (dantron/poloxamer)
25/200/5ml and 75/1000/5ml suspension.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104

                                           Codeine

Presentation
15mg, 30mg, and 60mg tablets.
25mg/5ml syrup.
15mg/5ml linctus.
3mg/5ml paediatric linctus.
60mg/ml injection.


Method of administration
Use the liquid, and flush with 15-30ml of sterile water.40,94,104




Produced by          Brenda Murphy, Pharmacist                                              35
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Colchicine

Presentation
500mcg tablets.

Method of administration
Tablets can be crushed and administered.104,105 Follow the directions on page 6.

                                     Co-phenotrope

Presentation
2.5/0.025 tablets (diphenoxylate/atropine).

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.

                                       Co-proxamol

Presentation
32.5/325 tablets (dextropropoxyphene/paracetamol).

Method of administration
Consider using an alternative analgesic which is available in a liquid, or can be given by a
non-enteral route. Alternatively, tablets can be crushed and administered.105 Follow the
directions on page 6.

                                       Co-tenidone

Presentation
50/12.5 and 100/25 tablets (atenolol/chlortalidone).

Method of administration
Tablet can be crushed for administration.58 Follow the directions on page 6.

Clinical guidance
Use immediately.58

                                     Co-triamterzide

Presentation
50/25 tablets (triamterine/hydrochlorothiazide).

Method of administration
Tablets can be crushed and administered.7,94,105 Follow the directions on page 6.


Produced by          Brenda Murphy, Pharmacist                                                 36
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                     Co-trimoxazole

Presentation
480mg and 960mg tablets.
240mg/5ml and 480mg/5ml suspension.
96mg/ml injection.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.40,104

                                          Cyclizine

Presentation
50mg tablets.
50mg/ml injection.

Method of administration
Consider using an alternative anti-emetic which is available as a liquid or suppositories, e.g.
metoclopramide, domperidone. Consider using injection.

Alternatively the tablets can be crushed and dispersed in water for administration.41,95 Follow
the directions on page 6. Protect from light.41

                              Cyclosporin (Ciclosporin)

Presentation
10mg, 25mg and 100mg capsule Neoral.
25mg, 50mg and 100mg capsule Sandimmun.
100mg/5ml oral solution Neoral.

Method of administration
Administer cyclosporin oral solution, Neoral. Do not flush with water after administering the
cyclosporin solution but use the same volume of orange juice instead.

Clinical guidance
Due to the oily component of the cyclosporin solution, adherence to the feeding tube may
occur and subtherapeutic doses are likely. Monitor drug levels closely. Leave a time gap of
one hour before administering next drug down the tube.

Dose equivalence depends on which brand of cyclosporin was used previously when
changing to the oral solution, consult with ward pharmacist.




Produced by          Brenda Murphy, Pharmacist                                                37
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                       Cyproterone

Presentation
50mg and 100mg tablets.

Method of administration
Tablets can be crushed for administration.59 Follow the directions on page 6.

Clinical guidance
No information available on whether cyproterone is likely to block tubes, or on the effect
crushing the tablets may have on absorption.59

                                        Dantrolene

Presentation
25mg and 100mg capsules.
20mg injection.

Method of administration
The capsules can be opened, and the contents dispersed in water or fruit juice for
administration.104,105

                                          Dapsone

Presentation
50mg and 100mg tablets.

Method of administration
The tablets can be crushed and dispersed in plenty of water for administration. Follow the
directions on page 6. Protect from light.41

                                        Deflazacort

Presentation
1mg, 6mg, and 30mg tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.




Produced by          Brenda Murphy, Pharmacist                                               38
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                     Demeclocycline

Presentation
150mg capsules.

Method of administration
A suspension can be prepared by Pharmacy. Do not open the capsules as the contents do not
disperse in water, and this has led to tube blockage.

                                      Desmopressin

Presentation
100mcg and 200mcg tablets.
10mcg/dose nasal spray.
100mcg/ml intranasal solution.
4mcg/ml injection.

Method of administration
Use the nasal route if appropriate. Alternatively the tablets can be crushed and
administered.104,105 Follow the directions on page 6.

                                    Dexamethasone

Presentation
500mcg and 2mg tablets.
2mg/5ml syrup.

Method of administration
Use the syrup and follow the directions on page 7.

                                         Diazepam

Presentation
2mg, 5mg and 10mg tablets.
2mg/5ml syrup, 5mg/5ml oral solution.
Diazepam injection solution.
Diazepam injection emulsion.
Diazepam rectal tubes.

