Can Entresto (sacubitril/valsartan) be administered via a gastrostomy tube?

Entresto Administration via G-Tube

Entresto (sacubitril/valsartan) can be administered through a gastrostomy tube, but the tablets must be crushed and suspended in water, then delivered immediately into the stomach—not distal to the stomach—as absorption occurs primarily in the stomach and proximal small bowel.

Critical Administration Requirements

Tube Position Verification

• Confirm radiographically that the G-tube tip terminates in the stomach before administering Entresto, as absorption occurs primarily in the stomach and proximal small bowel 1, 2
• Do not administer if the tube delivers medication distal to the stomach (e.g., gastrojejunostomy or jejunostomy tubes), as this will result in significantly reduced bioavailability 3, 2

Proper Crushing and Delivery Technique

• Crush the Entresto tablets and suspend them in 30-60 mL of water 4, 2
• Flush the G-tube with 30 mL of water before medication administration 1, 4, 2
• Administer the crushed tablet suspension immediately after preparation—do not allow it to sit 3
• Flush with another 30 mL of water after administration to ensure complete delivery 1, 4, 2
• If administering multiple medications, give each one individually with water flushes between them—never mix medications together 1, 4

Safety Equipment Standards

• Use ENFit-standard syringes and connectors that comply with ISO 80369-3 standards to prevent fatal misconnection errors 1, 4, 2
• Do not shake low-dose ENFit syringes to remove drug residue, as this alters the delivered dose and exposes healthcare workers to the medication 1, 4

Important Pharmacokinetic Considerations

Absorption Profile

• Sacubitril (the prodrug component) is rapidly absorbed and converted to sacubitrilat (the active neprilysin inhibitor) with peak concentrations at 0.5 hours for sacubitril and 1.5-2.0 hours for sacubitrilat 5
• Valsartan (the angiotensin receptor blocker component) reaches peak concentration at 2.0-3.0 hours 5
• The bioavailability through a gastric tube should be adequate if proper technique is followed, though crushing tablets is off-label use 4

Elimination and Drug Interactions

• Sacubitril is eliminated predominantly as sacubitrilat through the kidneys, while valsartan is eliminated mainly by the biliary route 5
• Monitor for potential drug interactions with commonly co-administered heart failure medications including furosemide, digoxin, carvedilol, and statins 5
• Co-administration with atorvastatin increases atorvastatin exposure approximately 2-fold for maximum concentration and 1.3-fold for total exposure 5

Common Pitfalls to Avoid

Tube Occlusion Risk

• Crushed solid dosage forms have a higher incidence of causing tube occlusions compared to liquid formulations 4
• Ensure adequate flushing before and after administration to minimize this risk 1, 4, 2
• Consider consulting pharmacy about liquid alternatives, though none are commercially available for Entresto 4

Legal and Safety Considerations

• Crushing Entresto tablets for G-tube administration is off-label use, as the Summary of Product Characteristics does not specifically authorize this route 4
• Consult a pharmacist before crushing to confirm appropriateness and proper technique 1, 4
• Healthcare workers should use appropriate precautions when crushing medications to avoid drug exposure 1, 4

Monitoring Requirements

Clinical Efficacy

• Monitor blood pressure response, as symptomatic hypotension is more common with sacubitril/valsartan than with ACE inhibitors 6, 7
• Assess for signs of heart failure progression or improvement, as Entresto reduces cardiovascular death and hospitalization in HFrEF patients 6, 8

Safety Parameters

• Monitor renal function regularly, as renal impairment increases sacubitrilat exposure (2.3-fold with moderate impairment, 3.3-fold with end-stage renal disease) 5
• Check serum potassium levels for hyperkalemia 7
• Watch for angioedema, though the incidence is low with sacubitril/valsartan 6, 7

Patient/Caregiver Education

• Over 30% of caregivers receive no information about proper medication administration through feeding tubes 4
• Provide explicit written and verbal instructions on the crushing, suspension, and flushing technique 4
• Emphasize the importance of immediate administration after preparation and proper flushing to prevent tube occlusion 1, 4