1
Administering
Medications
through
Feeding
Tubes
(GT,
NG,
JT,
NJ,
etc)
Updated August 2021
This
content
was
developed
by:
Adrian Turner, Pharm.D.- Cook Children’s Medical Center, Ft. Worth, TX
Marry Vuong, Pharm.D.- Nicklaus Children’s Health System, Miami, FL
Veronica Hood, PhD- Dravet Syndrome Foundation, Cherry Hill, NJ
This
information
should
not
replace
guidance
from
a
health
care
professional
managing
the
care
of
your
child
or
loved
one.
Caregivers
should
use
this
guide
to
help
inform
conversations
as
part
of
the
health
care
team,
working
with
medical
professionals
to
determine
the
best
medications
and
routes
of
administration
to
use
given
the
individual
patient’s
medical
history
and
needs.
Sometimes oral intake is not possible or is not ideal. In these instances, the use of alternative routes can be quite beneficial. Both nutrition and
medication administration can be improved or maintained through the appropriate use of enteral alternatives such as gastrostomy tubes (GT),
nasogastric tubes (NG), gastrostomy buttons (G-Buttons; GB), jejunostomy tubes (JT), and nasojejunal tubes (NJ). However, these routes present
unique barriers and considerations the traditional oral route does not.
Miscellaneous
tips
for
medication
administration
via
feeding
tubes
1-8
:
¥ Product
choices:
o Generally, products that are extended release or delayed release should not be crushed. There are a few exceptions, outlined below.
o If using a liquid formulation, elixirs and suspensions may be less likely to clump with enteral nutrition compared to syrups.
2
o Some liquids may contain high amounts of sugar alcohols (e.g. sorbitol, malitol) or have a high osmolality. Both of these can increase the
risk of developing abdominal cramping, bloating, nausea, and diarrhea. These side effects can be reduced via preparation methods such as
further dilution or switching to an alternative medication formulation. This risk of diarrhea is higher when medications are administered via
jejunostomy routes.
o If the medication is intended for administration in the cheek or under the tongue, continue to use via those routes. Using these products
through enteral tubes may reduce medication efficacy.
o It is recommended to use sterile or filtered water for preparation and flushing of medications.
¥ Administration:
o If multiple medications need to be administered, only administer one medication at a time unless your provider advises you differently.
o Flush with at least 5 to 10 mL water between each medication administration.
¥ Flushing:
o Regular flushing of the tube will prevent clogging and help prolong the life of the enteral feeding tube.
o Pulsatile flushing can create turbulence within the feeding tube. This can “clean” the inner walls and help keep the tube from clogging.
o Water is the best fluid to flush tubing. Sometimes, warm water may help prevent clogging.
o Anecdotally, soda and soda water have been used to unclog enteral tubes. However, caution must be used with this method as the acidic
nature of these liquids could further clog the tube by causing feed clumping.
General
crush
and
mix
recommendations
for
administration
of
tablets
via
feeding
tube
1,
2,
6,
7
:
1. Stop enteral feed and flush.
2. Place the tablet in the barrel of an appropriate size and type of syringe (usually, 30 to 50 mL syringes will suffice). May crush tablet within
syringe.
3. Draw up specified volume (per medication table below) within the syringe.
4. Allow tablet(s) to disperse.
5. Give medication.
6. Draw up specified flush volume (per medication table below) in the same syringe. Shake well to ensure any residual medication is not left
within the syringe.
7. Give this volume to ensure the full dose has been administered.
8. Flush tube, and restart feeds.
3
In
the
table
on
the
following
pages,
find
information
regarding
which
medicat i ons
can
be
given
through
alternative
enteral
routes
and
recommendations
on
preparation.
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Acetazolamide
(Diamox
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Do not use extended release capsules.
If tablets are used, note that this mixture can settle quickly. Be sure to shake
well prior to administration.
References: 1-16
Amantadine
(Symmetrel
®
,
Gocovri
®
,
Osmolex
ER
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
May open immediate release capsules or crush immediate release tablets and
mix in water. Do NOT use extended release formulations.
If using liquid formulation, dilute with at least 10 to 30 mL water. This
product has a very high osmolarity and considerable amounts of sorbitol
which can increase the risk of diarrhea and GI side effects.
Do not use extended release formulations
References: 1-12, 17-19
Baclofen (Gablofen
®
,
Lioresal
®
,
Ozobax
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution does contain sorbitol. If larger doses are required, consider
diluting with at least 10 mL prior to administration.
