Administration of Kremil-S with Clonazepam via PEG Tube
You can administer both Kremil-S (aluminum/magnesium hydroxide antacid) and clonazepam through a PEG tube, but they must be given separately with thorough water flushes between medications to prevent drug interactions and maintain tube patency. 1
Critical Drug Interaction Concern
- Aluminum/magnesium hydroxide antacids significantly impair benzodiazepine absorption, reducing both the rate and extent of absorption when given simultaneously 2, 3
- Clorazepate (a benzodiazepine prodrug) showed reduced peak concentrations by 31% and delayed time to peak by 1 hour when given with magnesium aluminum hydroxide 2
- Chlordiazepoxide absorption half-time doubled from 11 to 24 minutes with antacid co-administration, though total absorption remained unchanged 3
- The clinical implication is reduced and delayed sedative effects, which could compromise seizure control or anxiety management if clonazepam is being used for these indications 2
Proper Administration Technique
Medication Separation Protocol
- Administer clonazepam and Kremil-S at least 2-4 hours apart to minimize the interaction documented with benzodiazepines and aluminum/magnesium antacids 2, 3
- Give each medication individually through the PEG tube, never mixing them together 1, 4
Step-by-Step Administration
- Flush the PEG tube with 30 mL of water before administering the first medication to ensure tube patency 1, 4
- Prepare clonazepam: crush the tablet and dissolve in 15-30 mL of water (liquid formulations are preferred if available) 1, 4
- Administer the clonazepam solution through the tube 4
- Flush with 30 mL of water after clonazepam to ensure complete delivery and prevent tube clogging 1, 4
- Wait 2-4 hours before administering Kremil-S 2, 3
- Shake Kremil-S suspension well before administration 5
- Flush with 30 mL of water before giving Kremil-S 1
- Administer the antacid suspension 1
- Flush with 30 mL of water after Kremil-S to maintain tube patency 1, 4
PEG Tube Requirements
- Ensure the PEG tube has an adequate lumen size (minimum 15 Charrière) to prevent clogging with medication preparations 6, 1, 4
- Use ENFit-standard connectors to prevent misconnection errors 1, 4
- Never shake ENFit syringes to remove residual medication, as this alters the delivered dose and exposes personnel to the contents 1, 4
Additional Considerations for Clonazepam
- Avoid PVC tubing if using continuous infusion systems, as clonazepam can be lost by up to 50% through adsorption to PVC materials 7
- For PEG tube administration via bolus (which is standard), this PVC concern is less relevant, but non-PVC materials are still preferred if available 7
- Polyurethane PEG tubes are preferred over silicone for medication administration due to better patency retention 4
Monitoring and Safety
- Monitor for reduced clonazepam efficacy (breakthrough seizures, increased anxiety, or inadequate sedation) if the medications must be given closer together than recommended 2
- Assess the patient's clinical response and consider dose adjustment if therapeutic effects are diminished 2, 3
- The antacid's effect on benzodiazepine absorption may be less pronounced if given with food, though this is not applicable to PEG tube administration where medications are typically given separately from enteral nutrition 8
Practical Pitfall to Avoid
The most common error is administering these medications simultaneously or without adequate separation time, which will reduce clonazepam's peak concentration and delay its onset of action, potentially compromising therapeutic efficacy for seizure control or sedation 2, 3