What tube should be used to deliver medication for pruritus in a patient who cannot swallow oral antihistamines or liquid steroids?

Medication Delivery for Pruritus via Enteral Feeding Tube

For a patient unable to swallow oral antihistamines or liquid steroids, use a nasogastric (NG) tube or gastrostomy (G-tube) to deliver crushed antihistamines or liquid steroid formulations, with proper flushing technique using 30 mL of water before, between, and after each medication. 1

Tube Selection and Placement

• Use a standard nasogastric tube or gastrostomy tube for medication delivery when oral administration is not possible 1
• Polyurethane tubes are preferable to silicone tubes for medication administration due to higher retention of patency 1
• Confirm the tube tip location before administering medications, as the site of drug delivery significantly affects drug efficacy 1, 2
• Gastric delivery (standard NG or G-tube) typically provides adequate absorption for antihistamines and corticosteroids 2

Medication Preparation and Administration Protocol

Antihistamines

• Liquid formulations are strongly preferred over crushed tablets when available 3, 2
• If crushing is necessary, consult a pharmacist first to confirm appropriateness and verify the medication's Summary of Product Characteristics does not contraindicate crushing 3, 2
• Crushing medications carries risks of drug exposure to healthcare workers and inaccurate dosing 2

Corticosteroids

• Liquid steroid formulations should be used when possible 3
• When inhaled corticosteroids are given via tube, all of the dose enters the respiratory tract (bypassing first-pass metabolism), creating more potential for systemic side effects 1
• Oral liquid corticosteroids are safer than inhaled formulations for tube administration 1

Critical Administration Technique

Follow this exact sequence for each medication: 1, 3, 2

1. Flush with 30 mL of water before the first medication 1, 3, 2
2. Administer the first medication individually (never mix medications together) 1, 2
3. Flush with 30 mL of water between medications 1, 2
4. Administer the second medication 2
5. Flush with 30 mL of water after the final medication 1, 3, 2

• Using at least 30 mL of water for irrigation when giving medicines through small diameter tubes reduces tube occlusions 1
• Higher incidence of tube occlusions occurs when using crushed solid dosage forms 2

Safety Warnings and Common Pitfalls

• Never mix multiple medications together before administration due to risks of drug-drug interactions 1, 2
• Use appropriate ENFit-standard syringes and connectors to prevent fatal misconnection errors 3, 2
• Do not shake low-dose ENFit syringes to remove drug residue, as this exposes people to the drug and alters the delivered dose 3, 2
• Consider potential drug interactions with enteral formula—some medications bind to enteral formula and need to be administered apart from feeding 1
• Phenytoin, for example, binds directly to polyurethane tubes, though this is less relevant for antihistamines and steroids 1

Clinical Efficacy Considerations for Pruritus

• Antihistamines have limited efficacy for many types of chronic pruritus where histamine receptors do not play a decisive role 4
• Two Cochrane reviews showed no significant antipruritic effects of H1 antihistamine treatment in atopic eczema as single therapy 4
• However, H1-antihistamines may have a synergistic effect when combined with topical steroids for atopic dermatitis pruritus 5
• Adding IV corticosteroids to antihistamines for acute urticaria showed no clinical benefit and may be associated with persistent urticaria activity 6
• For urticaria specifically, antihistamines remain effective as they block histamine-mediated pruritus 7

Caregiver Training Requirements

• Over 30% of caregivers receive no information about proper medication administration through feeding tubes 2
• Two trained adult caregivers should demonstrate proficiency in tube medication administration before discharge 1
• Provide written instructions for the patient/caregiver to keep readily available 1