188x Filetype PDF File size 0.35 MB Source: secure.library.leicestershospitals.nhs.uk
Enteral Feeding - Preventing Drug Nutrient Interactions UHL Guideline Nutrition and Dietetic Service Trust reference B62/2019 1. Introduction and Who Guideline applies to 1.1 This guideline is for Dietitians to refer to, when reviewing patients on an enteral feed and medications. It may also be useful of other members of the Multidisciplinary Team (MDT). 1.2 The purpose of this guideline is to highlight possible drug and enteral feed interactions, advise when a break should be provided in an enteral feeding regimen to allow effective drug administration and allow the MDT to work effectively together to avoid drug nutrient interactions that may cause the medication to be ineffective. 1.3 A drug nutrient interaction has been defined as one that causes a 20% change in the pharmacodynamics or pharmacokinetics of the medication (Lingtak-Neander, 2013). 1.4 It is the responsibility of the Dietitians along with other MDT members to highlight these interactions. The Dietitian can then make appropriate adjustments to the patients enteral feeding plan. 1.5 There are 4 types of reactions: i) Chemical interaction, binding the drug and reducing its absorption. ii) Physical interaction between the drug formulation and the feed formulation, causing a change in the feed consistency and potentially resulting in blockage of the feeding tube. iii) Interaction between the drug and a specific nutrient involved in the metabolism of that drug which can cause loss of drug effect due to impaired absorption, increased drug clearance or blocking of pharmacological action. iv) Interaction with the feeding tube itself which can reduce plasma concentration of the drug compared to oral administration. 2. Guideline Standards and Procedures 2.1 General points to consider when a patient is on an enteral feed and requires medications that may interact with it. 2.2 Will Nurses be able to realistically implement the number of recommended breaks? 2.3 Will the number of breaks limit your ability to meet the patient’s full nutritional needs? 2.4 Will the number of breaks lead to higher feed rates and will that impact feed tolerance? 2.5 Liaise with pharmacy and medical team to review drug necessity (de-prescribe where possible), medication preparations, administration routes, timings or correct monitoring of the therapeutic effect. 2.6 Drugs with enteric coating should not be crushed to go down a tube as the enteric coating is designed to protect the medication. Slow release drugs should not be crushed as these are intended to be released over a long period of time. Cytotoxic and hormone medications should not be crushed due to risk to the administrator. Please refer to policy Administration of Medicines to Adult Patients who cannot Swallow Solid Dosage Forms (e.g: Tablets or Capsules) Guidelines for Practice (B31/2008) for further guidance. Enteral Feeding - Preventing Drug Nutrient Interactions UHL Guideline V2 approved by Policy and Guideline Committee on 20 March 2020 Trust ref: B62/2019 Next Review: April 2023 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents 2.7 Ensure that nurses are flushing the feeding tubes adequately before, between and after medications to minimise tube blocking. Please refer to Enteral Feeding Tube Administration in Adults Policy and Procedures (B30/2019) 2.8 Potential drug and enteral feed interactions will be documented on the enteral feeding regimen, and in the dietetic medical note entry. Verbal handover will be given to nursing staff and added to nerve centre where appropriate. Long term plans are to include a flagging system on eMeds. 2.8 Table one contains a list of possible drugs that may interact with enteral feeds. This list is not exhaustive and enteral feed and drug interactions should be considered if a medication is not providing expected results. Liaise with Pharmacist for more information. The information has been taken from 3 main sources and where there is conflicting information, the longest break period has been recommended. Table one. Medications that require an enteral feed break Name of Interaction Administration Additional Medication information and action required Anti-retroviral Dolutegravir interacts Dolutegravir with feed and Should be (HIV) medications containing administered 2 hours Dolutegravir polyvalent cations, such before or 6 hours after Elvitegravir as calcium, iron, zinc enteral feeds Raltegravir magnesium supplements. Elvitegravir and Raltegravir interact with Elvitegravir and medications and feeds Raltegravir containing polyvalent cations, such as calcium, Should be separated iron, zinc magnesium by 4 hours from supplements. enteral feeds . Bisphosphonates Feed/food reduces 2 hour break in Careful when : absorption feeding before and 2 crushing as drug Risedronate hour break in feeding powder can cause Alendronic acid after administration of irritation drug (osteoporosis) Carbamazepine Interacts