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MEDICATION ADMINISTRATION IN PATIENTS having swallong difficulties
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DRUG CRUSH OR OPEN?
DETAILS CAN INJECTION BE USED ORALLY?
LICENSED ALTERNATIVE?
THERAPEUTIC ALTERNATIVE?
SPECIAL AVAILABLE (PRICE) (£) (CORRECT AS JUNE 2011)
ABACAVIR Yes Manufacturer states no reason why crushing tablets would create stability concerns as long as administered immediately.
Liquid available
ACARBOSE Yes Can chew tablets with first mouthful of food. Tablets do not disperse easily in water but require gentle agitation for approx 5 minutes. Suspension can be flushed down 8Fr NG tube
Consider changing to insulin if appropriate
ACEBUTOLOL Yes Change to other beta-blocker available in liquid if absolutely necessary
ACETAZOLAMIDE Non-MR can be dispersed in water
If taking MR capsules convert to normal release. These disintegrate quickly in 10ml water which settles quickly and flushes down 8Fr NG tube without blockage but rinse all through to ensure total dose given
Injection can be taken orally or enterally – see handbook. May be stored in fridge for up to 24 hours
ACENOCOUMAROL Yes Disperse in 10ml water within 5 minuts to give dispersion which flushes via 8Fr NG tube without blockage
MEDICATION ADMINISTRATION IN PATIENTS WITH SWALLOWING DIFFICULTIES/DYSPHAGIA
TO SEARCH:HOLD DOWN CONTROL AND PRESS F THEN TYPE ITEM REQUIRED. For more information please ring pharmacy or ring manufacturers.
Preference - Crush tablets or open capsules first; then use licensed and therapeutic alternative after this and special use should be last resort due to cost implications
ACETYLCYSTEINE See over Tablets are effervescent 600mg BUT special
Injection solution diluted to 50mg/ml can be given orally or enterally. Very bitter. blackcurrant Orange syrup, orange juice or coke used
600mg tablets (100) £21
ACICLOVIR Dispersible tablets
Syrup available
ACITRETIN Open capsules immediately before use and take contents with food
Not water-soluble and are degraded by light. WARNING: not to be handed by women of childbearing potential.
Syrup available 5mg/5ml x 75ml £59
ALFACALCIDOL No One-Alpha injection administered orally or via feeding tube
Yes - injection
ALFUZOSIN Non-MR can be dispersed in water
Convert MR to standard release (commence at 2.5mg tds as risk of hypotension)
ALIMEMAZINE Yes Blue film-coating can be washed off tablets to make them easy to crush. Disperse in 1-2 minutes
Syrup available
ALLOPURINOL Yes Disperse in 10ml water for 5 minutes to form dispersion that flushes down 8FR NG tube without blockage
ALVERINE Yes Powder has anaesthetic effect on lips and oral mucosa
Convert to mebeverine if necessary
AMANTADINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes Syrup available
AMILORIDE Yes Syrup available
AMINOPHYLINE Do not crush MR
Theophylline liquid
AMIODARONE Yes Very bitter taste – mix with fruit juice or jam if neccessary
100mg/5mg x 100 ml £76
AMITRIPTYLINE Yes Bitter taste. MR capsules can be emptied out but swallow granules whole. Tablets do not disperse but can be crushed and disperse in 10ml water.
Syrup available
AMLODIPINE Yes Give immediately as light sensitive. Disperse in 10ml of water in 2 minutes to give dispersion that settles – flushes down an 8Fr NG tube without blockage.
Syrup available
ANASTROZOLE Yes Can be chewed if possible. WARNING: not to be handed by women of childbearing potential. Tablets disperse in 10ml water to give clear dispersion that lfushes down 8Fr NG tube without blockage.
ARTHROTEC® No NSAID plus gastro protection
ASASANTIN RETARD No Dispersible aspirin and liquid dipyridamole.Granules may be given whole, not chewed NB may clog tube.
ASCORBIC ACID Yes
ATOMOXETINE Yes Open capsules
ATENOLOL Yes Syrup available
ATORVASTATIN Yes Rinse residual tablet material down NG/PEG tube (does not disperse completely). Be aware that the insoluble powder may cause blockage. Or can sprinkle on cold, soft food.
ATROPINE Injection may be given orally and enterally
AZATHIOPRINE Yes but… Tablet can be crushed but should not be done on ward due to risk of exposure
50mg/5ml x 150ml £12
AZITHROMYCIN No Syrup available. Problems with feeds
BACLOFEN Yes Syrup available
BALSALAZIDE No Manufacturer advises that the capsules are NOT opened as the drug contains an AZO (DYE)-BOND and can badly stain skin, teeth etc that it comes into contact with
Use alternative treatment if necessary e.g. sulasalazine – see liquid available
BENDROFLUMETHIAZIDE Yes Disperse in 2 minutes when placed in 10ml water & give fine dispersion
Syrup available Other thiazides – Indapamide. Loop diuretics – furosmide and bumetanide oral solutions available
BENZTROPINE Injection may be given orally and enterally although manufacturer cannot recommend.
BETAHISTINE Yes When crushed finely the powder mixes easily with water and flushes down 8Fr NG tube
BEZAFIBRATE Yes if Non-MR Risk of tube blockage with MR – change to non-MR and can be dispersed in 10ml water and shake for 5 minutes to form coarse dispersion that may block fine-bore tubes but can be flushed through 8Fr NG tube
BICULTAMIDE Very insoluble Crush finely and suspend in water. . WARNING: not to be handed by women of childbearing potential
BISACODYL No Do not crush EC – irritant effect on stomach
Suppositories available
BISOPROLOL Yes Risk of tube blockage due to film coating. But do disintegrate rapidly in 10ml water to form fins suspension that flushes down 8Fr NG tube without blockage.
Atenolol liquid
BROMOCRIPTINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes NB Parlodel® tablets are autocatalytic and will begin to disintegrate as soon as they are broken up- administer immediately. Mix contents with water when powder if wetted; forms fine dispersion that fushes easily via 8Fr NG tube without blockage
BUDESONIDE Yes Opening capsules may cause the drug to be released in the wrong part of the intestine. Do not open MR capsules. May mix granules with fruit juice. Granules may stick to the side of enteral feeding tube.
BUMETANIDE Yes Syrup available
BURINEX A Yes Administer as separate components as liquid
BUSPIRONE Yes Take 5 minutes
CABERGOLINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes Tablets do not disperse readily in water but if shaken in 10ml water for 5 minutes will give clear solution which flushes via 8Fr NG tube without blockage.
CALCIUM CARBONATE Yes Calcichew, Cacit and Tiraloc disperse in water. Same applied for Vitamin D components also e.g. Cacit D3 granules.
Syrup available- Calcium-Sandoz
CALCIUM FOLINATE Yes Injection can also be given orally or enterally. Tablets disperse in 10ml water within 5 minutes and given via 8Fr NG tube without blockage.
Injection may be given orally or enterally
CALCIUM RESONIUM No When mixed with water resulting paste too think to administer via feeding tubes.
Enema available
CANDERSARTAN Yes Insoluble in water – administer immediately
Consider changing to ACEI
CAPECITABINE Yes see next column
Dissolve without crushing tablet in small amount of warm water. Takes approx 15 minutes
Normal tablets are special – 2mg x 100 £2325mg/5ml x 100ml £27
5mg/5ml £65
Suppositories or liquid available. 125mg rectal dose is equivalent to 100mg oral dose. Maximum dose by rectal route is 250mg qds. If patient has been taking MR tablets give the same total daily dose divided into three or four doses.
PEG/NG – enteral feeds may affect carbamazepine absorption – leave two-hour gap before and after dose, especially with Isocal® and Ensure plus®. NB also risk of adsorption onto PVC feeding tubes. If this is long term use, then measure levels and adjust dose accordingly. Liquid should be mixed with equal volume of water just prior to administration and flushed down tube well to minimise adsorption onto tubes.
CAPTOPRIL Yes Tablets disperse in 10ml water within 2 minutes to give suspension that flushes down 8Fr NG tube.
