Can oral tablets be given to a patient receiving enteral tube feeding?

Can Oral Tablets Be Given Through Enteral Feeding Tubes?

Yes, many oral tablets can be administered through enteral feeding tubes, but only after careful evaluation of each medication's suitability, proper preparation technique, and appropriate tube flushing protocols to ensure safety and efficacy. 1

General Principles for Tablet Administration

Liquid formulations are always preferred over tablets when available because they minimize the risk of tube obstruction and ensure more reliable drug delivery. 1 However, when liquid forms are unavailable, many tablets can be crushed and administered safely through feeding tubes with proper technique.

Medications That Should NEVER Be Crushed or Given Through Tubes

• Enteric-coated tablets must not be crushed because the coating protects the drug from gastric acid degradation and ensures delivery to the small intestine where absorption occurs. 2
• Extended-release or sustained-release formulations should never be crushed as this destroys the controlled-release mechanism and can result in toxic drug levels or loss of efficacy. 1
• Dabigatran capsules specifically should not be administered through enteral feeding tubes under any circumstances. 3

Proper Administration Technique

Pre-Administration Steps

• Flush the tube with at least 30 mL of water immediately before administering any medication to ensure tube patency and prevent obstruction. 4, 2, 1
• Verify that the medication is appropriate for crushing by consulting a pharmacist or medication reference. 1, 5

Tablet Preparation

• Crush tablets into a fine powder using a pill crusher or mortar and pestle. 1
• Suspend the crushed tablet in 60 mL of water (or the volume specified for that particular medication) to create a slurry that can pass through the tube. 1, 6
• For highly concentrated solutions, dilute with additional water to reduce osmolality and prevent gastrointestinal intolerance. 1, 6

Administration Protocol

• Administer each medication separately—never mix multiple medications together due to interaction risks and potential for tube obstruction. 4, 2, 1
• Deliver the medication immediately after preparation; crushed tablets should generally be used within 4 hours. 3
• Flush the tube with at least 30 mL of water immediately after medication delivery to ensure complete passage and reduce blockage risk. 4, 2, 1
• When administering multiple medications, flush with at least 5 mL of water between each medication. 1

Special Considerations for Specific Medications

DOACs (Direct Oral Anticoagulants)

• Apixaban: Crushed tablets may be suspended in 60 mL of water or D5W and delivered through nasogastric/gastric tubes; stable for up to 4 hours. Bioavailability is reduced if administered distal to the stomach. 3
• Rivaroxaban: Crushed tablets may be suspended in 50 mL of water and administered within 4 hours through nasogastric/gastric tubes. The 15 mg and 20 mg doses must be followed immediately with enteral feeding. Avoid administration distal to the stomach. 3
• Edoxaban: Crushed tablets may be suspended in 2-3 ounces of water and immediately administered through a gastric tube. 3

Phenytoin

• Do not administer phenytoin at the same time as enteral feeding because feeding preparations significantly lower phenytoin plasma levels and reduce therapeutic efficacy. 7
• Hold tube feeding for at least 1-2 hours before and after phenytoin administration, or consider alternative anticonvulsant therapy. 7
• More frequent serum phenytoin level monitoring is necessary in patients receiving enteral nutrition. 7

Critical Drug-Nutrient Interactions

• Phenytoin absorption is significantly impaired by concurrent enteral feeding, requiring temporal separation of drug and nutrition delivery. 7
• Many medications can have altered absorption when given with enteral formulas; consult a pharmacist to identify potential interactions. 1, 6
• Never add medications directly to the feeding formulation as this can cause incompatibility, tube clogging, and unpredictable drug delivery. 1

Common Pitfalls and How to Avoid Them

• Crushed tablets are the most frequent cause of tube obstruction—always ensure adequate water volume for suspension and flushing. 8
• Inadequate personnel training is a primary cause of administration errors; formal training programs significantly reduce tube obstructions and errors. 8
• Failure to properly assess medications before crushing leads to loss of drug efficacy or toxicity; always verify crushability before administration. 9, 8
• Discolored capsules should never be used—discard and obtain fresh medication. 7

When Tablets Cannot Be Given Through Tubes

• If a medication cannot be crushed (enteric-coated, extended-release) and no liquid formulation exists, consider the intravenous route as the most appropriate alternative. 6
• For medications requiring large dilution volumes that are impractical for bolus administration, IV delivery is often preferable. 6
• Consult with a pharmacist to identify alternative medications in the same therapeutic class that are available in liquid form or can be safely crushed. 1, 6

Monitoring and Safety

• Monitor for signs of tube obstruction including difficulty flushing, resistance to medication delivery, or inability to deliver enteral nutrition. 8
• Assess for therapeutic efficacy of medications to ensure adequate absorption through the enteral route. 9
• Watch for gastrointestinal side effects (diarrhea, cramping, nausea) which are the most common adverse effects with enteral medication administration. 1
• A multidisciplinary approach involving pharmacists and dieticians reduces administration errors and improves patient outcomes. 8