References: 1-12, 20
Brivaracetam
(Briviact
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution does contain sorbitol (209.8 mg/mL). If the patient has GI
discomfort or develops diarrhea, consider further diluting liquid with water.
Tablets may be crushed, but may taste bad
References: 1-12, 21
Calcium
carbonate-
vitamin
D
Yes
Yes
30-50 mL (prepare)
+ 10-30 mL (rinse)
Effervescent tablets preferred (reduced potential for GI side effects).
Effervescent tablets may help reduce volume (could use as little as 10 mL to
mix and dissolve). Allow time for effervescent tablet to completely dissolve
before administering.
References: 1-12, 17-19
4
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Cannabidiol
(Epidiolex
®
)
Yes
No
--
Do not use with tubes made of polyvinyl chloride (PVC) as they may harden
and potentially crack.
References: 1-12, 23
Cannabidiol (artisanal
brands)
Yes
No
--
Only oral solution/liquid eligible for enteral administration
Do not use with tubes made of polyvinyl chloride (PVC) as they may harden
and potentially crack.
References: 1-12, 23
Carbamazepine
(Carbatrol
®
,
Equetro
®
,
Tegretol
®
,
Tegretol
XR
®
)
Yes
Possible,
not
preferred*
10-60 mL (prepare)
+ 10 mL (rinse)
If oral solution is used, dilute dose with 30-60 mL water to ensure medication
does not stick to tubing and to prevent GI side effects as this contains
sorbitol.
If tablets are used, note that this mixture can settle quickly. Be sure to shake
well prior to administration. Note, converting non-liquid formulations for
enteral administration could still result in tube blockage.
Separate dose administration from feeds by at least 1 hour.
Do not used extended release capsules or tablets.
*Potential for increased side effects or loss of efficacy with GJ/JT
administration; consider decreasing dose and increasing frequency to avoid
negative outcomes.
References: 1-12, 26-28
Cenobamate (Xcopri
®
)
--
--
--
--
References: 1-12, 29, 30
Clemizole
--
--
--
--
Clobazam (Frisium
®
,
Onfi
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution preferred; if oral film, consider transition to oral solution or
tablet.
References: 1-12, 31
5
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Clonazepam
(Klonopin
®
)
Yes
Yes
10-60 mL (prepare)
+ 10-15 mL (rinse)
Some liquid formulations may not be compatible with tubes composed of
PVC or polystyrene. Please check with your physician or pharmacist.
If using liquid, ensure this is diluted with 30-60 mL water to prevent binding
to tubing.
Flushing can be performed by flushing three consecutive times with 5 mL or
by flushing with at least 5 mL water and immediately delivering a minimum
of 10 mL feeds after.
References: 1-12, 32,33
Clonidine (Catapres
®
,
Kapvay
®
)
Yes
Yes
10 mL (prepare)*
+ 10 mL (rinse)
Oral solution preferred
*Per 0.1 mg tablet
References: 1-12, 34
Diazepam (Valium
®
,
Valtoco
®
,
Diastat
®
)
Yes
Yes
10-60 mL (prepare)
+ 10 mL (rinse)
For oral liquid formulations, dilute with 30-60 mL water to prevent binding of
the medication to tubing and to prevent GI side effects.
If GT/NG: oral solution preferred. May mix with water to reduce resistance
when flushing.
If JT/NJ: tablets preferred to reduce GI discomfort. Oral solution does contain
sorbitol.
References: 1-12, 35-41
Eslicarbazepine
(Aptiom
®
)
Yes
Yes
10 mL (prepare)*
+ 10 mL (rinse)
*Minimal information regarding feeding tube administration available. May
need more volume to ensure full dose is administered (both mixing and
flushing).
References: 1-12, 42,43
Esomeprazole
(Nexium
®
)
Yes
Yes
25-50 mL water and 5 mL
air (prepare)
+ 25 mL water and 5 mL
air (rinse)
Packet for oral solution or tablet preferred
If preparing a solution, administer 5-10 mL at a time; invert syringe to ensure
medication is thoroughly mixed after each 5-10 mL given.
References: 1-12, 44-48
6
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Ethosuximide
(Zarontin
®
)
Yes
Yes
10 mL (prepare)*
+ 10 mL (rinse)
Oral solution is preferred. Mix with equal amount of water (ex. Dose = 5 mL;
mix with another 5 mL water) to reduce resistance to flushing.
*Minimal
information
regarding
feeding
tube
administration
available.