Method of administration

                                          First choice

Administer by IM or IV route or by rectum.



Produced by          Brenda Murphy, Pharmacist                                          39
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Second choice

Administer syrup, but dilute well with sterile water, as it is viscous, and flush pre and post
dose with 15-30ml of sterile water.

Clinical guidance
If diazepam is administered through PVC, NG and NJ tubes, drug loss may occur as
diazepam is significantly adsorbed onto (portex) PVC.9,12 Diazepam may also contribute
towards blockage of tubes.

Diazepam is suitable for NJ and jejunostomy administration as it is absorbed through the GI
tract.

The rectal solution can be administered through the NJ, NG, PEG and jejunostomy tube.
Rectal doses are equivalent to doses given orally.1

                                   Diclofenac sodium

Presentation
25mg and 50mg enteric coated tablets.
50mg dispersible tablets.
75mg and 100mg modified release tablets.
75mg and 100mg modified release capsules.
12.5mg, 25mg, 50mg, and 100mg suppositories.
25mg/ml injection.
Topical gel.

Method of administration
Use the injection or the suppositories for acute situations. Alternatively use the dispersible
tablets.94,104,105 Do not crush/open the modified release preparations.

                           Dicyclomine (Dicycloverine)

Presentation
10mg and 20mg tablets.
10mg/5ml syrup.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41




Produced by          Brenda Murphy, Pharmacist                                                   40
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                           Digoxin

Presentation
62.5mcg, 125mcg and 250mcg tablets.
50mcg/1ml elixir.

Method of administration
Use elixir; flush post dose with 15-30ml of sterile water.

Clinical guidance
The absorption of digoxin is affected by high fibre feeds such as Jevity. Allow a time gap of
two hours before and two hours after administration of Digoxin before administering high
fibre feeds.
The elixir has a different bioavailability from the tablets so dose adjustments are necessary.
Seek advice from ward pharmacist.


                   62.5mcg                  equivalent to             50mcg
                 Digoxin tablet                                    liquid (1ml)




                                     Dihydrocodeine

Presentation
30mg tablets.
10mg/5ml suspension.

Method of administration
Use suspension; flush post dose with 15-30ml of sterile water.

                                          Diltiazem

Presentation
Tablets and capsules are modified release.
There is no liquid formulation available.

Clinical guidance
All tablets and capsules are labelled as modified however the 60mg generic preparation is not
slow release and can be crushed.14 Follow directions on page 6.

Alternatively, switch to amlodipine. Contact ward pharmacist for advice.




Produced by          Brenda Murphy, Pharmacist                                               41
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                       Dipyridamole

Presentation
25mg and 100mg sugar coated tablet.
200mg modified release capsule.
10mg/2ml injection.
50mg/5ml suspension.

Method of administration
Administer the suspension, dilute with 30ml of sterile water. Alternatively use the injection
orally.44 Flush post dose with 15-30ml of sterile water.

Clinical guidance
A dosage adjustment is required for modified release capsules. Contact ward pharmacist for
advice.

                                      Disopyramide

Presentation
100mg and 150mg capsules.
150mg and 250mg controlled release capsules.
50mg/5ml injection.

Method of administration
The standard capsules can be opened and the contents mixed with water for administration
via enteral feeding tubes.87 Follow the directions on page 8.

The injection can be used orally if necessary. It has a strong, bitter taste, and a local
anaesthetic effect in the mouth, and so should be used with care if given orally to patients
with swallowing difficulties.40,97

Clinical guidance
The controlled release capsules should not be used. Seek advice from Pharmacy for patients
maintained on controlled release capsules.

                                          Docusate

Presentation
100mg capsule.
50mg/5ml adult oral solution. 12.5mg/5ml paediatric oral suspension.

Method of administration
Use liquid preparation. Flush post dose with 15-30ml of sterile water. Do not open the
capsule.41



Produced by          Brenda Murphy, Pharmacist                                                  42
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                      Domperidone

Presentation
10mg tablet.
5mg/5ml sugar free suspension.
30mg suppositories.

Method of administration
Use the sugar free suspension. Flush post dose with 15-30ml of sterile water. Alternatively
the suppositories can be used.

                                         Donepezil

Presentation
5mg and 10mg film-coated tablets.

Method of administration
Tablets can be crushed and administered.104,105 Follow the directions on page 6.

