Stockportccg.org

MEDICATION ADMINISTRATION IN PATIENTS WITH SWALLOWING DIFFICULTIES/DYSPHAGIA
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 TO SEARCH:HOLD DOWN CONTROL AND PRESS F THEN TYPE ITEM REQUIRED. For more information please ring pharmacy or ring
manufacturers.
DRUG
CAN INJECTION
LICENSED
THERAPEUTIC
BE USED ORALLY? ALTERNATIVE?
ALTERNATIVE?
AVAILABL
E (PRICE)
(£)
(CORRECT
AS JUNE
2011)
ABACAVIR
why crushing tablets would create stability concerns as long as administered immediately. ACARBOSE
not disperse easily in water but require gentle agitation for approx 5 minutes. Suspension can be flushed down 8Fr NG tube ACEBUTOLOL
Change to other beta-blocker available in liquid if absolutely necessary ACETAZOLAMIDE
Non-MR can If taking MR capsules convert water which settles quickly and in fridge for up to 24 flushes down 8Fr NG tube without blockage but rinse all through to ensure total dose given ACENOCOUMAROL
Disperse in 10ml water within 5 minuts to give dispersion which flushes via 8Fr NG tube without blockage ACETYLCYSTEINE
Tablets are effervescent 600mg Injection solution diluted orally or enterally. Very bitter. blackcurrant Orange syrup, orange juice or coke used ACICLOVIR
ACITRETIN
immediately not to be handed by women of before use ALFACALCIDOL
ALFUZOSIN
Non-MR can Convert MR to standard release be dispersed (commence at 2.5mg tds as risk in water ALIMEMAZINE
washed off tablets to make them easy to crush. Disperse in 1-2 minutes ALLOPURINOL
Disperse in 10ml water for 5 minutes to form dispersion that flushes down 8FR NG tube without blockage ALVERINE
AMANTADINE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
AMILORIDE
AMINOPHYLINE
AMIODARONE
AMITRIPTYLINE
emptied out but swallow granules whole. Tablets do not disperse but can be crushed and disperse in 10ml water.
AMLODIPINE
sensitive. Disperse in 10ml of water in 2 minutes to give dispersion that settles – flushes down an 8Fr NG tube without blockage.
ANASTROZOLE
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®
ASASANTIN RETARD
Dispersible aspirin and liquid dipyridamole.Granules may be given whole, not chewed NB may clog tube.
ASCORBIC ACID
ATOMOXETINE
ATENOLOL
ATORVASTATIN
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
AZITHROMYCIN
BACLOFEN
BALSALAZIDE
teeth etc that it comes into contact with BENDROFLUMETHIAZIDE
diuretics – furosmide and bumetanide oral solutions available BENZTROPINE
Injection may be given orally and enterally although manufacturer cannot recommend.
BETAHISTINE
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
BISOPROLOL
film coating. But do disintegrate rapidly in 10ml water to form fins suspension that flushes down 8Fr NG tube without blockage.
BROMOCRIPTINE (SEE
SEPARATE PD GUIDELINES
autocatalytic and will begin to disintegrate as soon as they are FOR MORE INFORMATION)
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
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
BURINEX A
Administer as separate components as liquid BUSPIRONE
CABERGOLINE (SEE
SEPARATE PD GUIDELINES
in water but if shaken in 10ml water for 5 minutes will give FOR MORE INFORMATION)
clear solution which flushes via 8Fr NG tube without blockage.
CALCIUM CARBONATE
for Vitamin D components also e.g. Cacit D3 granules. CALCIUM FOLINATE
disperse in 10ml water within 5 minutes and given via 8Fr NG tube without blockage.
CALCIUM RESONIUM
resulting paste too think to administer via feeding tubes.