May
need
more
volume
to
ensure
full
dose
is
administered
(both
mixing
and
flushing).
References: 1-12, 49,50
Famotidine (Pepcid
®
)
Yes
--
10 mL (prepare)
+ 10 mL (rinse)
Oral solution preferred.
If tablet, flush before and after administration.
References: 1-12, 51
Felbamate (Felbatol
®
)
Yes
--
10 mL (prepare)*
+ 10 mL (rinse)
Oral solution preferred; however, may still require dilution prior to
administration. Oral solution does contain sorbitol. If the patient has GI
discomfort or develops diarrhea, consider further diluting liquid with water.
*Minimal
information
regarding
feeding
tube
administration
available.
May
need
more
volume
to
ensure
full
dose
is
administered
(both
mixing
and
flushing).
References: 1-12, 52,53
Fenfluramine
(Fintepla
®
)
Yes
--
--
If the patient has GI discomfort or develops diarrhea, consider further
diluting liquid with water.
Product is compatible with most commercially available gastric and
nasogastric feeding tubes.
References: 1-12, 54
Gabapentin
(Neurontin
®
)
Yes
Yes
15 mL (prepare)
+ 15 mL (rinse)
Oral solution preferred. However, liquid may contain xylitol and could
contribute to GI discomfort. May dilute with liquid prior to administration to
help reduce GI side effects.
References: 1-12, 55
Glycopyrrolate
(Cuvposa
®
,
Robinul
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution preferred; however, the liquid does contain sorbitol and could
contribute to GI side effects/discomfort. To prevent these effects, consider
further diluting liquid with water.
References: 1-12, 56-58
7
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Lacosamide (Vimpat
®
)
Yes
n/a
10 mL (prepare)
+ 10 mL (rinse)
If oral solution, ensure tubes are composed of polyurethane and silicone.
Oral solution does contain sorbitol. If the patient has GI discomfort or
develops diarrhea, consider further diluting liquid with water.
References: 1-12, 59,60
Lamotrigine (Lamictal
®
,
Lamictal
XR
®
,
Subvenite
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
ODT and chewable tablets should be dissolved in a minimal amount of water
as these dissolve very quickly.
References: 1-12, 61-63
Lansoprazole
(Prevacid
®
)
Yes
Yes
10 mL water or sodium
bicarbonate 8.4%
(prepare)
+ 10 mL water or sodium
bicarbonate 8.4% (rinse)
Oral solution not preferred – granules may block the tube.
Capsules may be opened and dissolved in sodium bicarbonate 8.4%.
Orally disintegrating tablets may be dissolved in water.
If tube becomes blocked, you may “lock” the tube using sodium bicarbonate
8.4% to dissolve granules stuck in the tube
References: 1-12, 64,65
Levetiracetam
(Keppra
®
)
Yes
Yes
10 mL (prepare)*
+ 10 mL (rinse)
Oral solution preferred. However, oral solution does contain malitol. If the
patient has GI discomfort or develops diarrhea, consider further diluting
liquid with water.
*Per
500
mg
tablet
References: 1-12, 66-68
Levocarnitine
(Carnitor
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution preferred.
References: 1-12, 69
Lorazepam (Ativan
®
)
Yes
Yes
15 mL (prepare)
+ 15 mL (rinse)
Oral concentrate preferred.
References: 1-12, 70-72
Lorcaserin
--
--
--
--
References: 1-12, 73
8
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Methsuximide
(Celontin
®
)
Yes*
No**
--
If enteral administration is desired, the compounded oral suspension must be
used. This product will likely need to be filled with a specialty pharmacy.
*Must
use
oral
suspension.
No
data
to
support
opening
and
mixing
capsule.
**Administration
via
a
jejunostomy
tube
is
discouraged
at
this
time
(minimal/no
data).
References: 1-12, 74
Midazolam (Versed
®
,
Nayzilam
®
)
Yes
Yes
--
Oral syrup does contain sorbitol. If the patient has GI discomfort or develops
diarrhea, consider further diluting liquid with water.
The oral syrup, if combined with feeds, can create clumping and increase the
possibility of clogging the tube. Please pause feeds and flush with water
before and after administration.
References: 1-12, 75-78
Mycophenolate
mofetil
(Cellcept
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution preferred. However, oral solution does contain sorbitol. If the
patient has GI discomfort or develops diarrhea, consider further diluting
liquid with water.
Mycophenolate is considered a hazardous medication and opening
capsules/crushing tablets are not considered to be safe.