                                Dothiepin (Dosulepin)

Presentation
25mg capsules.
75mg tablets.
25mg/5ml liquid.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104 The tablets have been crushed but
this is not recommended as they have a local anaesthetic action.105

                                         Doxazosin

Presentation
1mg, 2mg, and 4mg tablets.
4mg and 8mg modified release tablets.

Method of administration
The standard tablets can be crushed and mixed with sterile water for administration.37 Follow
the directions on page 6.
The modified release tablets are not suitable for tube administration. Contact ward
pharmacist for advice.

Clinical guidance
Sterile water must be used, and no other drugs/fluids should be mixed with doxazosin as the
drug will precipitate in the presence of chloride ions. Flush tube well with water before and
after each dose.37
Produced by          Brenda Murphy, Pharmacist                                              43
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                          Doxepin

Presentation
10mg, 25mg, 50mg, and 75mg capsules.

Method of administration
The capsules can be opened, and the contents dissolved in water.37 Follow the directions on
page 8.

                                        Doxycycline

Presentation
50mg and 100mg capsules.
100mg dispersible tablets.

Method of administration
Use the dispersible tablets.
Do not open the capsules as the contents are irritant.94

Clinical guidance
Doxycycline binds to calcium ions and may have reduced absorption when given via enteral
feeding tubes. Prescribe at the higher end of the standard dosage range.94

                                    Dydrogesterone

Presentation
10mg tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.

                                          Enalapril

Presentation
2.5mg, 5mg, 10mg and 20mg tablets.

Method of administration
The tablets can be crushed and dispersed in water for administration,40,41 flush post dose with
15-30ml of sterile water. Follow the directions on page 6.

Clinical guidance
No ACE inhibitor is available in a liquid or injectable form, consult with ward pharmacist for
a suitable alternative(s).




Produced by          Brenda Murphy, Pharmacist                                               44
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Entacapone

Presentation
200mg film-coated tablets.

Method of administration
Tablets can be crushed and administered.104,105 Follow the directions on page 6. Entacapone
does not fully dissolve in water, so flush well after administration. The drug also stains
orange, and may stain an enteral feeding tube.105

                                       Erythromycin

Presentation
250mg capsules.
250mg and 500mg film-coated tablets.
125mg/5ml, 250mg/5ml, and 500mg/5ml suspension.
1g injection.

Method of administration
Consider whether using the injection is appropriate. Alternatively, use the liquid, and flush
with 15-30ml of sterile water.94,104

                                       Escitalopram

Presentation
10mg film-coated tablets.

Method of administration
Consider switching to citalopram as this is available in a liquid form. Alternatively, the
tablets can be crushed and administered.105 Follow the directions on page 6. Flush well as
the tablets are poorly soluble.

                                      Esomeprazole

Presentation
20mg and 40mg film-coated tablets.

Clinical guidance
Consider switching to lansoprazole ‘Fastabs’.




Produced by          Brenda Murphy, Pharmacist                                                  45
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Ethambutol

Presentation
100mg and 400mg tablets.

Method of administration
Tablets can be crushed and administered.104,105 Follow the directions on page 6.

                             Ethamsylate (Etamsylate)

Presentation
500mg tablets.

Method of administration
Tablets can be crushed and administered.104 Follow the directions on page 6.

                                      Ethosuximide

Presentation
250mg capsules.
250mg/5ml syrup.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41,104

                                         Etidronate

Presentation
200mg tablet.

Method of administration
Crush the tablet and disperse in water for administration via enteral feeding tube.104,105
Follow the directions on page 6.

Clinical Guidance
Flush post dose with 50ml of sterile water. Stop feed two hours before and two hours after
administration of etidronate.

                                        Famciclovir

Presentation
125mg, 250mg, 500mg, and 750mg tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6.

Produced by          Brenda Murphy, Pharmacist                                               46
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                            Felodipine

Presentation
2.5mg, 5mg, and 10mg modified release tablets.

Clinical guidance
Felodipine tablets should not be crushed and are not suitable for enteral feeding tube
administration.60 Consider amlodipine as an alternative. Consult ward pharmacist to discuss.

                                           Fenofibrate

Presentation
67mg, 200mg, 267mg capsules. 160mg modified release tablet.

Method of administration
The capsules can be opened and the contents dispersed in water.61 Follow the directions on
page 8.
The modified release tablet is not suitable for enteral tube administration.

                                       Ferrous sulphate

Presentation
200mg enteric coated tablet.

Method of administration
Use ferrous fumarate liquid.

