Medication Administration

Alternative Routes of Administration for Medications
Key Points: Solutions or soluble tablets are the formulation of choice for enteral feeds. Do not assume that liquid
formulation will be suitable. Do not crush tablets or open capsules unless an alternative formulation or drug is
Maintained by the Provincial unavailable. When clinical data is not available on crushing of tablets, enteral tube administration, or other routes
Drug Information Service of administration, use clinical judgment and monitor for efficacy and tolerability.
Updated: 5/31/2019 Ensure paper copies are reviewed for new versions at least every 30 days Page: 1
Drug on NIOSH List: No

5-aminosalicylic acid (5-ASA) Use an Enteral Closed System: No
Oral: Pentasa Extended-release tablet (Ferring Inc)

Preparation: Do NOT crush tablets (2, 235). Tablets can be dispersed in two ways: (3, 235)
1. PENTASA is readily (approx. 10 seconds) dispersed in 50 mL water, but may require a gentle stir to facilitate this. It may take
1 or 2 rinses of the glass to get all the granules out of the glass. Please note, once dispersed, the mixture should be swallowed
immediately. The tablets should not be dispersed and used at a later time. Do NOT crush the pellets.
2. PENTASA tablet(s) can be placed on a tablespoon with water. Wait 10 seconds for the tablets to disperse. The mixture
should be swallowed right away. Do NOT crush the pellets.
Stability: Use immediately (3).
Updated: 2018-December-14
Oral: Asacol Delayed-release tablet (Allergan)

Preparation: Do NOT crush - the tablet coating is designed to delay release until the medication reaches the terminal ileum and
colon (1, 2, 235). If the patient cannot swallow the tablet whole, the prescriber will need to be contacted to explore therapeutic
alternatives (235).
Oral: Salofalk Delayed-release tablet (Aptalis Pharma)

Preparation: Do NOT crush - the tablet coating is designed to delay release until the medication reaches the terminal ileum and
colon (1, 2, 235). If the patient cannot swallow the tablet whole, the prescriber will need to be contacted to explore therapeutic
alternatives (235).
Oral: Mezavant Delayed- and extended-release tablet (Shire Pharma Canada ULC)
Preparation: Do NOT crush - the tablet coating and the MMX Multi Matrix System formulation is designed to delay release until
the medication reaches the terminal ileum and colon and promote release along the length of the entire colon (1, 2, 235). If the
patient cannot swallow the tablet whole, the prescriber will need to be contacted to explore therapeutic alternatives (235).
The brand names included in this list are specific for the references. If the brand name used differs, professional judgment should be used to determine
if a medication can be administered in the manner described. Under NO circumstances should drugs be added to the enteral feed bottle/bag.
Use a CLOSED SYSTEM to administer medications in the following categories: Corticosteroids, Hormones, Antibiotics, Immunosuppressants,
Cytotoxics and Phenothiazines
A closed system using a crushing syringe is preferred for cytotoxics or hormones for which no liquid formulation is available, so as to avoid environmental
contamination and exposure of a caregiver to the medicine. 1. Stop the enteral feed. 2. Flush the enteral feeding tube with water. 3. Place the medication in the
barrel of the crushing syringe and push the plunger down. 4. Put the cap on the crushing syringe and rotate the barrel of the syringe to crush the medication. 5.
Remove the cap and draw 10-15 mL of water into the crushing syringe. 6. Replace the cap and shake the syringe to ensure that the powder is mixed well. 7. Inspect
the syringe contents to ensure that there are no large particles that may block the tube. 8. Flush this suspension down the enteral feeding tube. 9. Draw a further 10
-30 mL of water into the crushing syringe and shake before flushing down the neteral feeding tube; this will ensure that the whole dose is given. 10. Flush again
before re-starting the enteral feed.
FOR ALBERTA HEALTH SERVICES. Unauthorized distribution, copying or disclosure is PROHIBITED. Alberta Health Services assumes no liability for
use of this information.
Intragastric: Pentasa (Ferring Inc)