Can also be given S/L- dose should be halved and given twice as frequently e.g., 12.5 mg tds=6.25 mg 6 times a day
CARBAMAZEPINE No
CARBIMAZOLE Yes Tablets disperse in 10ml and shaken vigorously for 5 minutes 0 give via 8Fr NG tube without blockage
Syrup available 30mg/5ml x 100ml £7
CARBOCISTEINE No Liquid available
CARVEDILOL Yes Disperses in 1-5 minutes immediately before administration as small particles will form in water
CEFALEXIN No Liquid available
CEFUROXIME Yes Disperse in water and administer however should be avoided as risk of sensitisation
Liquid and injection available
CELECOXIB No Capsule contents have low aqueous solubility and poor stability, but can be removed just prior to administration. May be added to cold or room-temperature apple sauce if swallowing difficulties
Change to rofecoxib liquid
CELIPROLOL Yes
CETIRIZINE No Tilomed brand disintergrate if shaken in 10ml water for 5 minutes.
Liquid available
200mg/5ml x 200ml £2
No Consider alternative in elderly patient e.g. benzos, - temazepam
CHLORAL HYDRATE
200mg/5ml x 50ml £15
500mg/5ml x 200ml £8
CHLORDIAZEPOXIDE Yes
CHLOROQUINE Yes Crush to ensure film-coating is broken. Very bitter taste
Liquid available – do not give at same time as antacids
CHLORPHENAMINE No Injection can be given orally.
Liquid available. Acid solution. Direct interaction of drug and feed causing coagulation in the tube. Dilute with equal volume of water
CHLORPROMAZINE No Suppositories, injection and liquid available
CHLORTALIDONE Yes Take care to give all, as it will sediment quickly.
CICLOSPORIN Yes Do not give via tubes as it will adsorb to the plastic
Concentrate for infusion and liquid available
CILAZAPRIL Yes Flush tube well after dose – may block
CIMETIDINE Yes Incompatible with feeds – stop one hour before and after. Dilute with same volume of sterile water and flush post dose
Injection can be given enterally. May be reduced absorption when cimetidine administered directly into jejunum.
Liquid and injection available.
CINNARIZINE Yes Disperse in 10ml water and flushes easily via 8FR Ng tube
Change to Promethazine Hydrochride
CIPROFIBRATE Yes
Ciprofloxacin absorption may be reduced by up to 25% by interaction with Jevity®, Ensure® and Resource® and also chelated by ions in tap water.
Stop feed for 1 hour before and 2 hours after dose. Consider increasing dose if feed needs to be continued.
Use distilled water for dissolving tablets/flushing tubes.
CITALOPRAM Yes The powder is poorly soluble so care should be taken to not block tube. 8 drops of the liquid is equivalent to 20mg tablet. REF. Can add water to required number of drops. Flush tube well to prevent clogging.
Oral drops available
CLARITHROMYCIN Yes Liquid available, may clog tube so dilute with same volume of water prior to administration
Unpleasant taste and odour – try masking with flavoured syrup e.g. blackcurrant, cherry.
Liquid availableCIPROFLOXACIN Yes – disperse in 30-60ml of sterile water and take
75mg/5ml x 80ml £9
CLINDAMYCIN Yes Suspension has been discontinued in the UK but can be imported through IDIS from other countries
Capsules open easily and powder pours from capsule when squeezed; care must be taken to ensure entire contents are emptied out. Mixes easily with water and flushes via 8Fr Ng tube without blockage
5mg/5ml x 150ml £35
5mg/5ml x 100ml £3
CLOMETHIAZOLE No Liquid available
CLOMIPRAMINE Yes (non-MR capsules only)
Small capsules – mix with water and flush down 8Fr NG tube without blockage.
Consider changing to alternative tricyclic
125mcg/5ml x 150ml £130
2mg/5ml x 150ml £46
500mcg/5ml x 150ml £39
CO-AMILOFRUSE Yes Give components separately as liquids
CO-AMILOZIDE Yes
Liquid and injection available. Do not mix suspension with water - it will create an emulsion and the active ingredient will precipitate out.
CLOBAZAM Yes
CLONAZEPAM Yes Injection solution may be given orally or enterally after dilution with 1ml water for injection. Excipients include ethanol, glacial acetic acid, benzyl alcohol and propylene glycol.
Liquid and dispersible tablets available. 250/62 syrup is designed for children - for dysphagic adults use dispersible tablets.
NG/PEG –if syrups are used, thin with an equal quantity of water before putting down tube (avoids ‘crusting’ of tube with syrup).
CO-APROVEL No Give separate components and see on hereDipsersible tablets available. Administer immediately once dissolved.
Do not empty the MR capsule - the capsule shell is part of the MR mechanism.
NB dispersible tablets have a quicker onset and shorter duration of action and cannot be substituted for normal release without a review of therapy. Give at different time to feed as may interfere with absorption of levodopa. Do not open capsules
CO-CARELDOPA (Sinemet ®preparations) SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION
Yes Administer immediately once dissolved. Do not crush M/R products
CO-CODAMOL Yes dispersible available
CO-DANTHRAMER Liquid available - now very limited indications for this drug
CO-DYRAMOL No Liquid available or convert to soluble/liquid components
CODEINE Yes Dispersion occurs slowly Liquid available
CO-AMOXICLAV Yes
CO-BENELDOPA (Madopar ®' preparations) SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION
No
COLECALCIFEROL See Calcium and Vitamin D
30units/1ml x 100ml £100
CO-PHENOTROPE Yes Disperse in water and flush down 8Fr NG tube without blockage.
CO-TENIDONE Yes however should suspend in
CO-TRIAMTERIZDE Yes
CO-TRIMOXOZOLE No Liquid and dispersible tablets available
COLCHICINE Yes Disperses in 2 minutes when placed in 10ml water to give coarse dispersion that breaks up further when drawn into syringe. Flushes down 8Fr Ng tube without blockage.
CO-PROXAMOL Yes Suggest using alternative analgesic e.g. co-codamol 8/500 solubleCOVERSYL No Switch to perindopril and
indapamide
CYCLIZINE Yes Powder may be mixed with food or syrup (to mask bitter taste) for administration.
Injection available and can be given enterally but manufacturers do not recommend.
50mg suppositories x 12 £46
CYCLOPENTHIAZIDE Yes
CYCLOPHOSPHAMIDE No Injection can be used to prepare solution for oral use. It has been used enterally.
50mg/5ml x 100ml £56
CYPROPHEPTADINE Yes
CYPROTERONE Yes
DANTROLENE Yes Powder may be emptied from capsule and mixed - with orange juice or other acidic liquid.
DAPSONE Yes Protect from light, use immediately
DEFLAZACORT Yes Disintegrates in water and flushes down 8Fr NG tube without blockage
DEFERIPRONE No Liquid available
Remove capsule contents, mix with water and flush down tube.
Contents do not disperse in water and tube blockage has been reported. Flush well
Consider whether the patient is fluid restricted as this is often the case if this drug is being used to treat SIADH
Irritant to the mucosa- DO NOT open for oral administration
Absorption reduced by calcium- Withhold feed 1 hour before and 2 hours post dose
DESMOPRESSIN Yes Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube
Nasal or sublingual route available
DEXAMETHASONE Yes Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube. Settles quite quickly
Can dilute and administer the injection orally or enterally.
Liquid available.
10mg/5ml x 200ml £29
2.5mg/5ml x 500ml £14
DICLOFENAC No Tablets are E/C or M/R and should not be crushed. Injections should be limited to max. 2 days treatment. Some MR capsules can be emptied and the contents given, but for some brands the capsule shell is involved in the slow release mechanism so cannot be emptied.
Liquid, dispersible tablet, suppositories , injection and emulgel available
50mg/5ml x 150ml £30
DEMECLOCYCLINE Yes
Liquid available but may absorb into plastic tubing. Suppositories available as well as IM or IV preps.