Clinical guidance
                                          Preparations35

Ferrous sulphate200mg tablets contain 65mg              ferrous fumurate140mg/5ml solution
of iron                                                 contain 45mg of iron

                                         Equivalent doses

                     200mg tablet                                    7.2ml liquid
                       200mg tds                                     10ml bd




Produced by             Brenda Murphy, Pharmacist                                            47
Updated by              Jen Smyth, Pharmacist
Checked by              Sue Lord, Pharmacist
Date of Production       January 2004
                                      Fexofenadine

Presentation
120mg and 180mg tablets.

Method of administration
Consider switching to an alternative antihistamine available as a liquid, e.g. loratadine.
Alternatively the tablets can be crushed and adminstered.62 Follow the directions on page 6.

Clinical guidance
Tablets should be given on an empty stomach, so leave a 2 hour feed gap either side of
administration.62

                                        Finasteride

Presentation
5mg film coated tablet.

Method of administration
The tablet will dissolve in water.63 Follow the directions on page 6.

Clinical guidance
Women who are or who may become pregnant should not handle crushed, broken, or
dissolved tablets.64

                                         Flavoxate

Presentation
200mg film-coated tablets.

Method of administration
Tablets can be crushed and administered.105 Follow the directions on page 6. Flavoxate has a
bitter taste when crushed. Flush tubes well after dosing.105




Produced by          Brenda Murphy, Pharmacist                                             48
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Flecainide

Presentation
50mg and 100mg tablets.
25mg/5ml oral liquid.

Method of administration
Use the liquid. If necessary, tablets can be crushed and dispersed in water for
administration.40 Follow the directions on page 6. Crushed tablets have a local anaesthetic
effect, so should be used with care in patients with swallowing difficulties.40

Tablets should be flushed with sterile water, and should not be mixed with alkali solutions,
sulphate, phosphate, or chloride ions.95 Do NOT mix this drug with other medications prior
to administration.

                                       Flucloxacillin

Presentation
250mg and 500mg capsules.
125mg, 250mg and 500mg liquid.
250mg, 500mg and 1g injection.

Method of administration
For short courses, consider using the injection. Alternatively, use the liquid, and flush post
dose with 15-30ml of sterile water.

Clinical guidance
Stop feed for half to one hour before and after administration of flucloxacillin liquid.
Flucloxacillin has to be given on an empty stomach.35 If this is not possible then consider
increasing dose and decreasing frequency of administration.

                                        Fluconazole

Presentation
50mg, 150mg, and 200mg capsules.
50mg/5ml and 200mg/5ml suspension.
50mg and 200mg infusion.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104

Clinical guidance
Fluconazole interacts with Jevity enteral feeds. Stop the feed for one hour before and one
hour after each dose of fluconazole.105



Produced by          Brenda Murphy, Pharmacist                                                   49
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                     Fludrocortisone

Presentation
100mcg tablets.

Method of administration
The tablets will disperse in water.7,40,41 Follow the directions on page 6.

                                         Fluoxetine

Presentation
20mg capsule.
20mg/5ml liquid.

Method of Administration
Use liquid and dilute with the same volume of sterile water, flush post dose with the 15-30ml
of sterile water.

Clinical guidance
Absorption of fluoxetine appears to occur through the GI tract 9,16 and is well absorbed when
given through a NJ and jejunostomy tube. Fluoxetine liquid is the preferred preparation for
administration and it does not contain sorbitol.

                             Flupenthixol (Flupentixol)

Presentation
3mg sugar-coated tablets.
20mg/ml, 100mg/ml, and 200mg/ml depot injections.

Method of administration
The tablets can be crushed and administered.105 Follow the directions on page 6. The tablets
are poorly soluble, so flush well after dosing. Crushed tablets can also be mixed with fruit
juice for administration to patients with swallowing difficulties.104

                                       Fluphenazine

Presentation
1mg, 2.5mg, and 5mg tablets.

Method of administration
The tablets can be crushed and dispersed in water for administration.41 Follow the directions
on page 6.




Produced by          Brenda Murphy, Pharmacist                                              50
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                         Flutamide

Presentation
250mg tablets.

Method of administration
The tablets can be crushed and mixed with milk or fruit juice for administration.105

                                        Fluvastatin

Presentation
20mg and 40mg capsules. 80mg modified release tablet.

Method of administration
The capsules can be opened and the contents administered.65 Follow the directions on page
8.
The modified release tablet is not suitable for tube administration. Contact ward pharmacist
for advice.