CANDERSARTAN
CAPECITABINE
Yes see next Dissolve without crushing tablet column in small amount of warm water. Takes approx 15 minutes CAPTOPRIL
Tablets disperse in 10ml water within 2 minutes to give CARBAMAZEPINE
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. CARBIMAZOLE
CARBOCISTEINE
CARVEDILOL
Disperses in 1-5 minutes immediately before administration as small particles will form in water CEFALEXIN
CEFUROXIME
CELECOXIB
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 CELIPROLOL
CETIRIZINE
CHLORAL HYDRATE
CHLORDIAZEPOXIDE
CHLOROQUINE
CHLORPHENAMINE
solution. Direct interaction of drug and feed causing coagulation in the tube. Dilute with equal volume of water CHLORPROMAZINE
Suppositories, injection and liquid available CHLORTALIDONE
Take care to give all, as it will sediment quickly. CICLOSPORIN
CILAZAPRIL
CIMETIDINE
Incompatible with feeds – stop Injection can be given CINNARIZINE
CIPROFIBRATE
CIPROFLOXACIN
Yes – disperse in 30-60ml of reduced by up to 25% by sterile water interaction with Jevity®, and take 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
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. CLARITHROMYCIN
Liquid available, may clog tube so dilute with same volume of water prior to administration CLINDAMYCIN
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 CLOBAZAM
CLOMETHIAZOLE
CLOMIPRAMINE
Yes (non-MR Small capsules – mix with water capsules only) and flush down 8Fr NG tube CLONAZEPAM
Injection solution may be given orally or enterally acid, benzyl alcohol and propylene glycol.
CO-AMILOFRUSE
CO-AMILOZIDE
CO-AMOXICLAV
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
CO-BENELDOPA (Madopar
®' preparations) SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION
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 Yes
®preparations) SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION
CO-CODAMOL
CO-DANTHRAMER
Liquid available - now very limited indications for this drug CO-DYRAMOL
Liquid available or convert to soluble/liquid components COLECALCIFEROL
CO-PHENOTROPE
Disperse in water and flush down 8Fr NG tube without blockage. CO-TENIDONE
CO-TRIAMTERIZDE
CO-TRIMOXOZOLE
COLCHICINE
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
Suggest using alternative analgesic e.g. co-codamol 8/500 soluble COVERSYL
CYCLIZINE
Powder may be mixed with food Injection available and or syrup (to mask bitter taste) can be given enterally but CYCLOPENTHIAZIDE
CYCLOPHOSPHAMIDE
CYPROPHEPTADINE
CYPROTERONE
DANTROLENE
Powder may be emptied from capsule and mixed - with orange juice or other acidic liquid. DEFLAZACORT
Disintegrates in water and flushes down 8Fr NG tube without blockage DEFERIPRONE
DEMECLOCYCLINE
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
DEXAMETHASONE
Disintegrates within 5 minutes Can dilute and administer Liquid available. in 10 ml water and give via 8Fr the injection orally or Ng tube. Settles quite quickly Injection has been given Liquid available but may DIAZEPAM
PEG/NG – syrup/crushed tablets not recommended as drug may enterally, however adsorb onto tubing. APS brand manufacturers do not disperses within 2 minutes in 10 recommend. Drug loss through long PVC tubes as it is significantly absorbed onto PVC. It may also contribute to DICLOFENAC
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. DICYCLOVERINE
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
DILTIAZEM
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 accordingly Tildiem 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) • 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 DIPYRIDAMOLE
water (Persantin). Sugar coated administered orally or by available.
so may block tube. Flush well therefore enteral feeds should be withheld for one hour before and one opened and contents taken in soft food or suspended in water Granules should not be crushed or dissolved in hot water 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.
DISODIUM
ETIDRONATE(also included
stopped for 2 hours before and 2 hours after administration of in Didronel PMO pack)
etidronate as drug interacts with calcium in feed.
DOCUSATE
DOMPERIDONE
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
powder is local anaesthetic – avoid hot drinks after. Can sprinkle on small amount of food. Tablets may be crushed and DOXAZOSIN
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 When converting from MR to plain halve the dose and titrate upwards according to response resulting solution has a bitter taste which is difficult to mask. DOXYCYCLINE
NOT be opened for oral administration as the hyclate salt present is irritant to the oesophagus. Doxycycline binds to calcium ions and may have reduced Doxycycline 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
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
EFAVIRENZ
Liquid available – conversion necessary ENALAPRIL
Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube ENTACAPONE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
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
Crush and suspend in water. Can also mix with apple sauce EPROSARTAN
ERGOCALCIFEROL
ERYTHROMYCIN
ESCITALOPRAM
ESMOPRAZOLE
dissolve, but leave EC beads. Lansoprazole Fastabs® best for use down tubes. ETHAMBUTOL
ETHOSUXIMIDE
ETIDRONATE
after dose. Flush line well with plain water post dose Avoid antacids and mineral supplements 2 hours before and after administration.