DIAZEPAM Yes PEG/NG – syrup/crushed tablets not recommended as drug may adsorb onto tubing. APS brand disperses within 2 minutes in 10 ml water and give via 8Fr Ng tube
Injection has been given enterally, however manufacturers do not recommend. Drug loss may occur if administered through long PVC tubes as it is significantly absorbed onto PVC. It may also contribute to blockage of tubes
DICYCLOVERINE Yes Liquid available
Bioavailability of liquid differs from that of the tablets i.e. 65% for tablets vs. 75% for liquid. The company recommends that dose changes are not generally necessary – monitor levels after change. Do not dilute liquid.
IM NOT recommended. Contact pharmacy for information on IV use. If converting from IV to oral give 20% reduced doseLeave a two hour gap in the feed before and after administering the dose.
DIHYDROCODEINE Yes (but not MR)
Liquid available
Preparations that are once or twice daily all MR, so crushing/dissolving is not recommended; an alternative calcium channel blocker should be considered. Three times daily formulation is not mr and can be crushed. May crush Tildiem 60mg tablets & flush down tube with water.If patient on SR prep then convert to plain 60mg tablets. Due to differences in bioavailability of the MR preps give 60mg TDS and adjust accordinglyTildiem LA Capsules- open and sprinkle content in water or mix in soft food. However due to size of micropellets may block feeding tubes1. DO NOT crush the pellets Do not crush M/R forms (e.g. Tildiem retard)
Liquid and Injection available
DILTIAZEM No but see next column
DIGOXIN Yes
• Adizem SR/XL -capsule contents can be mixed in water or soft food. DO NOT crush the pellets. Due to size of pellets may block feeding tubes
• Patient should stay dedicated to one brand due to differing bioavailabilities
• Alternatively change to amlodipine
Crush or disperse tablet in water (Persantin). Sugar coated so may block tube. Flush well after dose.
Dispersion occurs slowly
Persantin Retard may be opened and contents taken in soft food or suspended in water
Granules should not be crushed or dissolved in hot water
May block tube
Dipyridamole/aspirin capsules (Asasantin) may be opened and the contents given in a small quantity of liquid or food.
Care should be taken to not crush the granules as the dipyridamole component is a sustained release granule. Do not dissolve in hot water.Anecdotal reports that the granules may block PEG or NG Tablets may be crushed, but taste is unpleasant-this may be masked by mixing with an acidic beverage e.g. orange juice.
Liquid dipyridamole available.
Diluted injection can be administered orally or by feeding tube. Should be given on empty stomach therefore enteral feeds should be withheld for one hour before and one hour after dose.
DIPYRIDAMOLE Yes (Non MR only)
DISODIUM ETIDRONATE(also included in Didronel PMO pack)
Yes PEG/NG – feed should be stopped for 2 hours before and 2 hours after administration of etidronate as drug interacts with calcium in feed.
DOCUSATE No Liquid available
DOMPERIDONE Yes Liquid (high sorbitol content and may cause diarrhoea) and suppositories available
DONEPEZIL DO NOT use Aricept Evess for feeding tube administration as these tablets will only dissolve in an environment where digestive enzymes are present ie the mouth. They will not dissolve in water.
DOSULEPIN Yes Crushing tablets/emptying capsules not recommended as powder is local anaesthetic – avoid hot drinks after. Can sprinkle on small amount of food.
Consider other antidepressant
25mg/5ml x 500ml £29
Tablets may be crushed and mixed/washed down with distilled water as the chloride ions in tap water will precipitate out the active drug. REF. Sudden hypotensive effect when crushed tablets given by enteral route – monitor patients BP
DOXAZOSIN Yes
When converting from MR to plain halve the dose and titrate upwards according to response
Do NOT crush MR preparations.
DOXEPIN Yes Can open capsule and mix the powder with water. The resulting solution has a bitter taste which is difficult to mask.
Consider other antidepressant
Can remove capsule contents to flush down tube. They should NOT be opened for oral administration as the hyclate salt present is irritant to the oesophagus. Doxycycline binds to calcium ions and may have reducedDoxycycline binds to calcium ions and may have reduced absorption when given via enteral feeding tubes.
Prescribe at higher end of standard dosage range. Can be put in thick and easy. But break in feeding not necessary
DULOXETINE Yes Open capsules and mix with apple juice or sauce. Enteric-coated beads inside should not be chewed or crushed. Give immediately. NG – no information, try opening capsule and flushing NG tube with apply juice.
DUTASERIDE Do NOT empty capsules, may irritate GI tract
DYDROGESTERONE Yes
EFAVIRENZ NO Liquid available – conversion necessary
DOXYCYCLINE Yes Dispersible tablets available
ENALAPRIL Yes Give immediately after crushing and mixing with water. Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube
Consider other ACEI. 2mg/5ml x 100ml £62
Caution: Tablet powder will stain orange, so avoid spillage on clothes etc., and contact with lips etc. May also stain tube. Wear gloves. May be added to jam, honey or orange juice.
PEG/NG tubes: tablet powder mixes in water but does not dissolve fully, so ensure all residue is rinsed thoroughly down tube. See guidelines at end of table
EPLERENONE Yes Crush and suspend in water. Can also mix with apple sauce
EPROSARTAN Yes Change to ACEI
1500units/1ml x 20ml £3
3000units/1ml x 120ml £122
3000 units/1ml x 20ml £21
ERYTHROMYCIN No Liquid available
ESCITALOPRAM Yes Powder is poorly soluble so care should be taken to not block tube.
Citalopram drops
ESMOPRAZOLE No MUPS formulation so will dissolve, but leave EC beads. Lansoprazole Fastabs® best for use down tubes.
Alternative PPI
ENTACAPONE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes
Daily supplements with Calcium and Vitamin D or injection.
ERGOCALCIFEROL No
ETHAMBUTOL Yes
ETHOSUXIMIDE No Liquid available
Stop feed 2 hours before and after dose. Flush line well with plain water post dose
Avoid antacids and mineral supplements 2 hours before and after administration.
ETOPOSIDE No (cytotoxic) Injection - Unpleasant taste. Can be given enterally or in orange juice for oral administration. A conc. of 0.4mg/ml or less avoids the risk of precipitation
EXEMESTANE Yes
EZETIMIBE Yes Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube
FAMCICLOVIR Yes Tablets do not disperse in water easily. Hard to crush but will crush with persistence and will suspend in water and give via 8Fr Ng tube
FAMOTIDINE Yes Ranitidine (40mg famotidine = ranitidine 300mg)
FELODIPINE No Drug is formulated in a MR matrix, so crushing is NOT advised - conversion to alternative drug may be necessary
Amlodipine
FENOFIBRATE Yes Can given capsule contents in orange
FERROUS SULPHATE No Crush tablet and give via tube if necessary
Liquid available. Change to Sytron (sodium feredetate) 10ml=200mg FeSO4.
ETIDRONATE Yes
FEXOFENADINE Yes Change to other antihistamine available as liquid
FINASTERIDE Yes Tablets may be crushed and dispersed in water, however tablet powder should NOT be handled by pregnant women, or those with any possibility of being pregnant. Disintegrates within 5mins 10 ml water and give via 8Fr Ng tube
FLAVOXATE Yes Ensure all drug is rinsed out of crusher and administered. Bitter taste. Tablets hard to crush but can be ground to fine powder which mixes well with water and give via 8Fr Ng tube
FLECAINIDE Yes Tablets may be crushed/injection used orally (same dose)-may have a local anaesthetic effect. Do not mix with tap water due to chelation of ions. Use distilled water .Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube
Injection has been administered enterally undiluted. This should be used in emergency, and monitor for clinical/adverse effects. If giving via enteral feeding tube, always flush with deionised water, do not mix with alkali solutions, sulphate, phosphate,or chloride ions. Do not mix drug with medications prior to administration
25mg/5ml x 500ml £47
FLUCLOXACILLIN Yes PEG/NG – ideally, stop feed for 1 hour before and after dose of flucloxacillin, as food impairs drug absorption.
Liquid and injection available
FLUCONAZOLE Yes Interacts with Jevity® - stop feed for one hour before and one hour after.
