Choosing an appropriate method of administration

There are many points to be considered when choosing the most appropriate formulation and route of medication administration for patients with enteral feeding tubes or swallowing difficulties. For this reason it is recommended that such patients are reviewed by a health professional with a full understanding of the issues involved.

Some of the factors to be considered include:-

whether the situation is short-term or long-term - alterations to medication should be kept to a minimum for management of short-term swallowing problems
the likelihood and potential seriousness of causing a feeding tube blockage - possibly resulting in admission to hospital
the ability to monitor the effect of medication - where the effect of medication can be monitored, the absorption (or failure to absorb) can be easily seen
the potential seriousness of missing medication doses, and the importance of the medication during the period of the swallowing problem (particularly when the problem is short-term)

For most medicines in this guide, a variety of administration methods are offered. Where more than one method is available for a specific medicine, a suggested order of preference for the recommendations is indicated.

Not all of the options will be appropriate for all patients, therefore a full patient review is always recommended.

The reasoning behind the standard order of preference used in this guide is given below:-

(Please note that with certain drugs the editorial board may recommend that a different order be followed to that shown below).

Enteral tubes:-

1st choice - An enteral formulation licensed for administration via enteral feeding tubes,

licensed method of administration
licensed product with full quality-control testing
maintains the enteral route

2nd choice - Non-enteral administration (the same medication, or an alternative), e.g. intravenous, suppositories,

licensed method of administration
licensed product with full quality-control testing
placing intravenous access solely for the administration of medication may not be appropriate due to the risks of intravenous catheterisation - infection, etc.
consider tolerability (to patient) of alternative route
may not be suitable for long-term swallowing problems

3rd choice - Licensed liquid formulation, dispersible tablet or effervescent tablet (the same medication, or an alternative), given via enteral feeding tube,

unlicensed method of administration (unlicensed route)
manufactured product with full quality-control testing
maintains the enteral route
reduced particle size and improved dispersion of particles compared with crushed tablets, reducing the likelihood of tube blockage

4th choice - Crush tablets / open capsules,

unlicensed method of administration (unlicensed route)
manufactured product with full quality-control testing
readily available medication, reducing missed doses
maintains the enteral route
larger particle size compared with manufacturered liquids, increasing the possibility of tube blockage

5th choice - Pharmacy-prepared liquid product (extemporaneous),

unlicensed method of administration (unlicensed route)
unlicensed product
reasonably readily available
expensive on staff time and pharmacy resources
relatively short product expiry
maintains the enteral route

6th choice - "Special" liquid produced by a known specials manufacturer complying with Good Manufacturing Practice,

unlicensed method of administration (unlicensed route)
unlicensed product
may take some time to obtain
maintains the enteral route
can be considerably more expensive than other enteral options

7th choice - Injection solution administered enterally (only certain injections are suitable for this),

unlicensed method of administration (unlicensed route)
manufactured product with full quality control testing
readily available in secondary care settings
may take longer to obtain in primary care
can be considerably more expensive than other enteral options
serious safety issues around using a product enterally which is intended for use parenterally (click here for more information)

Swallowing difficulties:-

1st choice - Licensed liquid formulation, dispersible tablet or effervescent tablet (the same medication, or an alternative),

licensed method of administration
licensed product with full quality-control testing
maintains the enteral route
improved patient tolerance to the medication (acceptable route, and good palatability)

2nd choice - Non-enteral administration (the same medication, or an alternative), e.g. intravenous, suppositories,

licensed method of administration
licensed product with full quality-control testing
placing intravenous access solely for the administration of medication may not be appropriate due to the risks of intravenous catheterisation - infection, etc.
consider tolerability (to patient) of alternative route
may not be suitable for long-term swallowing problems

3rd choice - Pharmacy-prepared liquid product (extemporaneous),

unlicensed product
reasonably readily available
expensive on staff time and pharmacy resources
relatively short product expiry
maintains the enteral route

4th choice - "Special" liquid produced by a known specials manufacturer complying with Good Manufacturing Practice,

unlicensed product
may take some time to obtain
maintains the enteral route
can be considerably more expensive than other enteral options

5th choice - Crush tablets / open capsules,

unlicensed method of administration
manufactured product with full quality-control testing
readily available medication, reducing missed doses
maintains the enteral route
consider palatability of medication

6th choice - Injection solution administered enterally (only certain injections are suitable for this),

unlicensed method of administration (unlicensed route)
manufactured product with full quality control testing
readily available in secondary care settings
may take longer to obtain in primary care
can be considerably more expensive than other enteral options
serious safety issues around using a product enterally which is intended for use parenterally (click here for more information)