Referen ces: 1-12 , 79-81
Mycophenolic
acid
(Myfortic
®
)
--
--
--
Do not crush. Speak with your provider about alternative formulations.
References: 1-12, 82
Nystatin (Bio-Statin
®
)
Possible,
not
preferred
Possible,
not
preferred
10 mL (prepare)
+ 10 mL (rinse)
Ask your provider what the purpose of the medication is for the patient. For
some, oral administration may be needed to appropriately treat or prevent
the infection.
Nystatin oral solution has a very high osmolality; if a non-oral route is
needed, dilute solution with at least equal volume of water to dose.
References: 1-12, 83,84
9
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Oxcarbazepine
(Trileptal
®
,
Oxtellar
XR
®
)
Yes
Possible,
not
preferred*
10-60 mL (prepare)
+ 10 mL (rinse)
If oral solution is used, dilute dose with 30-60 mL water to ensure medication
does not stick to tubing and to prevent GI side effects as this contains
sorbitol.
If tablets are used, note that this mixture can settle quickly. Be sure to shake
well prior to administration. Note, converting non-liquid formulations for
enteral administration could still result in tube blockage.
Separate dose administration from feeds by at least 1 hour.
Do not used extended release capsules or tablets
*Potential
for
increased
side
effects
or
loss
of
efficacy
with
GJ/JT
administration;
consider
decreasing
dose
and
increasing
frequency
to
avoid
negative
outcomes
References: 1-12, 85,86
Perampanel
(Fycompa
®
)
Yes
Possible,
not
preferred*
10 mL (prepare)
+ 10 mL (rinse)
*Site
of
absorption
not
specifically
known,
but
due
to
rapid
absorption,
it
is
likely
upper
GI
tract.
Therefore,
jejunostomy
not
ideal
for
administration.
If
administered
jejunally,
monitor
for
decreased
efficacy.
If using oral suspension, this product does contain sorbitol. If the patient has
GI discomfort or develops diarrhea, consider further diluting liquid with
water.
References: 1-12, 87,88
Phenobarbital
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
If NJ/JT: mix liquid with water to reduce potential for side effects.
References: 1-12, 89-92
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Phenytoin (Dilantin
®
,
Phenytoin
InfaTabs
®
)
Yes
Possible,
not
preferred*
30-60 mL (prepare)
+ 10 mL (rinse)
*Phenytoin
requires
specific
amounts
in
the
blood
to
be
effective.
Giving
through
a
jejunostomy
tube
can
affect
these
concentrations
and
is,
therefore,
not
preferred.
Stop the enteral feed and flush the tube 2 hours before dosing to prevent the
medication from binding to the feeds (could potentially make medicine less
effective).
For liquid, mix with 30-60 mL water to prevent binding of the medication to
the tubing.
Allow powder from capsules to dissolve for about 5 minutes.
References: 1-12, 93-95
Polyethylene
glycol
3350
(Miralax
®
)
Yes
Yes
Per product instructions
Follow product instructions.
References: 1-12, 96,97
Potassium
citrate/
citric
acid
(Cytra-K
®
)
Yes
Possible,
not
preferred*
120-320 mL (prepare)
+ 10 mL (rinse)
All products should be diluted with water prior to administration (regardless
of oral or enteral routes). Oral solution should be mixed with 4 to 8 ounces of
water.
*This product is highly concentrated and could cause GI discomfort and/or
diarrhea. If jejunal administration is required, this medication may require
more than 8 ounces of water to avoid GI side effects.
References: 1-12, 98
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Prednisone
(Deltasone
®
,
Rayos
®
)
Yes
Yes
For doses less than 5 mg:
5 mL (prepare)
+ 5 mL (rinse)
For doses greater than 5
mg but less than 50 mg:
10-20 mL (prepare)
+ 10 mL (rinse)
For doses 50 mg or more:
20-30 mL (prepare)
+ 10-20 mL (rinse)
If a liquid product is needed, oral solution preferred over the oral
concentrate as it is less likely to cause GI irritation.
If using oral concentrate or oral solution, these products do contain sorbitol.
If the patient has GI discomfort or develops diarrhea, consider further
diluting liquid with water.
Do not crush delayed release tablets.
Consider using prednisolone orally disintegrating tablets instead.