Liquid and injection available
FLUDROCORTISONE Yes Disintegrates within 2 minutes in 10 ml water and give via 8Fr Ng tube
Prozac liquid available. Dilute with the same volume of sterile water and flush post dose
• Open capsule and disperse in water or fruit juice – do immediately prior to administration
• Dissolves slowly- 5 minutes
• Irritant to eyes and skin. Wear protective clothing
FLUPENTHIXOL Yes Flush well post dose. Disintegrate if shaken in water for 5 minutes and give via 8Fr Ng tube
FLURBIPROFEN Yes (open capsules, do not crush tablets)
Do not crush beads as may block tube
FLUTAMIDE Yes Tablets may be crushed and given mixed with milk or fruit juice
FLUVASTATIN Yes May be difficult to remove all capsule contents. Do not put MR down tubes.
FLUOXETINE Yes
FLUVOXAMINE Yes No information on enteral tube admin
Consider alternative SSRI
FOLIC ACID Yes No information on enteral tube admin
Liquid available
FORCEVAL Yes Capsule contents may be administered by snipping end of capsule off and withdrawing contents (gelatinous), but will not be whole dose. Also tastes foul, so giving in jam etc. would be a good idea!
Consider alternative liquid multivitamin
FOSINOPRIL Yes No information on enteral tube admin
Change to other ACEI
FUROSEMIDE Yes No information on enteral tube admin
Injection and liquid available
FUSIDIC ACID No Liquid available - 500mg sodium fusidate tablets are approximately equivalent to 750mg fusidic acid suspension
FYBOGEL No Do not put down tube due to the risk of congealing and blocking the tube.
GABAPENTIN Yes Mixing with Ribena® or other strong-flavoured liquid may mask the very bitter taste of the powder. Use immediately due to hydrolysis. Powder may also be sprinkled on cold, soft food. REF Open capsules and mix with 10ml water, mixes easily and flushes down 8Fr NG tube
GALANTAMINE Yes Will disperse in 5 minutes when places in 10ml water which can flush down 8Fr NG tube
Liquid available
GANCICLOVIR No Carcinogenic and teratogenic
GLIBENCLAMIDE Yes Give just before the start of a feed. REF Monitor blood glucose levels as may be more effective crushed
5mg/5ml x 150ml £118
GLICLAZIDE Yes Watch for associated increase in bioavailability (monitor blood glucose carefully). REF Preferably swith to insulin for better glycaemic control
GLIMEPIRIDE Yes May take 5 minutes to disperse – DO NOT CRUSH
GLIPIZIDE Yes Disperses readily in water once finely crushed.
GLYCERYL TRINITRATE No Buccal, S/L Spray, patches
Tablets are special 1mg x 100 £64
2mg x 100 £99
GRANISETRON Yes Give injection orally or give IV
125mg/5ml x 100 £30
500mg tablets £52
HALOPERIDOL Yes Liquid and injection available
HYDRALAZINE Yes Crushing tablets leads to more rapid absorption of drug and possible rapid fall in BP - \caution – review choice of therapy? Absorption is decreased in the presence of food – leave a one hour gap before and after the dose.
Reconstitued injection can by given orally or enterally
Injection given orally
GRISEOFULVIN No Change to alternative drug such as terbinafine
GLYCOPYRRONIUM Yes
HYDROCHLORTHIAZIDE Yes Disperse in water
HYDROCORTISONE Yes Will disperse in 5 minutes when placed in 10ml water which can flush down 8Fr NG tube
Injection available and can be given orally or enterally. Contains significant amount of phosphate
10mg/5ml x 100ml £105
HYDROXYCHOLOQUINE Yes
HYDROXYZINE Yes May be difficult to crush as sugar coated. Risk of tube-blockage so flush well.
Liquid available
HYOSCINE N BUTYLBROMIDE
Yes Injection may be used orally. Tablets are sugar coated so may be hard to crush. REF
Injection available and may be used orally or enterally. Content of ampoule may be stored in fridge for up to 24 hours once opened.
HYOSCINE HYDROBROMIDE
Yes Tablets can be sucked and will be absorbed through oral mucosa.
Injection solution may be given orally and enterally
Patches and injection available
IBUPROFEN No Can however crush and disperse brufen tablets
Liquid and brufen granules available
IMATINIB Yes Disperse in water or apple juice – at least 50ml of fluid for 100mg tablet
IMIPRAMINE Yes If giving down tube, put some syrup down first to decrease adsorption on tubing.
Liquid available Consider alternative tricyclic antidepressant
INDAPAMIDE Yes Do not crush MR preps
HYDROXYUREA Yes Caution: care with handling - avoid contact of drug powder with skin, mucous membranes, inhalation etc. - drug is cytotoxic.
INDOMETHACIN Yes MR capsules may be emptied and the granules swallowed whole. MR capsules irritant on stomach – do not open.
Suppository available 25mg/5ml x 100 £14
INDORAMIN Yes Can sprinkle on soft food to mask taste.
IRBESARTAN Yes Crush and suspend in water Will disperse in 5 minutes when placed in 10ml water –larger particles break up when draw into syringe and can flush down 8Fr NG tube
Consider changing to ACE inhibitor
ISONIAZID Yes Will disperse in 5 minutes when placed in 10ml water which can flush down 8Fr NG tube
50mg/5ml x 500ml £26
ISOSORBIDE MONONITRATE
Yes Normal release tablets can be crushed and will dissolve but do not crush MR. Release properties may change so monitor patient.
GTN patch
ISOTRETINOIN No Capsules can be cut or pierced and mixed in food or stirred into warm milk. Can also freeze and cut into halves or quarters
ISRADIPINE Yes Low solubility
ITRACONAZOLE Open capsules and dissolve contents.
Stop feed 2 hours pre and post dose but possible reduced absorption
Liquid available
IVABRADINE Yes Also fix with yoghurt or soft food
KETOCONAZOLE Yes Stop feed 2 hour before and after dose
LABETOLOL No It is not recommended to crush due to film coating and rapid oxidisation. The injection solution can be used orally, mixed with orange juice to mask taste. REF can be dispersed in water if tablets are ground down enough but may block tube.
Injection can be used orally or enterally if necessary. Injection can also be given with fruit juice or squash to disguise bitter taste.
LACIDIPINE Yes Very insoluble in water therefore crush tablets and flush down tube
Consider alternative calcium channel blocker
LAMIVUDINE No Use liquid in order to avoid exposure of operator to active constituents of crushed tablets.
Liquid available
LAMOTRIGINE Yes Dispersible tablets available and even non-dispersible will dissolve once crushed. Dispersible tablets can be chewed.
Granules may be emptied from the capsule and swallowed (without crushing or chewing) with water or in soft food e.g. a spoonful of apple sauce.
LANSOPRAZOLE Yes see next column
Granules from capsule (do not crush may be flushed down tubes (except v. fine bore tubes) preferably with apple juice (manufacturer recommends 40ml; this reduces adhesion of granules compared to water).
Fastabs® are best for tubes, as the microspheres are smaller than in the capsules. Dissolve in apple juice or orange juice, put down tube and then flush again with the fruit juice. (Juice is better than water as it makes the granules less sticky)
PEG/NG- sachets not suitable for tube administration, as the suspension is too viscous.
Fast tabs are not absorbed sublingually – not supposed to be broken up in the mouth and the drug is not absorbed there.
LEFLUONOMIDE Yes Monitor patient for signs of exaggerated or diminished effects. Will disperse in 5 minutes when placed in 10ml water which can flush down 8Fr NG tube
LERCANIDIPINE Yes Light sensitive so use immediately
LEVETIRACETAM Yes Tablets can be crushed and sprinkled into soft food such as apple puree or yoghurt but do have bitter taste. Liquid can also be added to food. 500mg tablets will disperse in 5 minutes when placed in 10ml water which can flush down 8Fr NG tube
Liquid available
LEVODOPA Yes Only sparingly soluble with insoluble excipients. Will stain skin, teeth, tongue and tube. See handbook for further details on brand.