with enteral 2 hour break in Medical team to feeding tube (polyvinyl feeding before and 2 check bloods levels (seizures) tube) which in some hour break in feeding of the drug studies has been shown after administration of regularly. to reduce plasma drug if therapeutic If short term concentration of the drug levels of carbamazepine is when compared with oral carbamazepine are required a administration. not reached. suppository is Enteral Feeding - Preventing Drug Nutrient Interactions UHL Guideline V2 approved by Policy and Guideline Committee on 20 March 2020 Trust ref: B62/2019 Next Review: April 2023 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents recommended. Appropriate dilution of Dietitians to raise drug with sterile water awareness of to minimise the impact of starting or interactions. stopping an enteral feed may have on carbamazepine levels. Digoxin This is affected by high If patient requires a Ensure the medical fibre intake. Changes in fibre feed stop feed 2 team are made (Atrial fibrillation) enteral fibre content can hours before aware – blood have an effect on drug’s administration and for levels need to be narrow therapeutic 1 hour afterwards. No checked regularly. window break required in a Changing to a lower non fibre containing fibre feed can could feed. cause a rise in the therapeutic level Fluconazole Some reports indicate If feeding allows give that enteral fluconazole a feeding break but if (Antifungal) interacts with feeds on continuous not particularly Jevity. necessary to compromise feeding unless on Jevity in which case the risk of sub therapeutic treatment should be weighed against benefits of feeding. If withheld – 1hr before and 1 hour after Itraconazole Requires stomach pH to 2 hour break in be as acidic as possible feeding before and 2 (Antifungal) for absorption.(NB - this hour break in feeding does not apply to after administration of commercial liquid drug. preparation) Levothroxine Interacts with calcium Usually prescribed in This is not time and iron in enteral feeds the morning at 06.00 critical and will be (hypothyroidism) and interacts with the therefore consider if applicable to feeding tube. Most likely need break 1 hour patients receiving to have reduced before and 1 after. feeds for more than therapeutic levels with 5-7 days. Suggest jejunostomy feeds. to medical team that thyroid function may require monitoring in long term patients on enteral feeds. Enteral Feeding - Preventing Drug Nutrient Interactions UHL Guideline V2 approved by Policy and Guideline Committee on 20 March 2020 Trust ref: B62/2019 Next Review: April 2023 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents Penicillin The peak plasma levels 2 hour break in No problems with Flucloxacillin of feeding before and 1 amoxicillin. phenoxymethylpenicillin hour break in feeding Penicillin and (antimicrobial) and flucloxacillin are after administration of flucloxacillin are affected by the presence drug. dosed QDS and so of food and therefore the number of best given on an empty breaks may be stomach. Amoxicillin is impractical. Speak unaffected. with medical team or pharmacist to consider different antibiotic or different preparation. Phenytoin Phenytoin reacts with the 2 hour break in Not applicable if enteral feeding tube itself feeding before and 2 prescribed (seizures) and the protein in the hour break in feeding intravenously (IV). feed. This reduces drug after administration of absorption and phenytoin (oral or Discuss with consequent plasma enteral dose) is Pharmacist the concentration required. ability to reduce frequency or alter timings of administration NB – Caution - despite using feeding break there have been reports of unexpected low phenytoin levels Quinolones: Bioavailability can be 2 hour break in Advise medical decreased by up to 33 feeding before and 2 team to consider Ciprofloxacin with some quinolones hour break in feeding doses at the higher Levofloxacin when administered via after administration of end of the dosage Ofloxacin jejunostomy and drug range if on enteral Moxifloxacin absorption is reduced a feed and medical further 25% if Ensure Nurses are team to liaise with (antibiotics) administered with flushing feeding tube microbiology about continuous enteral feed thoroughly before and this. as it binds with ions in after drug the feed to produce administration. insoluble chelates. Rifampicin Interact with Rifampicin: Isoniazid carbohydrate in enteral 2 hour break in feed and reduce plasma feeding before and 1 (Antibacterial) levels. hour break in feeding after administration. Isoniazid: 1 hour break in feeding before and 1 hour break in feeding Enteral Feeding - Preventing Drug Nutrient Interactions UHL Guideline V2 approved by Policy and Guideline Committee on 20 March 2020 Trust ref: B62/2019 Next Review: April 2023 NB: Paper copies of this document may not be most recent version. The definitive version is held on INsite Documents
no reviews yet
Please Login to review.