Do you crush medications (meds) for administration through a nasogastric (NG) tube?

Medication Administration Through Nasogastric (NG) Tubes

Crushing medications for NG tube administration should be avoided whenever possible due to potential risks of drug exposure and inaccurate dosing, with liquid formulations preferred when available.1

Proper Medication Administration via NG Tube

General Principles

• Consult with a pharmacist before administering any medication through an NG tube to confirm appropriateness and proper administration technique 1
• The necessity and appropriateness for drug administration through an enteral tube should be confirmed, considering the site of drug delivery and potential interactions with enteral formula 1
• Liquid medications are preferred over crushing solid dosage forms when available 2, 3

Administration Process

• Use appropriate ancillaries including syringes with connectors of a recognized standard (ISO 80369-3/"ENFit") to avoid misconnection errors 1
• Flush the tube with at least 30 mL of water before and after medication administration to prevent tube obstruction 1
• For continuous feeding, flush tubes every 4 hours if medications are being administered 1
• Never add medications directly to enteral formula 3
• Administer each medication separately with appropriate water flushes between medications 3

Medication Considerations

Dosage Forms

• Liquid formulations:

  • Preferred for enteral administration but may be hypertonic or contain sorbitol, which can cause diarrhea 1, 3
  • Be cautious with liquid medications containing high osmolality (>500-600 mOsm/kg) as they can cause gut disturbances 1

• Solid dosage forms:

  • Crushing tablets or opening capsules should be avoided whenever possible 1
  • Higher incidence of tube occlusions when using crushed solid dosage forms through nasogastric tubes 1
  • Verify that the medication is suitable for crushing before administration - many extended-release, enteric-coated, or specially formulated medications should not be crushed 4, 5

Common Pitfalls and Caveats

• Drug recovery after NG tube administration can be variable and often less than the prescribed dose 6
• Flushing the administering syringe increases drug recovery 6
• When using low-dose ENFit syringes, do not shake the syringe to remove drug moat as this exposes people to the drug and affects dose delivered 1
• Some medications may interact with enteral formulas, reducing efficacy (e.g., phenytoin, carbamazepine, warfarin, fluoroquinolones) 3
• Tube occlusion is a common complication that can be prevented with proper flushing techniques 1, 5
• Using products outside the terms of their Summary of Product Characteristics carries additional responsibility that should be accepted prior to medicine prescription, supply or administration 1

Special Considerations

• For medications that must be crushed, determine the appropriate volume of water needed to dissolve the drug and the volume needed to rinse the tube after administration 5
• Some medications are inappropriate for feeding tube administration, particularly for direct jejunal administration 5
• Consider the tube size and placement when selecting medications and administration techniques 3
• Patient and caregiver education regarding proper medication administration through enteral tubes is essential but often lacking 1