ETOPOSIDE
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
EZETIMIBE
Disintegrates within 5 minutes in 10 ml water and give via 8Fr Ng tube FAMCICLOVIR
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
Ranitidine (40mg famotidine = ranitidine 300mg) FELODIPINE
matrix, so crushing is NOT advised - conversion to alternative drug may be necessary FENOFIBRATE
FERROUS SULPHATE
to Sytron (sodium feredetate) 10ml=200mg FeSO4. FEXOFENADINE
Change to other antihistamine available as liquid FINASTERIDE
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
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
(same dose)-may have a local undiluted. This should be anaesthetic effect. Do not mix used in emergency, and with tap water due to chelation monitor for of ions. Use distilled water .Disintegrates within 5 minutes giving via enteral feeding in 10 ml water and give via 8Fr tube, always flush with Ng tube deionised water, do not mix with alkali solutions, sulphate, phosphate,or chloride ions. Do not mix drug with medications prior to administration FLUCLOXACILLIN
flucloxacillin, as food impairs drug absorption. FLUCONAZOLE
FLUDROCORTISONE
Disintegrates within 2 minutes in 10 ml water and give via 8Fr Ng tube FLUOXETINE
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
Flush well post dose. Disintegrate if shaken in water for 5 minutes and give via 8Fr Ng tube FLURBIPROFEN
capsules, do block tubenot crush tablets) FLUTAMIDE
Tablets may be crushed and given mixed with milk or fruit juice FLUVASTATIN
May be difficult to remove all capsule contents. Do not put MR down tubes. FLUVOXAMINE
FOLIC ACID
FORCEVAL
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! FOSINOPRIL
FUROSEMIDE
FUSIDIC ACID
Liquid available - 500mg sodium fusidate tablets are approximately equivalent to 750mg fusidic acid suspension Do not put down tube due to the risk of congealing and blocking the tube. GABAPENTIN
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
places in 10ml water which can flush down 8Fr NG tube GANCICLOVIR
GLIBENCLAMIDE
glucose levels as may be more effective crushed GLICLAZIDE
Watch for associated increase in bioavailability (monitor blood glucose carefully). REF Preferably swith to insulin for better glycaemic control GLIMEPIRIDE
May take 5 minutes to disperse – DO NOT CRUSH GLIPIZIDE
Disperses readily in water once finely crushed. GLYCERYL TRINITRATE
GLYCOPYRRONIUM
GRANISETRON
GRISEOFULVIN
Change to alternative drug such as terbinafine HALOPERIDOL
HYDRALAZINE
Crushing tablets leads to more Reconstitued injection can rapid absorption of drug and \caution – review choice of therapy? Absorption is decreased in the presence of food – leave a one hour gap before and after the dose. HYDROCHLORTHIAZIDE
HYDROCORTISONE
Will disperse in 5 minutes when Injection available and placed in 10ml water which can can be given orally or enterally. Contains significant amount of phosphate HYDROXYCHOLOQUINE
HYDROXYUREA
Caution: care with handling - avoid contact of drug powder with skin, mucous membranes, inhalation etc. - drug is cytotoxic.
HYDROXYZINE
sugar coated. Risk of tube-blockage so flush well.
HYOSCINE N
Injection may be used orally. Injection available and BUTYLBROMIDE
enterally. Content of ampoule may be stored in fridge for up to 24 hours once opened.
HYOSCINE
Tablets can be sucked and will Injection solution may be Patches and injection HYDROBROMIDE
IBUPROFEN
IMATINIB
Disperse in water or apple juice – at least 50ml of fluid for 100mg tablet IMIPRAMINE
INDAPAMIDE
INDOMETHACIN
whole. MR capsules irritant on stomach – do not open.
INDORAMIN
Can sprinkle on soft food to mask taste. IRBESARTAN
placed in 10ml water –larger particles break up when draw into syringe and can flush down 8Fr NG tube ISONIAZID
ISOSORBIDE
MONONITRATE
crushed and will dissolve but do not crush MR. Release properties may change so monitor patient. ISOTRETINOIN
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
ITRACONAZOLE
capsules and dose but possible reduced dissolve IVABRADINE
KETOCONAZOLE
LABETOLOL
It is not recommended to crush Injection can be used due to film coating and rapid dispersed in water if tablets are ground down enough but may block tube.
LACIDIPINE
LAMIVUDINE
exposure of operator to active constituents of crushed tablets. LAMOTRIGINE
Dispersible tablets available and even non-dispersible will dissolve once crushed. Dispersible tablets can be chewed.