References: 1-12, 101-103
Prednisolone
(Millipred
®
,
Orapred
®
,
Pediapred
®
,
Veripred
®
)
Yes
Yes
For doses less than 5 mg:
5 mL (prepare)
+ 5 mL (rinse)
For doses greater than 5
mg but less than 50 mg:
10-20 mL (prepare)
+ 10 mL (rinse)
For doses 50 mg or more:
20-30 mL (prepare)
+ 10-20 mL (rinse)
If a liquid product is needed, oral solution preferred over the oral syrup as it
is less likely to cause GI irritation.
If using oral syrup or oral solution, these products do contain sorbitol. If the
patient has GI discomfort or develops diarrhea, consider further diluting
liquid with water. Of note, Orapred
®
brand contains less sorbitol compared to
Pediapred
®
brand.
Do not crush enteric coated tablets. Use orally disintegrating tablets.
References: 1-12, 104-107
Pregabalin
(Lyrica
®
,
Lyrica
CR
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution preferred. If oral solution not a feasible option, utilize capsule
formulation.
Oral solution does contain artificial sweeteners. If the patient has GI
discomfort or develops diarrhea, consider further diluting liquid with water.
References: 1-12, 108,109
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Primidone (Mysoline
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
--
References: 1-12, 110
Rufinamide (Banzel
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Oral solution does contain sorbitol. If the patient has GI discomfort or
develops diarrhea, consider further diluting liquid with water.
References: 1-12, 111, 11 2
Soticlestat
Yes
--
10 mL (prepare)
+ 10 mL (rinse)
--
References: 1-12, 113
Stiripentol (Diacomit
®
)
Yes
Yes
Per product instructions
Packet for oral suspension preferred. Do not open and crush capsule.
Mix oral packet for suspension with package instructions.
Oral suspension does contain sorbitol. If larger doses are required, consider
diluting with at least 10 mL prior to administration.
References: 1-12, 114-116
Topiramate
(Topamax
®
,
Qudexy
XR
®
,
Trokendi
XR
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
Tablets and oral suspension preferred. Do NOT open and mix extended
release capsules.
For tablets, must shake in water for 5 minutes to create a slurry mixture.
Oral suspension does contain sorbitol. If the patient has GI discomfort or
develops diarrhea, consider further diluting liquid with water.
Capsule contents do not work well for enteral tube administration as the
granules/beads stick to the tubing and can block the tube.
References: 1-12, 117-120
Tiagabine (Gabitril
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)
--
References: 1-12, 121
Medication
NG/GT
JT/NJ
Amount
of
water
to
prepare
non-liquid
medications
for
enteral
administration
Other
Pertinent
Information
Valproic
acid/
Divalproex
Sodium
(Depakote
®
,
Depakote
ER
®
,
Depakote
Sprinkles
®
,
Depakene
®
,
Depacon
®
)
Yes
No
10 mL (prepare)
+ 10 mL (rinse)
If using liquid, dilute with water to improve resistance to flushing.
Do NOT use delayed release capsules or extended release tablets. May use
delayed release tablets if directed to do so by physician.
If NJ/JT: use tablet (delayed release). Your physician may choose to draw labs
to ensure the patient remains within a therapeutic range.
References: 1-12, 122-128
Vigabatrin (Vigadrone
®
,
Sabril
®
)
Yes
Yes
10 mL (prepare)
+ 10 mL (rinse)*
Use sachet formulation.
*Mix packet with 10 mL and give specified volume per the patient’s
prescription.
References: 1-12, 129-131
Zonisamide
(Zonegran
®
)
Yes
No
10 mL (prepare)
+ 10 mL (rinse)
Oral suspension does contain sorbitol. If the patient has GI discomfort or
develops diarrhea, consider further diluting liquid with water.
References: 1-12, 132,133
Abbreviations: gastrointestinal (GI); gastrostomy tube (GT); jejunostomy tube (JT); nasogastric tube (NG); nasojejunal tube (NJ); orally
disintegrating tablet (ODT); polyvinyl chloride (PVC)
Questions?
Email:
[email protected]
References
1. National Institutes of Health, U.S. National Library of Medicine, DailyMed Database.
2. White R, Bradnam V. Handbook of drug administration via enteral feeding tubes [Internet]. Grayslake (IL): Pharmaceutical Press; 2007. 590 p. Available from:
http://www.rlandrews.org/pdf_files/handbk_of_enteralfeeding.pdf
3. Wensel TM. Administration of proton pump inhibitors in patients requiring enteral nutrition [Internet]. P T. 2009 Mar; 34(3):143-60. Available from:
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2697083/pdf/ptj34_3p143.pdf
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