Can Vraylar (cariprazine) be administered through a tube in an intubated patient by opening the capsules without crushing?

Administration of Vraylar (Cariprazine) via Enteral Tube in Intubated Patients

Do not administer Vraylar through an enteral tube by opening capsules, as there is no evidence supporting the safety, efficacy, or pharmacokinetic reliability of this practice, and medication errors during enteral administration can lead to treatment failure and adverse drug reactions.

Critical Pharmaceutical Considerations

Lack of Evidence for Capsule Opening

• No published data exist on the stability, absorption, or bioavailability of cariprazine when capsule contents are administered through feeding tubes 1, 2, 3
• Cariprazine is formulated as capsules for oral administration, and the manufacturer has not provided guidance for alternative administration routes 1, 2
• Opening capsules and administering contents through tubes represents an off-label modification that bypasses the intended delivery system 4

Pharmacokinetic Concerns

• Cariprazine undergoes extensive hepatic metabolism via CYP3A4 with formation of active metabolites, and any alteration in drug formulation could unpredictably affect absorption and metabolism 3
• The parent compound has elimination half-lives of 2-5 days, while the active didesmethyl metabolite has a half-life of 2-3 weeks, making dose adjustments extremely difficult if absorption is compromised 3
• Exposure to the active metabolite didesmethyl-cariprazine is several times that of the parent compound, and disrupting the capsule formulation could alter this critical metabolite ratio 3

Documented Risks of Enteral Medication Administration

Medication Errors in Enterally Fed Patients

• Multiple medication errors commonly occur during enteral drug administration, including errors in dosage form selection and methods of administration 4
• These errors can reduce drug effectiveness, lead to unsuccessful treatment, and increase the risk of adverse drug reactions 4
• Lack of drug knowledge among physicians, inadequate nurse training, and absence of pharmacist participation contribute to these errors 4

Tube Occlusion and Drug Interactions

• Crushed medications dissolved in water can cause tube occlusion and drug-nutrition formula incompatibilities 4
• The lipophilic nature of cariprazine may result in poor dissolution and unpredictable delivery through enteral tubes 3

Alternative Management Strategies

Consider Alternative Antipsychotic Formulations

• If continuation of antipsychotic therapy is essential in an intubated patient, consult pharmacy and psychiatry to identify antipsychotics available in liquid, injectable, or other tube-appropriate formulations
• Haloperidol has established IV and IM formulations suitable for critically ill patients 5
• Some antipsychotics are available in orally disintegrating tablets or liquid suspensions that may be more appropriate for enteral administration

Temporary Discontinuation Considerations

• Given cariprazine's extremely long half-life (2-5 days for parent compound, 2-3 weeks for active metabolite), temporary discontinuation during intubation may be reasonable 3
• Steady-state concentrations of the active metabolite are not reached for weeks, providing a pharmacokinetic buffer during short-term discontinuation 3
• Reassess the need for continuation versus the risks of unreliable delivery through an enteral tube

Common Pitfalls to Avoid

• Do not assume that opening capsules provides equivalent bioavailability to intact oral administration - this has not been studied for cariprazine 4, 3
• Do not crush medications without explicit manufacturer guidance or pharmacy consultation - this represents a significant medication error 4
• Avoid administering medications through feeding tubes without verifying compatibility with enteral nutrition formulas 4
• Do not proceed without involving clinical pharmacy - their expertise is essential to prevent medication errors in enterally fed patients 4