LANSOPRAZOLE
the capsule and swallowed (without crushing or chewing) with water or in soft food e.g. a spoonful of apple sauce.
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
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
LEVETIRACETAM
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 LEVODOPA
Only sparingly soluble with insoluble excipients. Will stain skin, teeth, tongue and tube. See handbook for further details on brand.
LEVOFLOXACIN
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 LEVOMEPROMAZINE
Will disperse in 2 minutes when Injection can be given placed in 10ml water which can orally and enterally. Note 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 LEVOTHYROXINE
10ml water and shaken, this can flush down 8Fr NG tube LINEZOLID
Liquid available but may be too thick for feeding tubes.
LISINOPRIL
conversion necessary. Monitor blood levels closely. 520mg/5ml as lithium citrate -equivalent to 200mg of lithium carbonate. LOFEPRAMINE
LOPERAMIDE
Liquid available but large sugar content so caution in diabetics. Flushes down NG tube without resistance.
LORATADINE
LORAZEPAM
LOSARTAN
Mix with 10ml water to form fine suspension which flushes down 8Fr NG tube without blockage LOXAPINE
Crushed tablets should be dissolved in water and given immediately MAGNESIUM
Capsule contents can be mixed with soft food MEBENDAZOLE
MEBEVERINE
Yes but only Fairly soluble in water. Change MR to normal release tablets or liquid. Stop feed for 30 minutes pre and post dose MEDROXYPROGESTERONE Yes
minutes. Suspension will flush used orally, although little via 8Fr NG tube without MEFENAMIC ACID
– virtually insoluble. Can mix with food or jam MEGESTROL ACETATE
Tablets may be crushed and given in water, fruit juice or jam. May take 5 minutes for tablets to dissolve.
MELATONIN
mixed with yoghurt, fruit juice or jam.
Circadin tablets should not be crushed as controlled release. MELOXICAM
suppositories for the shortest time possible MEMANTINE
MENADIOL
MERCAPTOPURINE
tablet in water, however unstable in aqueous solutions. Use immediately.
MESALAZINE
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
METHOTREXATE
Cytotoxic therefore do not crush. Place in water and conditions consider S/C or I/M. 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 METHOTRIMEPRAZINE
Tablets disperse in water. Injection has been use orally.
METHYLDOPA
coating may not dissolve. Interacts with Ensure®, Ensure plus® and Osmolite® - stop feed for two hours before and one hour after. REF METHYLPREDNISOLONE
Tablets will disperse in water. Do not crush M/R tablets METHYLPREDNISOLONE
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 METOCLOPRAMIDE
METOLAZONE
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. METOPROLOL
METRONIDAZOLE
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
Capsule can be cut open and the contents administered if necessary.
MEXILITINE
contents in distilled water. Can orally. It has also been flush down feeding tube. 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
Tablets may be crushed, but difficult. Mix with plenty of water. MIDAZOLAM
Injection can be given orally. The injection has a diluted with apple or blackcurrant juice, raspberry or cherry syrup, chocolate sauce or cola MINOXIDIL
Disperse in water within 2 minutes to give dispersion which flushes via 8Fr NG tube without blockage. MIRTAZPINE
MISOPROSTOL
Caution: powder should not be handled by pregnant women. Change to lansoprazole if for this indication MOCLOBEMIDE
Solution flushes down 8Fr NG tube without blockage MODAFINIL
MONTELUKAST
Give immediately as unstable in water. Granules can be mixed in soft food or place directly onto the tongue and swallow.
MORPHINE M/R
TABLETS/CAPSULES
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
Tablets have a bitter taste. 400mg tablet will dissolve in 20mls of water. Stop feed one hour before and 2 hours after administration.
MOXONIDINE
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
Remove capsule contents and disperse in water NAFTIDROFURYL
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
NAPROXEN
NATEGLINIDE
NEBIVOLOL
Administer solution immediately. Doesn’t dissolve very well – flush. NEFAZODONE
NEOMYCIN
NEOSTIGMINE
NEVIRAPINE
NICARDIPINE
The powder can be removed from the capsule and dissolved, preferably in orange juice NICORANDIL
Dispersion occurs slowly (at least 5 minutes). Use in care with enteral feeding tube as may cause blockage.
NICOUMALONE
NIFEDIPINE
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
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
NITROFURANTOIN
NIZATIDINE
NORETHISTERONE
Suspension flushes via 8Fr NG tube without blockage NORFLOXACIN
Flush well as poorly soluble. Stop feed 1 hour before and 2 hours after. Unpleasant taste.
