Can tenofovir be crushed for a patient with a Ryle's (nasogastric) tube?

Can Tenofovir Be Crushed for Nasogastric Tube Administration?

Tenofovir formulations should generally NOT be crushed for nasogastric tube administration, with the critical exception depending on which specific tenofovir product is being used.

Formulation-Specific Guidance

Bictegravir/Tenofovir Alafenamide/Emtricitabine (B/F/TAF)

• Crushing this combination is explicitly NOT recommended by the International Antiviral Society-USA Panel 1
• Case reports demonstrate conflicting outcomes: one patient maintained viral suppression with crushed B/F/TAF 2, while another experienced virologic failure with viral load increasing from 5,887 to 8,047 copies/mL despite adherence 3
• The virologic failure case developed minor resistance mutations (E157Q and V118I) while receiving crushed B/F/TAF via PEG tube 3

Elvitegravir/Cobicistat/Emtricitabine/Tenofovir DF (Stribild)

• This formulation CAN be safely crushed based on pharmacokinetic data 4
• A randomized crossover trial in 24 healthy volunteers demonstrated bioequivalence when crushed and suspended with enteral nutrition (90% CI for AUC within 80-125%) 4
• Crushed Stribild with breakfast showed bioequivalence for AUC but slightly lower Cmax, which was not considered clinically relevant 4

Single-Agent Tenofovir Products

• No specific pharmacokinetic studies exist for crushing tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF) alone
• General pharmaceutical principles suggest that crushing may alter absorption characteristics and potentially lead to dose dumping or underdosing 5

Alternative Strategies When Crushing Is Not Recommended

Consider Liquid or Alternative Formulations

• If chemotherapy-induced severe mucositis or swallowing difficulties are anticipated, switching to regimens available in liquid formulation or that can be safely crushed should be considered 1
• Raltegravir, dolutegravir, or other integrase inhibitors metabolized independently of CYP450 may offer more flexible administration options 1

Two-Drug Regimens

• Dolutegravir/lamivudine or dolutegravir/rilpivirine combinations may be considered as alternatives that minimize drug-drug interactions and may have more administration flexibility 1

Critical Safety Considerations

Risks of Inappropriate Crushing

• Crushing can result in fatal overdose or treatment failure due to altered drug absorption 5
• Healthcare workers crushing tablets face exposure to potentially carcinogenic, teratogenic, or allergenic drug particles 5
• Improper crushing technique can reduce the medication dose received and compromise treatment efficacy 6

Monitoring Requirements

• If crushed administration is attempted with formulations lacking safety data, close viral load monitoring is essential 3
• Resistance testing should be performed if viral rebound occurs 3

Practical Algorithm

1. Identify the specific tenofovir formulation being prescribed
2. If Stribild (elvitegravir/cobicistat/emtricitabine/TDF): Can be crushed and suspended with enteral nutrition 4
3. If B/F/TAF (bictegravir/emtricitabine/tenofovir alafenamide): Do NOT crush; switch to alternative regimen 1
4. If single-agent TDF or TAF: Avoid crushing; consider alternative antiretroviral with established crushing data
5. Coordinate with pharmacy to ensure proper crushing technique and vehicle selection if crushing is deemed necessary 6