Preparation: Pentasa tablets are composed of extended-release microgranules of mesalamine with a semi-permeable
ethylcellulose coating compressed into tablets. (3) The tablets may be dispersed in 50 mL of water as noted under the "oral"
entry for this product. (3) The manufacturer recommends administering the dispersed microgranules via PEG as soon as the
tablet has evenly dispersed in water. (204) However, The Handbook of Drug Administration via Enteral Feeding Tubes notes
that, due to the size of the microgranules, the dispersed tablet can only be drawn into a catheter-tipped syringe for
administration and will only flush down a 16 French tube without blockage. (1) Based on this information, unless the patient
has a large-bore (16 French) gastric tube, it will likely be necessary to discuss alternative therapeutic options, such as
conversion to sulfazalazine oral liquid, use of a systemic steroid preparation, or use of alternative agents such as infliximab, with
the patient's gastroenterologist. (1)
Stability: Use immediately (204)
Updated: 2018-April-23
Rectal: Pentasa Suppository; rectal suspension (Ferring Inc)

Preparation: Rectal products available: Salofalk Suppositories and Salofalk Rectal Suspension (2). Refer to the product
monograph for each preparation for complete administration instructions (2).
Rectal: Salofalk Suppositories; rectal suspension (Aptalis Pharma)

Preparation: Rectal products available: Salofalk Suppositories and Salofalk Rectal Suspension (2). Refer to the product
monograph for each preparation for complete administration instructions (2).
Rectal: Mezera Suppository; foam enema (Avir Pharma Inc.)

Preparation: Rectal products available: Mezera suppositories and Mezera foam enemas (2). Refer to the product monograph
for complete administration instructions (2).

abacavir Use an Enteral Closed System: No
Oral: Ziagen Tablet (ViiV Healthcare)

Preparation: Use commercially available oral solution (2). Alternatively, information on crushing the film-coated tablets is
available in the HIV/HCV Drug Therapy Guide (drug information section) available at http://app.hivclinic.ca/OpWUm/. Treat as a
hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for
additional information on the safe handling of this and other hazardous medications.
Stability: Use immediately if crushing the film-coated tablet.
Oral: Ziagen Oral solution (ViiV Healthcare)

Preparation: Recommended route of administration (1,2). Treat as a hazardous drug. Refer to the Hazardous Medication
Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information on the safe handling of this
and other hazardous medications.
Intragastric: Ziagen oral solution (Glaxosmithkline Inc)

Preparation: Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
albertahealthservices.ca/17382.asp) for additional information on the safe handling of this and other hazardous medications.
Administration: 1.Stop enteral feed
2.Flush the enteral feeding tube with the recommended volume of water
3.Draw the medication solution into the appropriate size and type of syringe
4.Flush the medication dose down the feeding tube
5.Finally, flush with the recommended volume of water
6.Re-start the feed, unless a prolonged break is required. (1)
Intrajejunal: Ziagen oral solution (Glaxosmithkline Inc)

Administration: Same as intragastric administration. No specific data exists, therefore monitor for increased side-effects or loss
of efficacy.(1)

abacavir/lamivudine Use an Enteral Closed System: No
Oral: Kivexa film-coated immediate release tablet (ViiV Healthcare)

Preparation: May crush/split tablet and may then add to water or food.(4) Treat as a hazardous drug. Refer to the Hazardous
Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information on the safe
handling of this and other hazardous medications.
Other info: Contact patient’s HIV clinic for specific recommendations:
Southern Alberta HIV Program- 403-955-6399
Northern Alberta HIV Program- 780-407-1852 (Kaye Edmonton Clinic) OR 780-735-4811 (Royal Alexandra Hospital)

abacavir/lamivudine/dolutegravir Use an Enteral Closed System: No
Oral: Triumeq film-coated tablet (ViiV Healthcare)

Preparation: Tablet may be crushed/split and added to a small amount of semi-solid food or liquid immediately prior to
administration.(4, 185) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Stability: Use immediately after crushing tablet.(4, 185)
Nasogastric: Triumeq Tablet (ViiV Healthcare)

