Preface

The NEWT Guidelines is a unique resource which aims to provide prescribers and other healthcare professionals with a single point of reference which draws together the available information relating to medicines management in patients with enteral feeding tubes or swallowing difficulties, and presents it in a practical fashion.

In most cases, drugs are listed alphabetically under the name by which they are known in the British National Formulary (BNF). This is usually their recommended International Non-proprietary Name (rINN) or, for certain products, their British Approved Name (BAN) or registered brand name.

How The NEWT Guidelines is constructed:
The NEWT Guidelines is unusual for a clinical resource. Much of the information it contains relates to medication administration outside the marketing authorisation (product licence); for this reason there is little scientific evidence to back up the information, and many of the recommendations are based on anecdotal reports which can conflict with each other. Often the availability of information on a drug depends on the level of clinical experience with it, and therefore information about new drugs on the market is lacking.

Formulation manipulation (crushing tablets and opening capsules) can also be very dependent on the excipients in the formulation. This is one reason why reports can appear to contradict each other; a product made by one manufacturer may disperse well in water for administration, but the same medication produced by a different manufacturer with a different excipient may fail to disperse properly.

Historically in many settings, formulation manipulation was carried out routinely without consultation or evidence to support it. Little information was published on such administration except where the treatment failed or adverse events were obvious.

In today's risk-averse society, some sources will advise against manipulating drug formulations for administration to these patient groups, solely on the lack of information to say that such manipulation is safe. However, in the context of drugs which have been in use for many years, and have no doubt been administered in this fashion to many hundreds of patients, warnings against formulation manipulation which do not have supporting evidence or scientific reasoning to back them up may sometimes be judged as over-cautious, and over-ruled in favour of anecdotal reports which indicate efficacy. In all cases, where drugs are administered outside their marketing authorisation, the patient should be monitored for an appropriate clinical effect, and to establish any unexpected adverse effects.

Sources used to inform The NEWT Guidelines include summaries of product characteristics, pharmaceutical reference sources, medical literature, statutory information such as relevant safety warnings issued by the Commission on Human Medicines (CHM), information from product manufacturers, and anecdotal information from health professionals working in this area. As many of the methods of administration described in the guidelines are outside the products' marketing authorisations, the manufacturer's information is not consulted for every monograph. Users of the guidelines are invited to send in comments, both on the information in the guidelines, and any new information they have which they would like to see included. This feedback helps to ensure that the guidelines are up-to-date with current practice, and remain relevant to users. Such information is reviewed by the editor and Advisory Board, and then any appropriate amendments and additions are made to the text. Market research is also conducted at intervals to gather feedback on specific areas for future development.

Comments and constructive criticism should be sent to:
newt.guidelines@wales.nhs.uk,

or posted to
The NEWT Guidelines
Pharmacy Department
Wrexham Maelor Hospital
Croesnewydd Road
Wrexham
LL13 7TD

Disclaimers:
Information in a guideline of this type can never be all-inclusive, and therefore will not cover every eventuality. NEWT often refers to the use of drugs beyond the scope of their marketing authorisation. Readers should satisfy themselves as to the appropriateness of the information before applying it in practice. Particularly when prescribing a drug for the first time, a prescriber should study the contents of the summary of product characteristics, paying particular attention to the indications, contra-indications, cautions, adverse effects and drug interactions. This website is not a guide to diagnosis, nor to a drug's side effect profile. The responsibility for prescribing a drug outside its marketing authorisation lies with the prescriber.

These guidelines are primarily written for users in the UK, and references to e.g. the licence status of drugs, relate solely to the UK unless stated otherwise. Drugs which are no longer marketed in the UK may continue to be included in the guidelines as they may still be available in other countries, or in the UK as unlicensed imports.

There is a lack of good-quality clinical research to support the administration of medicines to patients with enteral feeding tubes, and the manipulation of formulations for patients with swallowing difficulties. The information in these guidelines is often based on small studies and anecdotal reports, and may therefore be superseded by more robust scientific information.

The NEWT Guidelines Website (www.newtguidelines.com) includes additional information which may be useful to healthcare professionals involved in prescribing.

Using The NEWT Guidelines in paediatric care:
The NEWT Guidelines is intended for use in adult patients, and there are currently no paediatric specialists on the editorial team. Some of the recommendations in NEWT are not appropriate for paediatric patients (for example, some of the orders of recommendations, formulation choices, and flush volumes). If the information in NEWT is used to manage paediatric or neonatal patients, this should only be done by specialist paediatric pharmacists who have a thorough knowledge of the specific issues which affect paediatric patients, and can adapt the information in NEWT accordingly.

Editorial team and delivery group:
The content and future development of The NEWT Guidelines is overseen by a Delivery Group. The Delivery Group is responsible for the direction of the guidelines, and oversees the review of current information, addition of new information, audit and research relating to future development. The Group also provides/seeks expert opinion in areas of controversy where scientific evidence is lacking.

Alterations and additions to the text are drafted by practicing clinical pharmacists who are directly involved in the care of patients with enteral feeding tubes and swallowing difficulties. Amendments to the text are made when new information is located which is reliable and which supersedes or appears to have a better evidence base than previous information.