What proton pump inhibitor (PPI) can be crushed for administration through a percutaneous endoscopic gastrostomy (PEG) tube?

Administration of Proton Pump Inhibitors Through PEG Tubes

Lansoprazole orally disintegrating tablets (ODT) are the preferred PPI formulation for administration through PEG tubes, as they can be dissolved in water and deliver approximately 86% of the active ingredient through the tube. 1

Recommended PPI Formulations for Tube Administration

First-Line Choice: Lansoprazole ODT

• Lansoprazole orally disintegrating tablets provide the most reliable delivery through enteral feeding tubes with mean recovery of 86.2% of active ingredient 1
• Dissolve the tablet in 5 mL of water and flush with 10 mL of water post-administration to ensure complete dose delivery 1
• The ODT formulation contains enteric-coated microgranules that remain intact during administration, protecting the drug from gastric acid 2
• Bioavailability of lansoprazole ODT administered via nasogastric tube is comparable to oral capsule formulations 3

Alternative Option: Esomeprazole

• Esomeprazole can be used through PEG tubes but delivers only approximately 37% of the administered dose 1
• Use 5 mL of water for suspension and 5 mL for flushing to optimize delivery 1
• This reduced bioavailability may require dose adjustment or consideration of alternative agents 1

PPIs That Should NOT Be Crushed or Used in Tubes

Avoid These Formulations:

• Standard omeprazole capsules deliver only 3.9% of active ingredient through tubes and should not be used 1
• Standard lansoprazole capsules deliver only 7.1% of active ingredient and are inappropriate for tube administration 1
• These formulations cause frequent tube obstruction and therapeutic failure 1

Proper Administration Technique

Pre-Administration Steps:

• Involve a pharmacist to confirm appropriate formulation selection and verify the Summary of Product Characteristics 4, 5
• Flush the tube with at least 30 mL of water before medication administration 4, 6
• Use ENFit-standard syringes and connectors to prevent fatal misconnection errors 4, 6

Administration Protocol:

• Administer each medication individually through the tube 6
• For lansoprazole ODT: dissolve in 5 mL water, administer immediately, then flush with 10 mL water 1
• Avoid crushing tablets whenever possible due to exposure risks and dosing inaccuracies 4, 6, 5

Post-Administration:

• Flush with 30 mL of water between medications if administering multiple drugs 6
• Do not shake low-dose ENFit syringes to remove drug residue, as this alters the delivered dose 4, 6

Critical Safety Considerations

Tube Obstruction Risk:

• Higher incidence of tube occlusions occurs with crushed solid dosage forms, particularly with 6 French tubes 1, 6
• All 6 French tubes were obstructed by PPIs in comparative studies; use 8 French or larger tubes when possible 1

Legal and Clinical Responsibility:

• Using crushed PPIs through enteral tubes constitutes off-label use in most cases 4, 5
• Prescribers carry additional responsibility for adverse events from unlicensed or off-label medication use 4, 5

Patient Education Gap:

• Over 30% of caregivers receive no information about proper medication administration through feeding tubes 4, 5
• Provide adequate written and verbal instructions to patients and caregivers 4

Common Pitfalls to Avoid

• Do not use standard omeprazole or lansoprazole capsules - they deliver inadequate drug concentrations and cause tube obstruction 1
• Do not use insufficient flush volumes - inadequate flushing leads to drug retention in the tube and reduced efficacy 1
• Do not administer through tubes smaller than 8 French - smaller tubes have unacceptably high obstruction rates with all PPI formulations 1
• Do not assume liquid formulations are always better - they may contain sorbitol causing diarrhea or have high osmolality causing gut disturbances 4, 5