NORFLOXACIN
Do not disperse well in water – give crushed tablets NORTRIPTYLINE
OFLOXACIN
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
Normal tablets will dissolve, but not as fast as velotabs OLSALAZINE
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
Liquid available – Maxepa Is it vital the patient has 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. PEG/NG tubes :- Manufacturer OMEPRAZOLE
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 ONDANSETRON
Injection has been used Injection, suppositories, 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 ORLISTAT
Open and stir into water or fruit juice or flush contents down the tube ORPHENADRINE
OXPRENOLOL
OXYBUTYNIN
OXYCODONE
due to possibility of powder becoming airborne.
OXYTETRACYCLINE
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
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. PANTOPRAZOLE
Tablets must be swallowed whole and may not be crushed. Patient should be changed to alternative e.g. lansoprazole or omeprazole.
PARACETAMOL
PAROXETINE
PENICILLAMNINE
PENICILLIN V
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)
PERINDOPRIL
PHENELZINE
Slow to disperse. Use immediately. No information on enteral tube administration PHENOBARBITAL
PHENOXYBENZAMINE
No information about whether this may block tube PHENYTOIN
crush and do and patients should be ECG and not disperse BP monitored. If given by IV readily in 90mg syrup is equivalent to 100mg capsule e.g. patient previously on 300mg in capsules should be given 45ml syrup.
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
PIMOZIDE
PINDOLOL
PIOGLITAZONE
Monitor blood glucose levels carefully if crushing tablets. For better glycaemic control switch to insulin.
PIROXICAM
PIVMECILLINAM
Probably more accurate to change dose to equate to half or quarter of tablet PIZOTIFEN
POTASSIUM
PRAMIPEXOLE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
PRAVASTATIN
PRAZOSIN
Insoluble so ensure wash down with water or mix with jam etc PREDNISOLONE
Soluble tablets available. Do not crush E/C. Plain tablets disperse in water.
PREGABALIN
Unpleasant taste. Give immediately after dissolved in sterile water. PRIMIDONE
PROCHLORPERAZINE
Buccal tablets, syrup, effervescent granules PROCYCLIDINE
PROGUANIL
PROMAZINE
PROMETHAZINE
PROPAFENONE
Local anaesthetic action and bitter taste PROPRANTHELINE
PROPRANOLOL
Granules from MR capsules can Can give injection orally; Liquid available. be swallowed whole. Flush given orally. However little information on it so not recommended.
PROPYLTHIOURACIL
PSEUDOEPHEDRINE
PYRAZINAMIDE
PYRIDOSTIGMINE
PYRIDOXINE
QUETIAPINE
Bitter taste therefore mix with soft food. Flush down tube. Can crush. Do not crush XL formulation QUINAPRIL
QUINIDINE
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
RALOXIFINE
Unpleasant taste. Care handling and crushing – maybe teratogenic. Discotinue if immobile. RAMIPRIL
Bitter taste. Place contents directly on mouth or bread. RANITIDINE
tablets, syrup (may cause diarrhoea).
REBOXETINE
REPAGLINIDE
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
RIFAMPICIN
can cause sensitisation. Stop feed one hour before and 30 minutes post dose. Can crush or disperse RILUZOLE
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
Do not give via feeding tube. Review need. 35mg tablets disperse in 10ml water within 5 minutes to give fine dispersion.
RISPERIDONE
Quicklets available and injection, liquid.
RIVASTIGMINE
ROPINIROLE (SEE
SEPARATE PD GUIDELINES
and mix with water for use down enteral feeding tubes.
FOR MORE INFORMATION)
ROSIGLITAZONE
May increase effect. Consider sliding scale.
ROSUVASTATIN
SALBUTAMOL
convert to liquid and give in 3-4 divided doses. Consider changing to nebulised therapy SECOBARBITAL
Open capsules and dissolve contents in water, use immediately and discard remainder SELEGILINE (SEE
SEPARATE PD GUIDELINES
FOR MORE INFORMATION)
SERTRALINE
bitter and has local anaesthetic effect. Ensure all powder is given if giving down tube SEVELAMAR
SILDENAFIL
Tablets will disperse in water, give immediately SIMVASTATIN
Give immediately as light sensitive and give via 8Fr NG tube. Take significant time to disperse. SITAGLIPTIN
SIROLIMUS
SODIUM BICARBONATE
Injection can be given orally or enterally SODIUM CHLORIDE
Injection may be given orally or enterally PHENYTLBUTYRATE
SODIUM CROMOGLICATE
Contents can be removed, dissolved in hot water, then diluted in cold water before taking SODIUM CLODRONATE
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
acid which is not as well absorbed as sodium fusidate: -500mg in tablets = 750mg in syrup SODIUM PICOSULFATE
SODIUM VALPROATE
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. SOLIFENACIN
Consider licensed beta blocker preparations SPIRONOLACTONE
Can take 5 minutes for tablet to completely disperse. Will flush 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
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
and after dose due to the risk of bezoar formation. Likely to block tube and no suitable for JEJ administration.