Preparation: Administer crushed Triumeq tablets. (183) Treat as a hazardous drug. Refer to the Hazardous Medication
Administration: Administration of crushed Triumeq tablets via nasogastric tube should not have an effect on the absorption of
the components of Triumeq. (183) However, given reductions in the absorption of Trivicay when coadministered with
polyvalent cations, including calcium, magnesium, aluminum, or iron, the manufacturer recommends that Triumeq be
administered 2 hours before or 6 hours after taking medications, antacids, or enteral nutrition containing polyvalent cations.
(183). Alternatively, medications, antacids, or enteral nutrition containing polyvalent cations can be taken 2 hours after or 6
hours before administration of Triumeq. (183) Note that a small The absorption of abacavir, dolutegravir and lamivudine are
thought to take place predominately in the promixal small intestine (duodenum/jejunum).
In contrast to the recommendations provided above by the manufacturer, a small (N=22), open-label, 3 period, randomized,
single-dose, cross-over study conducted in the Netherlands suggests that Triumeq tablets may be crushed and administered
with enteral feeding solutions without pausing feeds provided that only once-daily dosing is required. (185) The authors of the
study do not recommend administering Triumeq tablets in this manner to patients requiring twice-daily dosing, as increased
systemic exposure to dolutegravir was noted when Triumeq tablets were crushed and administered with enteral feeding
solutions. (185)
Stability: Use immediately after crushing tablet. (183)

abacavir/lamivudine/zidovudine Use an Enteral Closed System: No
Oral: Trizivir film-coated immediate release tablet (ViiV Healthcare)

Preparation: Crushing or splitting tablet has NOT been studied and is NOT recommended by manufacturer.(5) Treat as a

acarbose Use an Enteral Closed System: No
Oral: Glucobay tablet (Bayer Inc)

Preparation: Gently agitate the tablet in water for about 5 minutes. It should evenly disperse in the solution.
Updated: on or before 2016-Aug-26
Intragastric: Glucobay tablet (Bayer Inc)

Preparation: Gently agitate the tablet in water for about 5 minutes. It should evenly disperse in the solution, enabling it to be
flushed down an 8Fr NG tube without blockage.(1)
4.Draw 10 mL of water into the syringe.
5.Flush the medication dose down the feeding tube.
6.Draw another 10 mL of water into the syringe and also flush this via the feeding tube.
7.Finally, flush with the recommended volume of water.
8.Re-start feeds immediately.(1)
Intrajejunal: Glucobay tablet (Bayer Inc)

Preparation: Gently agitate the tablet in water for about 5 minutes. It should evenly disperse in the solution, enabling it to be
flushed.(1)
Administration: Same as intragastric administration.(1)

acebutolol Use an Enteral Closed System: No
Oral: tablet
Preparation: *No Data Available. (1)
Oral: Sectral capsule (Sanofi-Aventis)

Preparation: Capsules NOT available in Canada; tablets are available in Canada.(2) Do not use for parenteral administration.
(1)
Intragastric: Sectral capsule (Sanofi-Aventis)

Preparation: Capsules NOT available in Canada.(2)
Administration: 1.Stop enteral feed.
2.Flush the enteral feeding tube with the recommended volume of water.
3.Open the capsule and pour the contents into a medicine pot.
4.Add 15 mL of water.
5.Stir to disperse the powder.
6.Draw into an appropriate size and type of syringe and administer via a feeding tube.
7.Add a further 15 mL of water to the medicine pot; stir to ensure that any powder remaining in the pot is mixed with water.
8.Draw the dispersion into the syringe and flush down the tube. This will ensure that the whole dose is given.
9. Flush the tube with water.
10.Re-start the feed, unless a prolonged break is required.(1)
Intrajejunal: Sectral capsule (Sanofi-Aventis)

Preparation: Capsules NOT available in Canada.(2)
of efficacy.(1)

acenocoumarol Use an Enteral Closed System: No
Oral: Sintrom tablet (Paladin Laboratories Inc)

Preparation: Tablets disperse in 10 mL of water within 5 minutes to give a very fine white dispersion.(1)
Stability: Use immediately.(1)
Intragastric: Sintrom tablet (Paladin Laboratories Inc)

Preparation: Tablets disperse in 10 mL of water within 5 minutes to give a very fine white dispersion, which flushes via a 8Fr
NG tube without blockage.(1)
3.Place the tablet in the barrel of an appropriate size and type of syringe.
4.Draw 10 mL of water into the syringe & allow the tablet to disperse, shaking if necessary.
6.Draw another 10 mL of water into the syringe and also flush this via thefeeding tube.
8.Re-start feed, unless a prolonged break is required.(1)
Intrajejunal: Sintrom tablet (Paladin Laboratories Inc)

