Enteral feeding: Drug/nutrient interaction

doi:10.1054/clnu.2000.0155

Clinical Nutrition

Volume 20, Issue 2, April 2001, Pages 187-193

https://doi.org/10.1054/clnu.2000.0155 Get rights and content

Abstract

Enteral nutrition support via a feeding tube is the first choice for artificial nutrition. Most patients also require simultaneous drug therapy, with the potential risk for drug–nutrient interactions which may become relevant in clinical practice. During enteral nutrition, drug–nutrient interactions are more likely to occur than in patients fed orally. However, there is a lack of awareness about its clinical significance, which should be recognised and prevented in order to optimise nutritional and pharmacological therapeutic goals of safety and efficacy.

Learning objectives:

•
To raise the awareness of potential drug–nutrient interactions and influence on clinical outcomes.
•
To identify factors that can promote drug–nutrient interactions and contribute to nutrition and/or therapeutic failure.
•
To be aware of different types of drug–nutrient interactions.
•
To understand complex underlying mechanisms responsible for drug–nutrient interactions.
•
To learn basic rules for the administration of medications during tube-feeding.

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Cited by (50)

Fed-state gastric media and drug analysis techniques: Current status and points to consider
2016, European Journal of Pharmaceutics and Biopharmaceutics
Citation Excerpt :
Food effects can be induced via the direct interaction of drugs, due to their unique physicochemical properties, with food components [38]. Such interactions include formation of insoluble complexes (i.e. tetracyclines and calcium ions) [39], binding to proteins (i.e. phenytoin) [40], or interaction/exchange of drugs with anionic or cationic sites of dietary fibres (i.e. metformin) [41]. In this section the drug properties that can affect drug dissolution and absorption leading to a potential food effect are described.
Gastric fed state conditions can have a significant effect on drug dissolution and absorption. In vitro dissolution tests with simple aqueous media cannot usually predict drugs’ in vivo response, as several factors such as the meal content, the gastric emptying and possible interactions between food and drug formulations can affect drug’s pharmacokinetics. Good understanding of the effect of the in vivo fed gastric conditions on the drug is essential for the development of biorelevant dissolution media simulating the gastric environment after the administration of the standard high fat meal proposed by the FDA and the EMA in bioavailability/bioequivalence (BA/BE) studies. The analysis of drugs in fed state media can be quite challenging as most analytical protocols currently employed are time consuming and labour intensive. In this review, an overview of the in vivo gastric conditions and the biorelevant media used for their in vitro simulation are described. Furthermore an analysis of the physicochemical properties of the drugs and the formulations related to food effect is given. In terms of drug analysis, the protocols currently used for the fed state media sample treatment and analysis and the analytical challenges and needs emerging for more efficient and time saving techniques for a broad spectrum of compounds are being discussed.
Drug-food interactions in internal medicine: What physicians should know?
2015, Revue de Medecine Interne
Les interactions médicament–aliment sont définies par les modifications de concentrations plasmatiques, d’efficacité ou de toxicité d’un médicament par le biais de l’alimentation, d’extraits de plantes, de compléments alimentaires pris simultanément et sont généralement méconnues des internistes. Les interactions médicament–aliment peuvent engendrer une baisse des concentrations plasmatiques du médicament prédisposant à l’échec thérapeutique, ou à l’opposé, une augmentation des concentrations à l’origine d’un risque accru de toxicité parfois gravissime. Les patients âgés, polymédiqués, les transplantés, les patients cancéreux, les patients séropositifs pour le VIH, dénutris, et ceux sous nutrition entérale sont théoriquement les plus exposés. Cette mise au point propose une synthèse la plus exhaustive possible des différentes interactions médicament–aliment observées ou démontrées en pratique clinique quotidienne, leur risque potentiel et les messages clés pour l’interniste. Ce travail insiste notamment sur le rôle majeur du pamplemousse, de ses dérivés, du millepertuis et des autres plantes médicinales au cours des interactions médicament–aliment courantes en pratique clinique. Certaines situations cliniques particulières sont abordées, telles que le Ramadan, la polymédication et la nutrition entérale ou parentérale, de même que les interactions observées par les grandes familles de médicaments. De gros efforts ont été déployés pour mieux comprendre et prédire les interactions médicament–aliment en pratique clinique mais leur épidémiologie et leurs réelles conséquences restent méconnues. Une meilleure connaissance de ce type d’interactions est essentielle pour une meilleure diffusion de l’information auprès des cliniciens et des patients, et une optimisation de la prise en charge transversale multidisciplinaire en médecine interne.