SULFASALAZINE
Suppositories/enema for lower-bowel disease. Suspension available SULINDAC
SULPIRIDE
Can be dispersed to form fine dispersion which can be drawn up and flushes via 8Fr NG tube without blockage.
TACROLIMUS
Open capsules and mix contents with small amount of water. Do not inhale and wear maxk and gloves. TAMOXIFEN
Handle drug powder with care (avoid dust being inhaled, on skin etc. as far as possible – use mask, gloves and eye protection). TAMSULOSIN
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
Tablets not very soluble but will flush via 8Fr NG tube without blockage. Absorb moisture after crushing to give immediately. TEMAZEPAM
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
TERAZOSIN
May take 5 minutes to disperse. Insoluble excipients TETRABENAZINE
Dispersion occurs slowly at least 5 minutes THALIDOMIDE
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.
• 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.
THEOPHYLLINE
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. 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
THIOGUANINE
TIAGABINE
dispersion that flushes down 8Fr NG tube without blockage.
TIBOLONE
Consider changing to alternative beta blocker TIZANIDINE
Crush to fine powder for NG/PEG tubes.
TOLBUTAMIDE
TOLTERODINE
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.
TOPIRAMATE
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. TORASEMIDE
Crush and disperse in water. Slurry is formed so rinsing of tube essential.
TRAMADOL
Soluble tablets are most suitable for administration via enteral tubes. Capsule contents can be mixed TRANDOLAPRIL
taste or mixed in water to give via PEG/NG. May cause sudden hypotension if patient dehydrated. Capsules very small and difficult to open. TRANEXAMIC ACID
Tablets disperse in 2-5 minutes. Can use injection orally or enterally immediately after dilution. Store in fridge and use within 24 hours. TRAZODONE
TRIFLUOPERAZINE
Do not crush MR tablets. Spansules are s/r and cannot be opened/crushed. TRIHEXYPHENIDYL
flush down 8Fr NG tube without blockage.
TRIMEPRAZINE
TRIMETHOPRIM
and after administration of liquid. Well absorbed via enteral feeding tubes TRIMIPRAMINE
tablets in water. Has local anaesthetic action TROSPIUM
With disperse in 100ml water, orange or grape juice. Bitter taste.
URSODEOXYCHOLIC ACID Yes
water. Do not disperse in water. May block fine bore tubes. Capsules (Ursofalk) can be opened and contents sprinkled on to food. VALACICLOVIR
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
VANCOMYCIN
difficile- can also use via nasogastric tube. Consult pharmacy.
Capsule contents are gel-formed and not suitable for feeding tube administration.
VENLAFAXINE
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.
VERAPAMIL
anaesthetic action in mouth. Do on an empty stomach; not crush MR tablets. Doses the day. Ordinary tablets may hour after each dosebe 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. VIGABATRIN
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.
VITAMIN B COMPOUND
active substance present in very low concentrations VITAMIN E
VORICONAZOLE
Liquid available – take 1 hour before food or 1 hour after.
WARFARIN
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
May be difficult to crush, may result in increase peak levels. ZESTORETIC
ZIDOVUDINE
ZINC SULPHATE
Effervescent tablets and injection available ZOPICLONE
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.
Do not crush Zimovane as bioavailability may be altered. ZOLPIDEM
ZONISAMIDE
Open capsule and suspend contents in water. Has been added to food and apple juice ZUCLOPENTHIXOL
REFERENCES
NEWT guidelines
Enteral feeding book
Previous Dysphagia guidelines
Cornwall dysphagia guidelines
Waltham Forest guidelines
NELM Q and A which injections can be used orally
Manufacturers

Source: http://stockportccg.org/wp-content/uploads/2012/01/34838_Med_Admin_Dysphagia.pdf