Clinical guidance
There is no information available on whether fluvastatin is likely to block enteral feeding
tubes. Flush well.65

                                       Fluvoxamine

Presentation
50mg and 100mg tablets.

Method of administration
The tablets can be crushed and administered.105 Follow the directions on page 6.

                                          Folic acid

Presentation
400mcg and 5mg tablets.
400mcg/5ml and 2.5mg/5ml syrup.
15mg injection.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.94,104




Produced by          Brenda Murphy, Pharmacist                                                51
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                          Forceval

Presentation
Capsules and junior capsules.

Method of administration
Consider switching to an alternate multivitamin preparation available as a liquid.
Alternatively, snip off the end of the forceval capsule and withdraw the contents using a
syringe. – Take great care when using a syringe to prepare an ORAL dosage. The contents of
forceval capsules taste foul.

                                         Fosinopril

Presentation
10mg and 20mg tablets.

Method of administration
The tablets can be crushed and administered.105 Follow the directions on page 6.

                              Frusemide (Furosemide)

Presentation
20mg, 40mg and 500mg tablets.
1mg/1ml liquid.
40mg/5ml syrup.

Method of administration
Use liquid and dilute with the same volume of water. Flush post dose with 15-30ml of sterile
water.

                                           Fybogel

Clinical Guidance
Do not use as it may congeal and block the tube.

                                        Gabapentin

Presentation
100mg, 300mg and 400mg capsules.

Method of administration
Open the capsule, dissolve the contents in water, and give immediately (gabapentin has
limited stability in water).37 Has a bitter taste.37 Follow the directions on page 8.

Clinical guidance
Do not give at the same time as aluminium/magnesium antacids.35
Produced by          Brenda Murphy, Pharmacist                                            52
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                       Galantamine

Presentation
4mg, 8mg, and 12mg film-coated tablets.
4mg/ml solution.

Method of administration
Use the solution if it is available. Alternatively the tablets can be crushed and
administered.104 Follow the directions on page 6.

                                        Ganciclovir

Presentation
250mg and 500mg capsules.
500mg infusion.

Clinical guidance
Do not open the capsule.41 Contact Pharmacy for advice.

                                      Glibenclamide

Presentation
2.5mg and 5mg tablets.

Method of administration
The tablets can be crushed and administered.62 Follow the directions on page 6.

Clinical guidance
Give just before the start of a feed.62 Consider whether sliding scale insulin is more
appropriate for management.

                                         Gliclazide

Presentation
80mg tablet.

Method of administration
Crush the tablets well and mix with water for administration.45 Follow directions on page 6.
Consider switching to sliding scale insulin.




Produced by          Brenda Murphy, Pharmacist                                             53
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                        Glimepiride

Presentation
1mg, 2mg, 3mg, and 4mg tablets.

Clinical guidance
Crushing the tablets may affect their bioavailability.62 Consider whether sliding scale insulin
would be more appropriate for patient management.

                                          Glipizide

Presentation
2.5mg and 5mg tablets.

Method of administration
Crush the tablets and disperse in water.66 Follow the directions on page 6.

Clinical guidance
No information available on whether glipizide is likely to block tubes. Consider whether
sliding scale insulin would be more appropriate for patient management.66

                                   Glyceryl trinitrate

Presentation
Acute use preparations.
300mcg, 500mcg, and 600mcg sublingual tablets.
400mcg sublingual spray.
1mg/ml and 5mg/ml injection.

Prophylaxis preparations.
2mg, 3mg, and 5mg modified release buccal tablets.
2.6mg, 6.4mg, and 10mg modified release tablets.
5mg/24hours, 10mg/24hours, and 15mg/24hours transdermal patches.
2% ointment.

Method of administration
Acute use preparations.
For patients with an unsafe swallow, use the sublingual spray.

Prophylaxis preparations.
Buccal tablets can be continued in patients who are able to use them appropriately.
Modified release tablets intended for swallowing are not appropriate for crushing. Consider
switching to transdermal patches.

Clinical guidance
The sublingual and buccal tablets require moisture in the mouth for adequate absorption, and
may be less effective in patients with swallowing difficulties.
Produced by          Brenda Murphy, Pharmacist                                               54
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                     Glycopyrronium

Presentation
1mg and 2mg tablets (named patient only).40
200mcg/ml injection.