LEVOFLOXACIN Yes Bitter taste with metallic aftertaste. Stop feed 2 hours pre and post dose. If administer via tube consider changing to another quinolone as takes few minutes to dissolve. This forms milky dispersion which can flush down 8Fr NG tube
Injection and liquid
LEVOMEPROMAZINE Yes Will disperse in 2 minutes when placed in 10ml water which can flush down 8Fr NG tube but may block finer tubes.
Injection can be given orally and enterally. Note that excipients degrade to products which theoretically may induce asthma attacks when given enterally. No reports of attacks ever having been induced this way have been recorded by the manufacturers and the risk is considered to be small
Consider alternative antipsychotic
12.5mg/5ml x 100ml and 50ml both £42
LEVOTHYROXINE Yes Long half life so can be omitted for up for 5 days. Will disperse in 5 minutes when placed in 10ml water and shaken, this can flush down 8Fr NG tube
Liquid and injection (dose conversion necessary) available
LINEZOLID Yes Monitor for side effects Liquid available but may be too thick for feeding tubes.
2.5mg/5ml x 100ml £47
5mg/5ml x 100ml £23
LISINOPRIL Yes
LITHIUM No Withhold feed 1 hour before and 2 hours post dose
Liquid available but dose conversion necessary. Monitor blood levels closely. 520mg/5ml as lithium citrate -equivalent to 200mg of lithium carbonate.
LOFEPRAMINE No Has very bitter taste and hard to crush as film coating
Liquid available
LOPERAMIDE No Caution in stoma patients. Liquid available but large sugar content so caution in diabetics. Flushes down NG tube without resistance.
LORATADINE Yes Liquid available
LORAZEPAM Yes Can also be used sublingually but needs moist mouth
Injection can be given S/L.
Consider alternative anxiolytic
LOSARTAN Yes Mix with 10ml water to form fine suspension which flushes down 8Fr NG tube without blockage
LOXAPINE Yes Crushed tablets should be dissolved in water and given immediately
4mmol chewable tablet x 50 £16
5mmol/5ml x 200ml £60
Normal tablets x 100 £39
MAGNESIUM Yes Capsule contents can be mixed with soft food
Liquid available
MEBENDAZOLE No Liquid available
MEBEVERINE Yes but only non-MR
Fairly soluble in water. Change MR to normal release tablets or liquid. Stop feed for 30 minutes pre and post dose
Liquid available
MEDROXYPROGESTERONE Yes Dissolves slowly approx 5 minutes. Suspension will flush via 8Fr NG tube without blockage.
Depo-Provera has been used orally, although little data available.
MEFENAMIC ACID Yes Only suspend contents in water – virtually insoluble. Can mix with food or jam
Suspension available
MEGESTROL ACETATE Yes Tablets may be crushed and given in water, fruit juice or jam. May take 5 minutes for tablets to dissolve.
Tablets may be crushed and mixed with yoghurt, fruit juice or jam.
Circadin tablets should not be crushed as controlled release.
MELOXICAM Yes Disperse in 10ml water within 5 minutes and flushes down 8Fr NG tube without blockage.
Suppositories also available. Use suppositories for the shortest time possible
Alternative NSAIDS
MEMANTINE No Oral drops available. 5mg=10 drops
MENADIOL Yes 5mg/5ml x 50ml £80
MERCAPTOPURINE No Do not crush as cytotoxic. Place tablet in water, however unstable in aqueous solutions. Use immediately.
Suspension available
All specialsMELATONIN Yes
Tablets should not be crushed. If colon only affected a rectal preparation could be tried, or patient could be converted to sulphasalazine, which comes in a liquid.
Pentasa® brand tablets disperse very quickly in water; however, this leaves small beads in the liquid which must be swallowed or put down the tube intact. These are better than the sachets, which have larger granules. See enteral feeding book for more information.
METFORMIN Yes May block tube and may increase availability
Sachets available and much cheaper than liquid
10mg/5ml x 50ml £52
20mg/5ml x 100ml £73
METHOTREXATE No Cytotoxic therefore do not crush. Place in water and disperse. In rheumatoid conditions consider S/C or I/M.
Injection can be diluted with water and administered orally. Extended expiry can be given if preservative used. Can be given enterally although manufacturers cannot recommend. Absorption from injection gives similar plasma concentration to tablet formulation.
MESALAZINE Suppositories foam enema, sachets
No
METHOTRIMEPRAZINE Yes Tablets disperse in water. Injection has been use orally.
METHYLDOPA Yes May block tube as tablet coating may not dissolve. Interacts with Ensure®, Ensure plus® and Osmolite® - stop feed for two hours before and one hour after. REF
Suspension available
METHYLPREDNISOLONE Yes Tablets will disperse in water. Do not crush M/R tablets
METHYLPREDNISOLONE Yes The manufacturers are aware that Solu-Medrone® has been mixed with orange juice and water when given orally because it has an unpleasant taste which almost nothing will disguise. If orange juice is used, it must be added just before taking due to its low pH
Injection
METOCLOPRAMIDE Yes Dispersion occurs slowly. Injection can be used enterally
Injection and liquid available
METOLAZONE Yes Tablets can be crushed but be aware that the increased bioavailability may lead to increased postural hypotension. May need to be shaken for 5 minutes. Can flush via 8Fr NG tube without blockage. Do not crush MR formulations.
Syrup available
METOPROLOL Yes Do not crush MR formulations
METRONIDAZOLE Yes Injection can be given orally. Liquid also available but do not use in C.diff. or NJ/jejunostomy patients. Administer 1 hour before food to allow break down.
METYRAPONE Yes Capsule can be cut open and the contents administered if necessary.
MEXILITINE Yes Open capsules and dissolve contents in distilled water. Can flush down feeding tube.
Injection can be given orally. It has also been administered enterally. It has a very unpleasant taste. When the injection is being given to patients with swallowing difficulties, it should be given at least 30 minutes before food as it has a local anaesthetic action in the mouth
MIANSERIN Yes Tablets may be crushed, but difficult. Mix with plenty of water.
10mg/5ml buccal syrup x 5ml £40
12.5mg/5ml x 100 £86
MINOXIDIL Yes Disperse in water within 2 minutes to give dispersion which flushes via 8Fr NG tube without blockage.
MIDAZOLAM Injection can be given orally. The injection has a bitter taste so should be diluted with apple or blackcurrant juice, raspberry or cherry syrup, chocolate sauce or cola
MIRTAZPINE Yes Bitter taste and local anaesthetic effect
Dispersible tablets available but may block tubes.
Tablets may be crushed (and dispersed in water if necessary) IMMEDIATELY before use.
Caution: powder should not be handled by pregnant women. Change to lansoprazole if for this indication
MOCLOBEMIDE Yes Solution flushes down 8Fr NG tube without blockage
MODAFINIL Yes Use suspension immediately
MONTELUKAST Yes Give immediately as unstable in water. Granules can be mixed in soft food or place directly onto the tongue and swallow.
Tablets are special
MISOPROSTOL Yes
Try the MR capsules (Zomorph) which can be opened and the granules sprinkled on soft food or washed down with liquid. NB if using MXL® capsules the liquid used should be enteral feed, not water. This is due to the high lipophilicity of the granules which would lead to tube blockage. MR tablets should not be crushed.
Sachets are not always suitable for use down tubes due to high viscosity. The MST® sachets, once reconstituted with 10ml water, will pass down a Ryles tube (4.75mm internal diameter) and NG tubes of 1.05mm internal diameter or more.
Interacts with Jevity® and Pulmocare – stop feed for two hours before and one hour after.
MOXIFLOXACIN Yes Tablets have a bitter taste. 400mg tablet will dissolve in 20mls of water. Stop feed one hour before and 2 hours after administration.