Preparation: Tablets disperse in 10 mL of water within 5 minutes to give a very fine white dispersion.(1)
Administration: There are no specific data on jejunal administration of acenocoumarol. Administer as intragastric. Adjust the
dose depending on response. Acenocoumarol is almost completely absorbed from the upper GIT, although the specific site is
not documented.(1)

acetaminophen Use an Enteral Closed System: No
Oral: Tylenol Arthritis Pain extended release tablet (McNeil Consumer Healthcare)
Preparation: Do NOT crush.(2)
Intragastric: Tylenol tablet, oral solution, oral drops (McNeil Consumer Healthcare)
Administration: Use tablets dispersed in 50 mL of water (for adults) for intragastric or intrajejunal administration. Alternatively,
use the liquid formulation undiluted for intragastric administration.(1)
Other info: Similar absorption and metabolism observed with jejunal as with oral administration.(1)
Intrajejunal: Tylenol tablet, oral solution, oral drops (McNeil Consumer Healthcare)
Administration: Use the liquid formulation and dilute with at least an equal quantity of water to reduce osmolarity & viscosity.(1)
Other info: Similar absorption and metabolism observed with jejunal as with oral administration.(1)
Rectal: suppository
Preparation: Suppositories are commercially available.(2)

acetazolamide Use an Enteral Closed System: No
Oral: Diamox tablet (Goldshield)

Preparation: Use AHS compounded liquid(6) OR crush & mix with water, followed by adequate rinsing with water.(1)
Stability: Use immediately after crushing tablet.(1)
Intragastric: Diamox tablet (Goldshield)

7. Finally, flush with the recommended volume of water.
Intrajejunal: Diamox tablet (Goldshield)

Administration: Same as intragastric administration. Absorption begins in the stomach but occurs mainly in the duodenum and
upper jejunum where the surface area is larger.(1)
Parenteral:
Preparation: Refer to AHS Provincial Parenteral Monograph:
http://intraweb01.albertahealthservices.ca/pharmacy/pm/pm_preview.asp?id=5709

acetylcysteine Use an Enteral Closed System: No
Oral: Parvolex injectable prepared for oral use (Celltech)

Preparation: Use AHS compounded liquid.(6)
Other info: Injection can be given parenterally (see parenteral entry); it has also been used as a mouthwash, topically and as a
bladder washout.(1)
Intragastric: Parvolex injectable prepared for oral use (Celltech)

3.Draw the medication solution into the appropriate size and type of syringe.
bladder washout.(1)
Intrajejunal: Parvolex injectable prepared for oral use (Celltech)

bladder washout.(1)
Parenteral:

acitretin Use an Enteral Closed System: Yes
Oral: Soriatane capsule (Roche)

Preparation: Open capsule immediately before use & take the contents with food.(1) Treat as a hazardous drug. Refer to the
Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information on the
safe handling of this and other hazardous medications.
Intragastric: Soriatane capsule (Roche)

Preparation: Open capsule immediately before use.(1) Treat as a hazardous drug. Refer to the Hazardous Medication
Intrajejunal: Soriatane capsule (Roche)

Preparation: Open capsule immediately before use.(1) Treat as a hazardous drug. Refer to the Hazardous Medication
of efficacy.(1)

acyclovir Use an Enteral Closed System: No
Oral: Zovirax oral suspension (Glaxosmithkline Inc)

Preparation: Use the commercially available oral suspension.(1) Only use AHS compounded liquid if commercial product not
available/suitable.(6)
Oral: Zovirax tablet (Glaxosmithkline Inc)

Preparation: Must be dispersed in a minimuim of 50 mL of water.(1)
Intragastric: Zovirax tablet (Glaxosmithkline Inc)

4.Draw 10 mL of water into the syringe and allow the tablet to disperse, shaking if necessary.
Intrajejunal: Zovirax tablet (Glaxosmithkline Inc)

Administration: Same as intragastric administration. There is evidence that acyclovir is absorbed if delivered into the
duodenum. Therefore, jejunal administration is likely to be effective. Due to acyclovir’s generally low bioavailability, other
therapies should be considered.(1)
Parenteral:

alendronate Use an Enteral Closed System: No
Intragastric: Fosamax Tablet (Merck Frosst Canada Ltd)