Orally administered medications may interact with various fruits, vegetables, herbal medicines, functional foods or dietary supplements. Drug–food interactions, which are mostly unknown from prescribers, including internists, may be responsible for changes in drug plasma concentrations, which may decrease efficacy or led to sometimes life-threatening toxicity. Aging, concomitant medications, transplant recipients, patients with cancer, malnutrition, HIV infection and those receiving enteral or parenteral feeding are at increased risk of drug–food interactions. This review focused on the most clinically relevant drug–food interactions, including those with grapefruit juice, Saint-John's Wort, enteral or parenteral nutrition, their respective consequences in the clinical setting in order to provide thoughtful information for internists in their routine clinical practice. Specific clinical settings are also detailed, such as the Ramadan or multiple medications especially in elderly patients. Drug–food interactions are also presented with respect to the main therapeutic families, including the non-steroidal anti-inflammatory drugs, analgesics, cardiovascular medications, warfarin as well as new oral anticoagulants, anticancer drugs and immunosuppressant medications. Considerable effort has been achieved to a better understanding of food–drug interactions and increase clinicians’ ability to anticipate their occurrence and consequences in clinical practice. Describing the frequency of relevant food–drug interactions in internal medicine is paramount in order to optimize patient care and drug dosing on an individual basis as well as to increase patients and doctors information.
Oral drug administration by enteral tube in adults at a tertiary teaching hospital
2012, e-SPEN Journal
Citation Excerpt :
As to administering potassium chloride caplets by enteral tube, which occurred in 10% of our cases, crushing extended-release caplets is not recommended, because this leads potentially to toxic peaks and low troughs.4 Omeprazole, a drug used in 7.6% of our cases, is formulated in delayed-release capsules containing enteric-coated drug granules which have the potential to clog the enteral tube and, by affecting gastric acid secretion, reduce vitamin B12 absorption.10 This study allows us to conclude that: the practice of administering oral drugs by the enteral route is common; some drugs administered by tube can interfere with absorption of nutrients; nutrients present in enteral formulas can affect the pharmacokinetics of some drugs; and there are intravenous or other options for some drugs administered by tube.
Despite potential risks, the practice of giving oral drugs by enteral tube seems to be common in hospitals around the world. The aims of this study were to describe the frequency of oral drug administration by enteral tube, the number of tablets given per day, and the percentage of adults receiving enteral nutrition who also received intravenous medications in a tertiary teaching hospital.
This retrospective, cross-sectional study included all adults submitted to exclusive enteral nutrition (n = 170) on the wards of a university hospital. Medical charts were perused to obtain relevant clinical information, including the prescriptions for each patient, the number and frequency of oral drugs administered by tube, and the frequency of concurrent medications given intravenously.
Only 18.2% of the cases did not receive any drug by enteral tube. The remaining 81.2% (n = 139) of patients received a median of 10 [range 1–76] tablets/day and 4 [1–17] different pharmaceutical formulations/day; 72.8% of cases also received drugs by the intravenous route. The most often used drugs were captopril, acetylsalicylic acid, ranitidine, simvastatin, and phenytoin.
The practice of giving crushed tablets by enteral tube is very common on the general medical and surgical wards of our hospital, even when similar intravenous options are available.
Mechanisms underlying food-drug interactions: Inhibition of intestinal metabolism and transport
2012, Pharmacology and Therapeutics
Citation Excerpt :
Physicochemical mechanisms include binding of the drug by the food. For example, enteral nutrition formulas are incompatible with the antiepileptic agent, phenytoin, which can bind to proteins and salts in enteral formulations, resulting in reduced phenytoin absorption and potentially inadequate seizure control (Lourenço, 2001). Some tetracyclines and fluoroquinolones can bind to divalent cation-containing products (e.g., calcium in dairy), resulting in reduced drug absorption (Polk, 1989; Jung et al., 1997) and potential therapeutic failure.