MORPHINE M/R TABLETS/CAPSULES
MOXONIDINE Yes Crush well to minimise risk of blocking tube. Mix one tablet with 50ml water and allow to dissolve for 2 minutes. Solution flushes down 8Fr NG tube without blockage
MYCOPHENOLATE Reconstituted injection solution has been used enterally with a dextrose 5% flush before and after administration. Care should be taken when handling the powder (teratogenic risk). Contamination should be removed promptly by washing with soap and water (eyes – plain water
NABILONE Yes Remove capsule contents and disperse in water
NADOLOL Yes Crush and disperse in water
NAFTIDROFURYL No Do not open capsule- powder is irritant and anaesthetic to mouth/throat mucosa-ask Dr to review need for this drug. If drug absolutely necessary open capsule and disperse contents with water but drink large amount of fluid following dose.
NALIDIX ACID No
NAPROXEN Yes but not MR or EC
Can take 5 minutes for tablet to completely disperse
Suspension and suppositories available
NATEGLINIDE Yes
NEBIVOLOL Yes Administer solution immediately. Doesn’t dissolve very well – flush.
NEFOPAM Yes Dispersion occurs slowly, may need to be shaken. Ensure adequate rinsing of container.
Give IM injection orally. 20mg IM = 60mg oral.
NEFAZODONE Yes Special tablets 100mg x 60 £56
NEOMYCIN Yes
NEOSTIGMINE Yes
NEVIRAPINE Yes
NICARDIPINE Yes The powder can be removed from the capsule and dissolved, preferably in orange juice
NICORANDIL Yes Dispersion occurs slowly (at least 5 minutes). Use in care with enteral feeding tube as may cause blockage.
NICOUMALONE Yes Insoluble in water
Do not crush MR tablets (NB Adalat Retard® may be crushed and dispersed in water, as this does not affect the release mechanism.) Adalat LA® cannot be crushed.
Normal release capsules can be bitten (by the patient) or snipped (by staff if patient unable to bite) open and the liquid contents swallowed/given sub-lingually. However, nifedipine is very short acting in this form and to avoid sudden drop in BP, change to longer acting calcium channel blocker may be preferable. Please ask NG/PEG tubes - Capsule contents (oil) may be drawn up in syringe and flushed down tube with N-saline, not water, but see notes above.
It is not advised to open Coracten® preparations as the capsules contain mini-tablets which may be lost. There is also a danger that the patient may chew them and this would release a greater dose. If it is necessary to open the capsules there is no difference in effect if the mini-tablets are swallowed whole. See handbook of drug administration for more information
NIMODIPINE Yes Use immediately as extremely light sensitive. Give injection in non-PVC or glass apparatus. Also applied to tablets in solution. For PEG/NG tubes, ensure tablets are in fine powder after crushing - fragments of film coating can block tubes.
NITRAZEPAM Yes Liquid available
Consider alternative calcium channel blocker
20mg/1ml x 30ml oral drops £17
YesNIFEDIPINE
NITROFURANTOIN No Large granules may block fine bore tubes.
Liquid available
NIZATIDINE Yes May block tubes as excipients are insoluble
Consider changing to alternative H2 antagonist
NORETHISTERONE Yes Suspension flushes via 8Fr NG tube without blockage
NORFLOXACIN Yes Flush well as poorly soluble. Stop feed 1 hour before and 2 hours after. Unpleasant taste.
NORFLOXACIN Yes Do not disperse well in water – give crushed tablets
NORTRIPTYLINE No Consider alternative tricyclic
Do not disperse readily. Stop feed for one hour before and 2 hours after administration.Use de-ionised bottled water to avoid drug chelation with ions See notes under ciprofloxacin for PEG/NG tubes.
OLANZAPINE Yes Normal tablets will dissolve, but not as fast as velotabs
OLSALAZINE Yes Avoid mixing with acidic solution (eg orange juice) as active drug is alkaline. Disperse in warm sterile water. Capsule contents and dispersed tablets will stain bright orange
OLMESARTAN No Change to another ACEI
OFLOXACIN Yes
OMACOR Burning/bitter taste therefore not recommended. Very difficult to pierce and empty capsule. Oil not compatible with most plastics and oxidises quickly in air. Could dissolve capsules in hot, not boiling water, in a china cup, and administer immediately. Drink entire contents as oil doesn’t dissolve in water.
Liquid available – Maxepa liquid £20 for 150ml
Is it vital the patient has it?
PEG/NG tubes :- Manufacturer recommends one of two methods of administration to avoid tube blockages
Dissolve the tablet in 25ml water in the syringe, invert syringe to disperse drug pellets, and immediately run 5-10ml down tube. Invert syringe to mix contents again, run a further 5-10ml down tube. Repeat until all the liquid has been passed down the tube. Rinse syringe and flush tube with a further 25ml water. (This method is intended to avoid syringe and tube blockages by compacted pellets)
Dissolve the tablet in the syringe in 5ml water and add 5ml wholemilk yoghurt. Mix gently and pass down the tube. Flush with 10ml water to rinse down any remaining drug pellets.
NB: Lansoprazole Fastabs® are best for tube use. REF
OMEPRAZOLE Dispersible tablets
10mg/5ml x 50ml £138!
ONDANSETRON No Crush or disperse tablet in water.
Injection has been used enterally. This may be preferable for administration via enteral tubes terminating in the jejunum as the syrup contains sorbitol. The injection is acidic, so flush well before and after each dose to prevent precipitation of the drug when giving via enteral feeding tube
Injection, suppositories, syrup or melt tablets.
ORLISTAT Yes Open and stir into water or fruit juice or flush contents down the tube
ORPHENADRINE Yes Oral solutions available
OXPRENOLOL Yes (not mr forms)
Tastes very bitter
OXYBUTYNIN Yes (not mr forms)
Liquid and patch available
OXYCODONE No Do not open oxynorm capsules due to possibility of powder becoming airborne.
Liquid form available.
OXYTETRACYCLINE No Tablets may be crushed for administration down tubes only. It is not recommended that they be crushed for oral administration due to the risk of oesophageal ulceration and oesophagitis. Consider changing to alternative such as doxycycline. Also must stop feed 1 hour before and 2 hours after.
PANCREATIC ENZYMES Yes Creon® - empty the granules from the capsule. If giving with an enteral feed, give half the dose before the feed and half after. If the patient has a jejunal tube, crush the granules (or dissolve in sodium bicarbonate) and mix with feed.
Pancrex powder
PANTOPRAZOLE No Tablets must be swallowed whole and may not be crushed. Patient should be changed to alternative e.g. lansoprazole or omeprazole.
PARACETAMOL No For use through enteral tubes it is better to use the soluble tablets as the liquid is too thick
Suppositories and soluble tablets
500mg/5ml x 200 £2
PAROXETINE Yes Powder is bitter and has anaesthetic effect
Liquid available
PENICILLAMNINE Yes Take at least 5 minutes
PENICILLIN V Yes PEG/NG – If possible stop feed for 1 hour before and 2 hours after administration – absorption is unpredictable with enteral feeds – if not possible, consider higher dose or alternative antibiotic. REF
PERGOLIDE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes Slow to disperse. Can administer in Jam or yoghurt.
PERINDOPRIL Yes Leave a feed gap of two hours before and after dose.
Other ACEI or A2RB
PHENELZINE Yes Slow to disperse. Use immediately. No information on enteral tube administration
50mg/5ml alcohol free x 50ml £8
50mg/5ml normal liquid x 200ml £2
50mg/5ml x 60ml £3
50mg/5ml S/F x 150ml £25
PHENOXYBENZAMINE Yes No information about whether this may block tube
Injection should be given preferably by slow IV injection, and patients should be ECG and BP monitored. If given by IV infusion an in-line filter must be used.
90mg syrup is equivalent to 100mg capsule e.g. patient previously on 300mg in capsules should be given 45ml syrup.
PHENOBARBITAL
PHENYTOIN Yes but difficult to crush and do not disperse readily in water
Chewable tablets
Yes Liquid available but may be inappropriate in children due to high alcohol content
PEG/NG – Phenytoin absorption is significantly reduced if administered with enteral feeds. Give phenytoin as a single daily dose; stop feed two hours before giving and do not restart until 2 hours after dose. Alternatively, this could be managed by stopping feed overnight e.g. between 10pm and 6am, and giving phenytoin at midnight. Interacts especially with Osmolite®, Isocal®, Ensure® and Jevity®.