Preparation: Do NOT crush alendronate tablets (255). The 70 mg tablet should disperse in 2-5 minutes in 10 - 20 mL sterile
(deionized) water (1, 235, 255). Given the limited data available to support enteral administration of bisphosphonates, the use
of therapeutic alternatives to treat osteoporosis, such as IV zoledronic acid or SC denosumab, should be considered if
appropriate (235, 255). The manufacturer has no information on the safety or efficacy of their product when administered in this
manner, and notes that the bioavailability of alendronate is poor, even when taken as directed (273).
Administration: The following administration technique is suggested based on clinical references (1, 235, 255):
1. If administered via enteral feeding tube, the medication should be administered first thing in the morning, preferably after an
overnight fast, but after at least a 30 minute break in feeding. Do not administer other medications prior to administration of
alendronate, or for at least 30 minutes following alendronate administration.
2. Flush the enteral feeding tube with the recommended volume of water.
3. Place the tablet in the barrel of appropriate size and type of syringe.
4. Draw 10 - 20 mL of sterile (deionized) water into the syringe and allow the tablet to disperse, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10 mL of sterile (deionized) water into the syringe and also flush this down the feeding tube.
7. Finally, flush the enteral tube with an adequate amount of water - 50 mL has been suggested by one clinical reference.
8. Ensure the patient is upright or standing for at least 30 minutes after the dose.
9. Re-start the feed after at least 30 minutes has passed.
Other info: **If alendronate is administered to adults via a feeding tube, the once-weekly formula (70 mg) should be used (235,
255).**
Absorption of bisphosphonates occurs in the stomach, duodenum and jejunum (255, 271). There appears to be limited
published literature to suggest that administration of alendronate and risedronate via percutaneous gastric feeding tubes
reduces markets of bone turnover, and this information is observational in nature (271, 272).
Intrajejunal: Fosamax Tablet (Merck Frosst Canada Ltd)

Preparation: Do NOT crush alendronate tablets (255). The 70 mg tablet should disperse in 2-5 minutes in 10 - 20 mL sterile
(deionized) water (1, 235, 255). Given the limited data available to support enteral administration of bisphosphonates, the use
of therapeutic alternatives to treat osteoporosis, such as IV zoledronic acid or SC denosumab, should be considered if
appropriate (235, 255). The manufacturer has no information on the safety or efficacy of their product when administered in this
manner, and notes that the bioavailability of alendronate is poor, even when taken as directed (273).
Administration: Same as intragastric administration. No specific data appears to exists to support administration of
alendronate via this route; therefore, close monitoring for increased side effects or loss of efficacy is required (1, 255).
Other info: **If alendronate is administered via a feeding tube, the once-weekly formula (70 mg) should be used (235, 255).**
Absorption of bisphosphonates occurs in the stomach, duodenum and jejunum (255, 271). The manufacturer has no
information on the safety or efficacy of their product when administered in this manner, and notes that the bioavailability of
alendronate is poor, even when taken as directed (273).

alfacalcidol Use an Enteral Closed System: No
Intragastric: One-Alpha Oral drops (Leo Pharma Inc)

Preparation: Use oral drops (1). Alternatively, patients could be converted to intermittent IV dosing using the injectable product
(1,2).
Administration: One clinical reference suggests the following administration procedure (1):
1. Stop enteral feed.
3. Put the required number of drops into a medicine pot and add a small amount of water (e.g. 10 mL).
4. Draw into an appropriate size and type of syringe.
7. Re-start the feed, unless a prolonged break is required.
Intrajejunal: One-Alpha Oral drops (Leo Pharma Inc)

Preparation: Use oral drops (1). Alternatively, patients could be converted to intermittent IV dosing using the injectable product
(1,2).
Administration: No specific information on jejunal administration of this medication was located. One clinical reference
suggests that the oral drops may be administered according to the intragastric instructions; careful monitoring for clinical
efficacy or emergence of toxicity is required (1).

alfuzosin Use an Enteral Closed System: No
Oral: Xatral Prolonged-release tablet (Sanofi-Aventis)