Method of administration
Consider using subcutaneous doses when required, or a subcutaneous infusion by syringe
driver. Alternatively if the tablets are available, they can be crushed and administered.40
Follow the directions on page 6.

                                        Granisetron

Presentation
1mg and 2mg film-coated tablets.
1mg/5ml liquid.
1mg/ml injection.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.41

                                        Haloperidol

Presentation
1.5mg, 5mg, 10mg and 20mg tablets.
2mg/ml oral liquid.

Method of administration
Use liquid preparation and dilute with the same volume of sterile water. Flush post dose with
15-30ml of sterile water.

                                        Hydralazine

Presentation
25mg and 50mg sugar-coated tablets.
20mg injection.

Method of administration
The injection can be made up with Water for Injections and administered orally.98
The tablets can be crushed,98 but are sugar-coated and are likely to block feeding tubes.

Clinical guidance
Hydralazine absorption is reduced in the presence of enteral feeds. Monitor blood
pressure.87,90,95
Hydralazine injection, when used for oral/feeding tube administration, should only be made
up with Water for Injections, as it interacts with metal ions found in other water sources.98
Produced by          Brenda Murphy, Pharmacist                                                  55
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                                     Hydrocortisone

Presentation
10mg and 20mg tablets.
100mg/ml injection.

Method of administration
Tablet is insoluble but can be finely crushed and administered. Follow the directions on page
6. A keltrol-based suspension can be made in pharmacy.63

                                 Hydroxychloroquine

Presentation
200mg film-coated tablets.

Method of administration
The tablets can be crushed and administered.104,105 Follow the directions on page 6.

                       Hydroxyurea (Hydroxycarbamide)

Presentation
500mg capsules.

Method of administration
The capsules can be opened, and the contents dispersed in water for administration.105 Handle
with care - cytotoxic.

                                       Hydroxyzine

Presentation
10mg and 25mg sugar-coated tablets.
10mg/5ml syrup.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.94,104

                               Hyoscine butylbromide

Presentation
10mg coated tablets.
20mg/ml injection.

Method of administration
Do not crush the tablet. The injection can be administered orally.44 Flush post dose with 15-
30ml of sterile water.

Produced by          Brenda Murphy, Pharmacist                                              56
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                               Hyoscine hydrobromide

Presentation
300mcg tablet.
1mg/72hr patch (Scopoderm).
400mcg/ml injection.

Method of administration
Consider using the patch or the injection. The tablets may be sucked if the patient is able,
and absorbed through the lining of the mouth,103 although the level of absorption may vary,
particularly in patients with little saliva. The tablets can also be dissolved103 for
administration via enteral tube, but again, absorption may vary.

                                         Ibuprofen

Presentation
200mg, 400mg, and 600mg sugar-coated tablets.
100mg/5ml syrup.
600mg effervescent sachets.
800mg modified release tablets.
300mg modified release capsules.

Method of administration
Use the liquid, and flush with 15-30ml of sterile water.104

                                        Imipramine

Presentation
10mg and 25mg coated tablets.
25mg/5ml syrup (may not be available).

Method of administration
Use the liquid, if available, and flush with 15-30ml of sterile water.104,105 The drug may
adsorb to the tube, so flush well after dosing.

                                        Indapamide

Presentation
2.5mg coated tablets.
1.5mg modified release tablets.

Method of administration
The standard tablets can be crushed and administered.104,105 Follow the directions on page 6.
Do not crush the modified release tablets.



Produced by          Brenda Murphy, Pharmacist                                                 57
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004
                           Indomethacin (Indometacin)

Presentation
25mg and 50mg capsules.
25mg/5ml sugar free suspension.
100mg suppositories.
Modified release capsules and tablets.

Method of administration
Use the suspension or suppositories. If using the suspension, flush post dose with 15-30ml of
sterile water.

Clinical guidance
The modified release capsules are irritant on the stomach, so do not open.
Do not crush tablets.

                                         Indoramin

Presentation
20mg tablets (Doralese).

Method of administration
Tablets can be crushed.67 Follow the directions on page 6.

                                         Irbesartan

Presentation
75mg, 150mg, and 300mg tablets.

Method of administration
Tablets can be crushed and dispersed in water for administration.68 Follow the directions on
page 6.

Clinical guidance
No information available to indicate whether irbesartan is likely to block enteral feeding
tubes.68




Produced by          Brenda Murphy, Pharmacist                                               58
Updated by           Jen Smyth, Pharmacist
Checked by           Sue Lord, Pharmacist
Date of Production    January 2004

				
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