How should oral medications be administered and what can they be mixed with?

Administration of Oral Medications

Oral medications should be administered individually (not mixed together), with the tube flushed before, between, and after each medication using at least 30 mL of water. 1

General Principles for Oral Medication Administration

Timing and Food Considerations

• Most oral medications can be taken with or without food, though administration with meals may improve gastrointestinal tolerability for certain drugs like oseltamivir 1, 2
• Medications should be given at appropriate intervals to allow sufficient time for absorption and peak effect before subsequent doses 1
• Sustained-release and delayed-release formulations should be avoided in patients with short bowel syndrome or malabsorption, as they require intact proximal jejunum for proper absorption 1

Dose Preparation and Verification

• Always verify the medication label before each administration to avoid giving incorrect medication 1
• Hands and administration site should be clean before preparing medications 1
• For suspensions, gently roll or shake the container to resuspend the medication before drawing the dose 1

Administration Through Enteral Feeding Tubes

Key Safety Principles

• Each medication must be administered individually through the tube, never mixed together, due to risks of drug-drug interactions 1
• Flush the tube with 30 mL of water before, between, and after each medication to prevent tube occlusion and ensure complete drug delivery 1
• Confirm the appropriateness of administering each drug through an enteral tube, considering the site of drug delivery and potential interactions with enteral formula 1

Important Caveats

• Some medications bind to enteral formula (such as phenytoin) and must be administered separately from tube feedings 1
• Polyurethane tubes are preferable to silicone tubes for medication administration due to better retention of patency 1
• The site of the tube tip affects drug efficacy—for example, drugs delivered into the duodenum may have different absorption compared to gastric delivery 1

Alternative Formulations and Routes

Capsule Contents and Soft Foods

• Certain medications like omeprazole can have their capsule contents sprinkled onto soft foods as an FDA-approved alternative administration method 3
• This same approach is approved for other proton pump inhibitors including lansoprazole and esomeprazole 3
• Capsule contents can also be mixed with appropriate liquids for administration through nasogastric tubes in patients with swallowing difficulties 3

Liquid Formulations

• When available, liquid formulations should be considered as alternatives to solid dosage forms, especially in patients with absorption issues 1
• Crushed tablets or opened capsules may be options when liquid formulations are unavailable, though this should be verified for each specific medication 1

Special Populations and Considerations

Patients with Short Bowel Syndrome

• Solid dosage forms (tablets) require disintegration and dissolution in the stomach, duodenum, and proximal jejunum before absorption 1
• Most oral medications are absorbed in the proximal jejunum and can be used in these patients 1
• Monitor medication blood levels when applicable and consider dose escalation, frequency changes, or alternative routes if clinical response is inadequate 1

Antimotility Agents

• Loperamide should be administered approximately 30 minutes before meals and at bedtime for maximum effectiveness in reducing stool output 1
• High doses of loperamide may be needed (up to 32 mg/day) in patients without an ileum due to disrupted enterohepatic circulation 1

Common Pitfalls to Avoid

• Never mix multiple medications together before administration through feeding tubes—this practice occurs in over two-thirds of cases in some settings despite known drug-drug interaction risks 1
• Do not assume all medications can be crushed or opened—verify compatibility first, as some formulations lose efficacy when altered 1
• Avoid using bile acid sequestrants in short bowel syndrome—they can worsen steatorrhea and fat-soluble vitamin losses 1
• Do not use antimotility agents when bowel dilatation is present—they may worsen diarrhea by encouraging bacterial overgrowth 1