Preparation: Do NOT crush, chew, or break tablet; disruption of the GEOMATRIX® System tablet will result in dose-dumping
and potentially serious adverse effects (2, 235). Patients with benign prostatic hypertrophy who cannot swallow the intact tablet
should be converted to therapeutic alternatives such as prazosin, terazosin, dozazosin, or silodosin, if therapeutically
appropriate (235).

allopurinol Use an Enteral Closed System: No
Oral: Zyloric tablet (Glaxosmithkline Inc)

Other info: The Actavis brand can be crushed but is very insoluble.(1)
Intragastric: Zyloric tablet (Glaxosmithkline Inc)

Intrajejunal: Zyloric tablet (Glaxosmithkline Inc)

Administration: Same as intragastric administration. No specific data exists. Allopurinol has increased solubility at higher pH,
so may be absorbed from the jejunum. Monitor for increased side-effects or loss of efficacy.(1)

alprazolam Use an Enteral Closed System: No
Oral: Compounded liquid

Preparation: Use AHS compounded liquid (6).

amantadine Use an Enteral Closed System: No
Oral: Symmetrel capsule (Alliance)

Preparation: Open capsule and mix with water, administer immediately.(1) Commercially available syrup preparation preferred.
(2)
Intragastric: Symmetrel oral syrup (Alliance)

Intrajejunal: Symmetrel oral syrup (Alliance)

of efficacy.(1)
Other info: Capsules may be opened and mixed with water and administered immediately via an enteral feeding tube.(1)

amifampridine (3,4-diaminopyridine) Use an Enteral Closed System: No
Oral: crystals (Jacobus)

Preparation: No data currently available. Consider alternative.
Other info: Special Access Program

amiloRIDE Use an Enteral Closed System: No
Oral: tablet
Intragastric: tablet
Intrajejunal: tablet

amiloRIDE/hydrochlorothiazide Use an Enteral Closed System: No
Oral: tablet
Preparation: Tablets can be crushed and dispersed in water.(1)
4.Draw 10mL of water into the syringe and allow the tablet to disperse, shaking if necessary.
6. Draw another 10 mL of water into the syringe and also flush this via the feeding tube (this will rinse the syringe and ensure
that the total dose is administered).
Administration: Administer using the intragastric method. Monitor for increased side effects or loss of efficacy.(1)

aminophylline Use an Enteral Closed System: No
Oral: injectable prepared for oral use

Preparation: Aminophylline injection has been used in extemporaneous oral liquid preparations. As this is an immediate-
release preparation, appropriate adjustment to the dosing frequency should be made.(1)
Intragastric: injectable prepared for oral use

3.Measure the required dose of aminophylline extemporaneous preparation into an appropriate size and type of syringe.
4.Administer via feeding tube.
7.Re-start the feed, unless prolonged break is required.(1)
Intrajejunal: injectable prepared for oral use

Administration: Same as intragastric administration.(1) Aminophylline is absorbed when administered via jejunostomy.(1)

amiodarone Use an Enteral Closed System: No
Oral: Cordarone tablet (Sanofi-Synthelabo Canada Inc)

Other info: Oral absorption is slow & highly variable. NPO patients can go 5 days without amiodarone administration before IV
amiodarone is required due to its long half-life.(1)
Intragastric: Cordarone tablet (Sanofi-Synthelabo Canada Inc)

3.Place the tablet in a mortar and crush to a fine powder using the pestle.
4.Add a few mL of water and mix to form a paste.
5.Add up to 15 mL of water and mix thoroughly, ensuring that there are no large particles of tablet.
8. Add another 15 mL of water to the mortar and stir to ensure that any remaining drug is rinsed from the container. Draw this
water into the syringe and also flush this via the the feeding tube.
9.Finally, flush the enteral tube with the recommmended volume of water.
Intrajejunal: Cordarone tablet (Sanofi-Synthelabo Canada Inc)

of efficacy.(1)
Parenteral:

amitriptyline Use an Enteral Closed System: No
Oral: tablet
Other info: A case report of buccal administration of amitriptyline using crushed tablets demonstrated effective absorption.(1)
Administration: Same as intragastric administration. No specific data exists. Animal studies have shown that amitriptyline is a
P-glycoprotein substrate. Intrajejunal administration may result in reduced absorption due to increased efflux by P-gp in the
distal regions of the small intestine. Therefore monitor for increased side-effects or loss of efficacy.(1)
Rectal: compounded suppository

