What is an alternative to Ranexa (ranolazine) for a patient with a percutaneous endoscopic gastrostomy (PEG) tube?

Alternatives to Ranolazine for Patients with PEG Tubes

For patients with PEG tubes requiring an alternative to ranolazine, oral nitrates, calcium channel blockers, or beta-blockers in liquid formulation are recommended as they can be safely administered through feeding tubes and provide effective anti-anginal therapy.

Understanding Ranolazine and Its Limitations in PEG Tube Patients

Ranolazine is an extended-release medication used for chronic stable angina that works through inhibition of the late inward sodium current, reducing calcium overload and left ventricular diastolic tension 1. However, its extended-release formulation presents challenges for PEG tube administration:

• Ranolazine is available as an extended-release tablet designed for twice-daily dosing 1
• Crushing or dissolving extended-release tablets destroys their controlled-release properties
• The medication has low absolute bioavailability (35-50%) and undergoes extensive metabolism 1

Appropriate Alternatives for PEG Tube Administration

First-line Alternatives:

1. Liquid Beta-blockers

   • Available in solution form (e.g., propranolol, metoprolol)
   • Current guidelines recommend beta-blockers as initial therapy for stable angina 2
   • Can be safely administered through PEG tubes

2. Liquid Calcium Channel Blockers

   • Several are available in liquid formulations (e.g., amlodipine oral suspension)
   • Recommended when beta-blockers are contraindicated 2
   • Compatible with enteral feeding tubes

3. Nitroglycerin Preparations

   • Transdermal patches can be used regardless of PEG tube presence
   • Sublingual nitroglycerin can be used for acute relief 2
   • Does not require administration through the feeding tube

Administration Considerations for PEG Tube Patients

When administering medications through PEG tubes, follow these guidelines 3:

• Flush the tube with 40ml of water before and after medication administration
• Administer liquid medications separately from enteral nutrition when possible
• Ensure the tube has sufficient lumen size (at least 15 Charrière) to prevent clogging 3
• Check for drug-nutrient interactions that may affect medication efficacy

Monitoring and Follow-up

• Monitor for signs of angina control and medication side effects
• Regular assessment of PEG tube function and patency
• Ensure proper tube care to prevent complications like infection, blockage, or dislodgement 4

Common Pitfalls to Avoid

1. Never crush extended-release medications like ranolazine for PEG tube administration as this can lead to dose dumping and potential toxicity
2. Avoid medications that may interact with enteral nutrition or require specific timing relative to feeds
3. Don't neglect tube maintenance - daily cleaning with soap and water and proper positioning of the external fixation device are essential 4
4. Avoid medications that may clog the tube - choose liquid formulations when available

By selecting appropriate liquid or alternative formulations of anti-anginal medications, patients with PEG tubes can receive effective therapy for chronic stable angina without the limitations posed by ranolazine's extended-release formulation.