Food–drug interaction studies are critical to evaluate appropriate dosing, timing, and formulation of new drug candidates. These interactions often reflect prandial-associated changes in the extent and/or rate of systemic drug exposure. Physiologic and physicochemical mechanisms underlying food effects on drug disposition are well-characterized. However, biochemical mechanisms involving drug metabolizing enzymes and transport proteins remain underexplored. Several plant-derived beverages have been shown to modulate enzymes and transporters in the intestine, leading to altered pharmacokinetic (PK) and potentially negative pharmacodynamic (PD) outcomes. Commonly consumed fruit juices, teas, and alcoholic drinks contain phytochemicals that inhibit intestinal cytochrome P450 and phase II conjugation enzymes, as well as uptake and efflux transport proteins. Whereas myriad phytochemicals have been shown to inhibit these processes in vitro, translation to the clinic has been deemed insignificant or undetermined. An overlooked prerequisite for elucidating food effects on drug PK is thorough knowledge of causative bioactive ingredients. Substantial variability in bioactive ingredient composition and activity of a given dietary substance poses a challenge in conducting robust food–drug interaction studies. This confounding factor can be addressed by identifying and characterizing specific components, which could be used as marker compounds to improve clinical trial design and quantitatively predict food effects. Interpretation and integration of data from in vitro, in vivo, and in silico studies require collaborative expertise from multiple disciplines, from botany to clinical pharmacology (i.e., plant to patient). Development of more systematic methods and guidelines is needed to address the general lack of information on examining drug–dietary substance interactions prospectively.
Errors for delivery medications through gastrostomy devices: study of 109 children
2007, Archives de Pediatrie
La fréquence d'utilisation de la gastrostomie pour administrer des médicaments est inconnue et les modalités d'administration des médicaments sont mal définies.
Évaluer, dans une population d'enfants porteurs d'une gastrostomie, les modalités d'administration des différents traitements et les risques d'erreurs.
Le mode d'administration des médicaments a été étudié chez 109 patients (âge moyen : 8,4 ± 5,5 ans ; 72 % avaient une maladie neurologique ; 41 % vivaient en centre spécialisé) par l'intermédiaire d'un questionnaire adressé aux parents ou aux soignants des centres. Les erreurs d'utilisation ont été classées en 4 catégories : erreurs galéniques ; de préparation ; par interaction physicochimique ; par absence de rinçage. Les facteurs influençant la survenue d'erreurs ont été évalués : lieu de vie, maladie sous-jacente, nombre de médicaments.
Les 109 patients recevaient en moyenne 5,6 ± 2,7 médicaments par jour par leur gastrostomie. Les erreurs suivantes ont été répertoriées : galéniques (47 %), de préparation (42 %), par interaction physicochimique (51 %), par absence de rinçage (10 %). Les erreurs étaient plus souvent observées chez les enfants vivant en centre que chez ceux vivant à domicile (78 contre 25 %, p < 0,0005). Les erreurs galéniques étaient plus souvent observées chez les patients suivis pour une affection neurologique (57 contre 30 %, p < 0,005).
L'administration des médicaments par la gastrostomie est une pratique fréquente, les erreurs sont nombreuses et peuvent être dangereuses pour les patients.
Gastrostomy is frequently used in clinical practice for drug administration. However modalities of drug administration via a gastrostomy device have been poorly studied and remain uncodified.
To assess the mode of administration of drugs as well as errors associated with the use of a gastrostomy devices for drug delivery in children.
Mode of administration of drugs was studied in 109 children (mean age 8.4 ± 5.5 years, 72% neurologically impaired, 41% institutionalized children). A questionnaire was filled in by parents and/or caregivers. Errors of administration were classified as follows: galenic, due to preparation, physico-chemical interaction, lack of flushing the tube. Factors influencing the occurrence of errors were studied: living at home or in an institution, underlying disease, number of drugs administered via gastrostomy device.
Errors were frequently observed: galenic (47%), due to preparation (42%), physico-chemical interaction (51%), lack of flushing (10%). Errors occurred more frequently in institutionalized children compared to children living at home (78 versus 25%, P < 0.0005). Galenic errors were more frequent in neurologically impaired children (57 versus 30%, P < 0.005).
Many medications are administrated via gastrostomy tube in children. Errors are frequently observed and potentially dangerous.
Food-drug interactions: Types, causal mechanisms, potential consequences, and preventive strategies
2023, Cases on Teaching Pharmacology to Complementary and Alternative Medicine Students

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^f1: (Correspondence to: R L, Dept of Pharmacy, University Hospital Sta. Maria, Av. Prof. Egas Moniz, 1649-035 Lisbon, Portugal)

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Educational PaperEnteral feeding: Drug/nutrient interaction

Abstract

Clin Nutr

Gastroenterology

Am J Clin Nutr

Am J Med

Diet, nutrition and drug interactions

Drug-nutrient interactions: we are required to look for them!

Nutr Clin Pract

Stability of drug with enteral nutrient formulas

Ann Pharmacother

Assessment of drug-related problems in clinical nutrition patients

JPEN

Dietary influences on drug disposition

Drug-nutrient interaction