Preparation: Compounding recipe available from IJPC.(152)
Administration: Amitriptyline in a 50 mg suppository was reported to improve mood & sleep in 1 patient with colonic
adenocarcinoma.(7)

amLODipine Use an Enteral Closed System: No
Oral: Norvasc tablet (Pfizer Canada Inc)

Intragastric: Norvasc tablet (Pfizer Canada Inc)

Intrajejunal: Norvasc tablet (Pfizer Canada Inc)

Administration: Use the dispersed tablet, as this will have lower osmolarity than the suspension formulation. Same as
intragastric administration. No specific data exists. Monitor for increased side-effects or loss of efficacy.(1)
Other info: Amlodipine is slowly absorbed from the intestinal mucosa, therefore intrajejunal administration may result in
decreased absorption.(1)
Rectal:
Administration: Gradual absorption orally. Low first-pass effect. Cannot recommend rectal administration.(8)

amoxicillin Use an Enteral Closed System: No
Intragastric: oral suspension

5.Draw an equal volume of water into the syringe and also flush this via the feeding tube (this will rinse the syringe and ensure
Other info: For serious infections, ampicillin or another parenteral agent should be used in preference to enteral administration
of amoxicillin suspension. (1)
Updated: 2018-February-25
Intrajejunal: oral suspension

Other info: Effective absorption is expected to be maintained when this drug is administered into the duodenum or jejunum. (1).
However, for serious infections, ampicillin or another parenteral agent should be used in preference to enteral administration of
amoxicillin suspension. (1)

amoxicillin-clavulanic acid Use an Enteral Closed System: No
Oral: Clavulin tablet (Glaxosmithkline Inc)

Preparation: Do NOT crush tablets; choose an oral suspension with the same ratio of the active ingredients.(2)

amphetamine mixed salts Use an Enteral Closed System: No
Oral: Adderall XR capsule (Shire Biochem Inc)

Preparation: Use AHS compounded liquid.(6) OR Open carefully; Do NOT crush the beads, may sprinkle over applesauce and
refrain from chewing.(2)
Stability: Use immediately after opening capsule.(2)

ampicillin Use an Enteral Closed System: No
Oral: oral suspension

Preparation: Use commercially available oral suspension.(2)

Administration: Oral ampicillin is poorly absorbed compared to oral amoxicillin, making amoxicillin more suitable for intrajejunal
administration.(9)

Administration: Poorly designed studies. Efficacy has not been established. Rectal irritation noted in several studies.(8)
Parenteral:
Drug on NIOSH List: Yes

anastrozole Use an Enteral Closed System: Yes
Oral: Arimidex tablet (AstraZeneca Canada Inc)

Preparation: Treat as hazardous drug. Anastrozole is moderately soluble in water; agitate to aid dispersion. Anastrozole tablets
disperse in 10mL of water to give an almost clear dispersion. However, the tablets are slow to disperse and take in excess of 5
minutes.(1) Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for
Other info: Use a closed system when compounding this preparation.
Intragastric: Arimidex tablet (AstraZeneca Canada Inc)

disperse in 10mL of water to give an almost clear dispersion that flushes down an 8Fr NG tube without blockage. However, the
tablets are slow to disperse and take in excess of 5 minutes.(1) Refer to the Hazardous Medication Handling site on Insite (http:
//insite.albertahealthservices.ca/17382.asp) for additional information on the safe handling of this and other hazardous
medications.
6.Draw another 10mL of water into the syringe and also flush this via the feeding tube (this will rinse the syringe and ensure that
the total dose is administered).(1)
8.Re-start the feed, unless a prolonged break is required.
Intrajejunal: Arimidex tablet (AstraZeneca Canada Inc)

disperse in 10mL of water to give an almost clear dispersion. However, the tablets are slow to disperse and take in excess of 5
minutes.(1) Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for
of efficacy.(1)

apixaban Use an Enteral Closed System: No
Oral: Eliquis tablet (Bristol-Myers Squibb Canada)