Dilute syrup with equal volume of water and flush tube before and after drug administration.
Phenytoin is less effective if given down NJ tube – consider reviewing therapy. More convenient if dose changed to single daily dose.
PHYTOMENADIONE Yes Konakion MM Paed Injection orally. Flush well after each dose if giving via enteral feeding tube
20mg/1ml x 5ml £11
PIMOZIDE Yes Not very soluble in water
PINDOLOL Yes
PIOGLITAZONE Yes Monitor blood glucose levels carefully if crushing tablets. For better glycaemic control switch to insulin.
PIROXICAM Yes Suppositories or IM. Melts available
PIVMECILLINAM Yes Probably more accurate to change dose to equate to half or quarter of tablet
PIZOTIFEN Yes Liquid available
POTASSIUM Yes but only Sando-K
Do not crush Slow K. Kay-Cee-L liquid
PRAMIPEXOLE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes Light sensitive so use immediately
PRAVASTATIN Yes Use immediately Other Statin
PRAZOSIN Yes Insoluble so ensure wash down with water or mix with jam etc
PREDNISOLONE Yes Soluble tablets available. Do not crush E/C. Plain tablets disperse in water.
PREGABALIN Yes Unpleasant taste. Give immediately after dissolved in sterile water.
PRIMIDONE Yes Disperse in water (poorly soluble)
Liquid available 250mg/5ml xz 200ml £43
PROCHLORPERAZINE No Buccal tablets, syrup, effervescent granules
PROCYCLIDINE Yes Liquid available
PROGUANIL Yes
PROMAZINE No Liquid available
PROMETHAZINE Yes Dispersion flushes via 8Fr NG tube without blockage
Liquid, injection available
PROPAFENONE Yes Local anaesthetic action and bitter taste
PROPRANTHELINE Yes
PROPRANOLOL No Granules from MR capsules can be swallowed whole. Flush down tube or mix with soft food.
Can give injection orally; it has been mixed in raspberry syrup when given orally. However little information on it so not recommended.
Liquid available.
PROPYLTHIOURACIL Yes
PSEUDOEPHEDRINE No Liquid available
PYRAZINAMIDE Yes Leave a one hour feed gap either side of dose.
500mg/5ml x 300ml £52
5mg/5ml x 150ml £38
60mg/5ml x 150ml £37
PYRIDOXINE Yes Dispersion occurs slowly 10mg/5ml x 100ml £67
Liquid availablePYRIDOSTIGMINE Yes
QUETIAPINE Yes Bitter taste therefore mix with soft food. Flush down tube. Can crush. Do not crush XL formulation
QUINAPRIL No Change to other ACEI
QUINIDINE Yes Do not crush m/r tablets
QUININE Yes Only crush if necessary and going to need for long term. Crush or disperse in 200ml warm water as this will aim flushing. May block the tube.
RABEPRAZOLE No E/c will be destroyed and stops breakdown of product in stomach acid
Change to other PPI
RALOXIFINE Yes Unpleasant taste. Care handling and crushing – maybe teratogenic. Discotinue if immobile.
RAMIPRIL Yes Bitter taste. Place contents directly on mouth or bread.
RANITIDINE Yes Injection may be given enterally
Injection, dispersible tablets, syrup (may cause diarrhoea)..
REBOXETINE Yes
REPAGLINIDE Yes Crushing will speed absorption so monitor blood sugar carefully. NB if patient has a tube, note where it emerges in GI tract, as absorption will be faster in duodenum than stomach.
RIFABUTIN Yes
Crush tablets/open capsules can cause sensitisation. Stop feed one hour before and 30 minutes post dose. Can crush or disperse
Rifinah and Rifater.
RILUZOLE Yes Tablets may be crushed and given, preferably in sugar/soft food, as drug is not very soluble in water. Crush and mix into soft food
RISEDRONATE No Do not give via feeding tube. Review need. 35mg tablets disperse in 10ml water within 5 minutes to give fine dispersion.
RISPERIDONE No Quicklets available and injection, liquid.
RIVASTIGMINE Yes Solution and patch
ROPINIROLE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes Mix with soft food and crush and mix with water for use down enteral feeding tubes.
ROSIGLITAZONE Yes May increase effect. Consider sliding scale.
ROSUVASTATIN Yes Use immediately as light sensitive
SALBUTAMOL Yes Do not crush MR preparations – convert to liquid and give in 3-4 divided doses. Consider changing to nebulised therapy
Liquid
SECOBARBITAL Yes Open capsules and dissolve contents in water, use immediately and discard remainder
Syrup availableRIFAMPICIN No
SELEGILINE (SEE SEPARATE PD GUIDELINES FOR MORE INFORMATION)
Yes Liquid available
SENNA Yes Liquid available
SERTRALINE Yes Tablets may be crushed but powder is poorly soluble in water (Lustral). Can mix with food, e.g. jam. Powder tastes bitter and has local anaesthetic effect. Ensure all powder is given if giving down tube
Consider other drug available in syrup e.g. fluoxetine, citalopram oral drops.
SEVELAMAR No Not recommended in feeding tubes
25mg/5ml x 100ml £83
5mg/5ml x 100ml £83
5mg/5ml x 50ml £23
SIMVASTATIN Yes Give immediately as light sensitive and give via 8Fr NG tube. Take significant time to disperse.
SITAGLIPTIN Yes Readily soluble in water
SIROLIMUS Yes
SODIUM BICARBONATE Injection can be given orally or enterally
SODIUM CHLORIDE Injection may be given orally or enterally
SILDENAFIL Yes Tablets will disperse in water, give immediately
SODIUM PHENYTLBUTYRATE
Injection may be given orally
SODIUM CROMOGLICATE Contents can be removed, dissolved in hot water, then diluted in cold water before taking
SODIUM CLODRONATE Yes Open capsules and disperse contents. Stop feed for two hours before and after and take care not to give any calcium, milk etc in that period. Only mix with water. Can be opened and flushed via enteral feeding tube.
SODIUM FUSIDATE Yes Fucidin syrup comes as fusidic acid which is not as well absorbed as sodium fusidate: -500mg in tablets = 750mg in syrup
Liquid available
SODIUM PICOSULFATE No Liquid available
SODIUM VALPROATE No Epilim liquid may be administered rectally. Contact pharmacy for details. REF When switching g from oral to IV, the IV dose is the same as the oral dose. Epilim chrono formulations are interchangeable with other conventional or prolonged release formulations of equivalent daily doses.
Crushable tablets and injection
SOLIFENACIN Yes Dissolves quickly in water, however irritant to the eyes.
Consider switching to oxybutynin
SOTALOL Yes Consider licensed beta blocker preparations
25mg/5ml x 125ml £45
50mg/5ml x 125ml £48
SPIRONOLACTONE Yes Can take 5 minutes for tablet to completely disperse. Will flush down 8 FR NG tube without blockage.
STALEVO Yes Suspend in water. Only sparingly soluble with insoluble excipients. Will stain skin, teeth, tongue and tube. Max with yoghurt, milk, honey, jam, orange juice or water. Give immediately. See Parkinson information at end of document.
STAVUDINE no Open capsules and mix into water or food. Contents pour freely, mix with water when stirred and flush via 8Fr NG tube without blockage.
STRONTIUM No information regarding administration via tube but no reason why the product could not be administered via this route. Stop feed 2 hours before and after administration.
SUCRALFATE Yes Stop feed for one hour before and after dose due to the risk of bezoar formation. Likely to block tube and no suitable for JEJ administration.
Suspension available
SULFASALAZINE Yes Do not crush E/c. Suppositories/enema for lower-bowel disease. Suspension available
SULINDAC Yes
SULPIRIDE Yes Can be dispersed to form fine dispersion which can be drawn up and flushes via 8Fr NG tube without blockage.
TACROLIMUS See next Open capsules and mix contents with small amount of water. Do not inhale and wear maxk and gloves.
Tablets may be crushed and given mixed with jam or yoghurt.
TAMOXIFEN Yes Liquid available
Handle drug powder with care (avoid dust being inhaled, on skin etc. as far as possible – use mask, gloves and eye protection).
