Tube feeding and drugs in intensive care unit.
Article Type: Letter to the editor
Subject: Controlled release preparations (Dosage and administration)
Controlled release preparations (Complications and side effects)
Controlled release preparations (Case studies)
Enteral feeding (Case studies)
Tube feeding (Case studies)
Drugs (Controlled release)
Drugs (Dosage and administration)
Drugs (Complications and side effects)
Drugs (Case studies)
Author: Arimanickan, G.
Pub Date: 07/01/2011
Publication: Name: Anaesthesia and Intensive Care Publisher: Australian Society of Anaesthetists Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2011 Australian Society of Anaesthetists ISSN: 0310-057X
Issue: Date: July, 2011 Source Volume: 39 Source Issue: 4
Product: SIC Code: 2834 Pharmaceutical preparations
Accession Number: 264921647
Full Text: Nasogastric tube feeding is a common practice in neurological and neurosurgical intensive care units. Prescribed tablets have to be crushed and dissolved in water before given through these tubes. However, crushing destroys the sustained-release properties of sustained-release tablets resulting in erratic blood levels (1). Though this is a well-known fact, physicians often fail to consider it before prescribing special preparations.

In our case, a postoperative neurosurgical patient with a nasogastric tube in situ was receiving Acord-L o.d. (amlodipine 5 mg + losartan 50 mg) tablets, Aquazide (hydrochlorothiazide) 12.5 mg o.d. tablets and Nebiring (nebivolol) 2.5 mg o.d. tablets. Since her blood pressure was controlled, Minipress XL (prazosin) 5 mg HS was added. Although the patient's blood pressure dropped (84/42 mmHg) immediately after giving the 'crushed' Minipress

XL tablet, it recovered rapidly and remained high (210/120 mmHg) thereafter despite the five anti-hypertensive medications. This prompted our attention towards the nature of drug preparation. Minipress XL is a gastrointestinal therapeutic system controlled release preparation (2). The manufacturer has given a 'Do not break, crush or chew' warning on the tablet cover. The Minipress was ceased and the hypertension controlled with amlodipine 10 mg b.d. and losartan 50 mg b.d. tablets.

Enteric-coated tablets, sustained-release or extended release coated capsules or tablets, sublingual and buccal tablets, and microencapsulated products should never be opened or crushed for administering through a feeding tube (3). This can increase sideeffects or decrease efficacy. A list of medications that should not be crushed or altered has been published (4). If the particular drug has to be given, ordinary rapidly acting tablets can be used in appropriate divided doses. Alternatively a different route of administration or a liquid formulation can be selected (1,3,4).


(1.) Beckwith MC, Feddema SS, Barton RG, Graves C. A guide to drug therapy in patients with enteral feeding tubes: Dosage form selection and administration methods. Hosp Pharm 2004; 39:225-237.

(2.) Singleton W, Dix RK, Monsen L, Moisey D, Levenstein M, Bottiglieri DF et al. Efficacy and safety of Minipress XL, a new once-a-day formulation of prazosin. Am J Med 1989; 87:45S-52S.

(3.) Sacks GS. Drug-nutrient considerations in patients receiving parenteral and enteral nutrition. Pract Gastroenterol 2004; 28:39-48.

(4.) Mitchell JF. Oral dosage forms that should not be crushed or chewed. Hosp Pharm 2002; 37:213-214.

G. Arimanickam

Trivandrum, Kerala, India
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