TAMSULOSIN Yes MR capsules - the granules may be emptied out and mixed with cold water, but swallow whole, do not chew granules.(Small granules, so should go down NG or PEG tube too). May give sudden hypotensive effect if administered via PEG/NG. May block feeding tubes – flush well.
TELMISARTAN Yes Tablets not very soluble but will flush via 8Fr NG tube without blockage. Absorb moisture after crushing to give immediately.
TEMAZEPAM Yes Liquid available
TENOFOVIR Disperse in 100ml water, orange juice or grape juice and take immediately. Disperse in 5 minutes and flush via 8Fr Ng tube without blockage.
TERBINAFINE Yes
TERAZOSIN Yes May take 5 minutes to disperse. Insoluble excipients
TETRABENAZINE Yes Dispersion occurs slowly at least 5 minutes
Manufacturers advise that capsules should not be opened.
However, they do provide the following information:
• Thalidomide is not very soluble and may therefore block NG tubes. It may be given by NG by: Using a syringe suitable for connecting to the NG tube, remove the plunger and empty the contents of the capsule into the syringe. Add water or enteral feed, replace plunger and administer. Flush the syringe and the NG tube until the capsule contents have been completely administered. To avoid blockage administer only 1-2 capsules at a time.
• The contents of thalidomide may be mixed with soft food and given orally. Give immediately as stability unknown.
THALIDOMIDE No
• When administering staff should wear disposable gloves and masks, and the empty capsules should be disposed of in a cytotoxic waste bin.
• Pregnant members of staff should not handle the drug.
Do not crush M/R tablets 60mg/5ml x 300ml £136
M/R capsules. The granules can be emptied from the capsule and swallowed (whole) with soft food e.g., yoghurt.
DILUTE WITH equal volume of water
If converting to syrup from a M/R product, dosage regime will need to be adjusted – monitor levels. Divide total daily dose by 3 and give TDS.
THEOPHYLLINE
Do not crush Nuelin SA, Slo-phylline capsules may be opened and flushed through tube. Do not crush granules and may block tube, Flush well. Absorption may be decreased by 60-70% but increased absorption has also been reported. Aminophylline injection has been given orally and enterally.
Interacts with Osmolite®, Ensure® and Ensure plus® so stop feed for one hour before and after
THIAMINE Yes 30 minutes before food
THIOGUANINE No Suspension available
TIAGABINE Yes May take 5 minutes – gives fine dispersion that flushes down 8Fr NG tube without blockage.
Liquid available
TIBOLONE Yes Suspend in water
TIMOLOL No Consider changing to alternative beta blocker
TIZANIDINE Yes Crush to fine powder for NG/PEG tubes.
TOLBUTAMIDE Yes Crush and disperse in water
TOLTERODINE Yes Normal release prep can be crushed. XL capsules contain uniform time-release beads and can be opened and the intact beads administered. Settles quickly but draws up and flushes via 8Fr Ng tube without blockage.
Consider alternative Oxybutynin Elixir.
10mg/5ml x 100ml £42
25mg/5ml x 100ml £40
TORASEMIDE Yes Crush and disperse in water. Slurry is formed so rinsing of tube essential.
TRAMADOL No Remove capsule contents and disperse in water. Bitter taste. Soluble tablets are most suitable for administration via enteral tubes.
Injection, sachets, orodispersbiel tablets
Capsule contents can be mixed with fruit squash to mask bitter taste or mixed in water to give via PEG/NG.
May cause sudden hypotension if patient dehydrated. Capsules very small and difficult to open.
Consider changing to alternative ACEI.
TOPIRAMATE Yes Do not administer sprinkle beads via tubes as these stick and cause blockage. Sprinkle Sprinkles® in liquid or on soft food. Capsule contents stick to plastic tubes so not suitable for PEG/NG. Normal tablets can be crushed too.
TRANDOLAPRIL Yes
TRANEXAMIC ACID Yes Tablets disperse in 2-5 minutes. Can use injection orally or enterally immediately after dilution. Store in fridge and use within 24 hours.
TRAZODONE Yes-only open capsules and mix with water
Bitter taste Liquid available
TRIFLUOPERAZINE Yes Do not crush MR tablets. Spansules are s/r and cannot be opened/crushed.
TRIHEXYPHENIDYL Yes Disperse tablet in water and will flush down 8Fr NG tube without blockage.
Liquid available
TRIMEPRAZINE No Liquid available
TRIMETHOPRIM Yes Stop feed for 30 minutes before and after administration of liquid. Well absorbed via enteral feeding tubes
Liquid available
TRIMIPRAMINE Yes Open capsules and suspend in water or crush and suspend tablets in water. Has local anaesthetic action
Consider tricyclic antidepressants
TROSPIUM Yes With disperse in 100ml water, orange or grape juice. Bitter taste.
URSODEOXYCHOLIC ACID Yes Open capsules and suspend in water. Do not disperse in water. May block fine bore tubes. Capsules (Ursofalk) can be opened and contents sprinkled on to food.
Liquid available
VALACICLOVIR No but see next
Quite difficult to crush and powder does not suspend well, therefore not advised. If crushed and suspend in water, dose must be given immediately owing to the rapid rate of hydrolysis. Can flush down 8Fr NG tube without blockage but must be draw into syringe immediately. Check references
VALSARTAN Yes Tastes bitter Change to ACEI
Injection can be used orally for Clostridium difficile- can also use via nasogastric tube. Consult pharmacy.
Capsule contents are gel-formed and not suitable for feeding tube administration.
VANCOMYCIN Yes 125mg/5ml x 300ml £60
Normal release YES
Mix with jam and or liquid
VERAPAMIL Yes Only crush normal release tablets. Bitter taste and local anaesthetic action in mouth. Do not crush MR tablets. Doses should be divided throughout the day. Ordinary tablets may be crushed and dissolved in water but a drink of juice should be given afterwards to remove bitter taste/local anaesthetic effect. The beads from the MR capsules may be given, swallowed whole. May block tube. Stop feed 1 hour before and post dose.
Injection may be given orally or enterally. Give on an empty stomach; withhold enteral feeds for one hour before and one hour after each dose
Liquid available
VIGABATRIN Yes Disperse contents of sachet in water as well as crushing tablets and dispersing in water. Can put contents of sachet down 8Fr NG tube without blockage.
M/r -NO Capsule contents (MR granules) may be emptied out and given in smooth food e.g. yoghurt – granules not to be crushed or chewed. To convert from M/r to normal release, total daily dose is given as two divided doses and adjusted as necessary.
Mirtazepine Orodispersible Tablets
VENLAFAXINE
VITAMIN B COMPOUND Yes Ensure full dose is given as active substance present in very low concentrations
Liquid available
VITAMIN E No Liquid available
VORICONAZOLE No Liquid available – take 1 hour before food or 1 hour after.
Stop feed 1 hour before and 1-2 hours post dose. Monitor INr closely as crushing may increase absorption.
Vitamin K content of Osmolite® and other feeds may antagonise anticoagulant effect of warfarin.
ZAFIRLUKAST Yes May be difficult to crush, may result in increase peak levels.
ZESTORETIC Yes
ZIDOVUDINE No Syrup available
ZINC SULPHATE No Effervescent tablets and injection available
If for N/G or PEG tube use, crush as finely as possible, mix with water and give QUICKLY - the powder is designed to thicken in water. This may cause tube blocking so is very important. Hard to crush and bitter taste.
ZOPICLONE Yes Try other hypnotic e.g. Temazepam / Nitrazepam
WARFARIN Yes Liquid available
Do not crush Zimovane as bioavailability may be altered.
ZOLPIDEM Yes
ZONISAMIDE Yes Open capsule and suspend contents in water. Has been added to food and apple juice
ZUCLOPENTHIXOL Yes May block tube as not very soluble
REFERENCESNEWT guidelinesEnteral feeding bookPrevious Dysphagia guidelinesCornwall dysphagia guidelinesWaltham Forest guidelines
ManufacturersNELM Q and A which injections can be used orally