Preparation: For patients unable to swallow whole tablets, Eliquis tablets may be crushed to a fine powder using a mortar and
pestle or an adequate device designed for this purpose, suspended in water or mixed with applesauce. (2)
Administration: To administer crushed tablets, follow the following steps (2):
- use a mortar and pestle or similar device to crush the tablet(s)
- transfer the powder to a drinking glass or a small bowl
- when using water:
- add a small amount of water (30 mL) to the mortar and pestle/device and stir
- transfer the water to the drinking glass
- mix the powder with the water and drink right away
- rinse the glass with a small amount of water and drink right away
- when using applesauce:
- mix the powder with a small amount of applesauce (30 g) in a small bowl and eat with
a spoon right away
- add a small amount of water (30 mL) to the mortar and pestle/device and stir
- transfer the water to the bowl and drink right away
- rinse the bowl and spoon with a small amount of water and drink right away
Nasogastric: Eliquis Tablet (Bristol-Myers Squibb Canada)

Preparation: The manufacturer has indicated that results of an in-house, open-label, 3 person crossover study suggest that a
suspension of crushed tablet in D5W results in similar systemic exposure to tablets. (10)
Administration: In the in-house study mentioned above, the apixaban oral suspension was prepared as follows:
- the 5 mg tablet was crushed into a fine powder using a mortar and pestle
- the powder was then suspended in 60 mL of D5W and administered via a 10 French NG tube
- the mortar and pestle were rinsed three times with 60 mL of water; each rinse was also administered via NG tube
- after the apixaban suspension and the three rinses were administered via NG tube, the tube was flushed with 5 mL of NS
Stability: Use immediately. (10)

aprepitant Use an Enteral Closed System: No
Oral: Emend capsule (Merck Frosst Canada Ltd)


aqueous iodine oral solution Use an Enteral Closed System: No
Oral: Lugol's Solution oral solution

Preparation: Use commercially available product,(2) if NOT available then prepare and use AHS compounded liquid.(6)
Updated: 2016-September-2

aripiprazole Use an Enteral Closed System: No
Oral: Abilify compounded liquid (Bristol-Myers Squibb Canada)

Updated: 2017-November-17
Parenteral:

ASA (enteric coated) Use an Enteral Closed System: No
Oral: Aspirin, Entrophen tablet (enteric coated) (Bayer Inc, Pendopharm)

Preparation: Do NOT crush.(1) Use AHS compounded liquid.(6) Alternatively, convert patient to the chewable formulation and
crush tablet.
Intragastric: Aspirin tablet

Preparation: Use AHS compounded liquid.(6) Alternatively, convert patient to the chewable formulation and crush tablet.
4.Draw 10 mL of water into the syringe and allow the tablet to dissolve.
6.Draw an equal volume of water into the syringe and also flush this via the feeding tube.
Intrajejunal: Aspirin tablet

Preparation: Use AHS compounded liquid.(6) Alternatively, convert patient to the chewable formulation and crush tablet.
Rectal: ASA Suppositories suppositories

Administration: Commercial suppositories available. Strengths available: 150mg and 650mg.(2)

ASA/dipyridamole Use an Enteral Closed System: No
Oral: Aggrenox capsule (Boehringer Ingelheim Canada Ltd)

Preparation: Open carefully, Do NOT crush pellets; mix with water, flush with water.(12)

ascorbic acid Use an Enteral Closed System: No
Intragastric: effervescent tablets

3.Measure 20-50mL of water into a measuring pot.
4.Add the effervescent tablet and allow to dissolve.
5.Draw into an appropriate size and type of syringe.
7.Rinse the measuring pot and administer this also to ensure that the total dose is given.
Intrajejunal: effervescent tablets

Administration: Administer using the intragastric method.(1)
Parenteral:

atazanavir Use an Enteral Closed System: No
Oral: Reyataz capsule (Bristol Laboratories of Canada)

Preparation: Capsules may be opened and contents mixed with applesauce for immediate use with a light meal.(4)

atazanavir/cobicistat Use an Enteral Closed System: No
Oral: Evotaz tablet (Bristol Laboratories of Canada)

Preparation: Do NOT split/crush/ break tablets. Tablets should be swallowed whole.(2)

atenolol Use an Enteral Closed System: No
Oral: Tenormin tablet (AstraZeneca Canada Inc)

Intragastric: Tenormin tablet (AstraZeneca Canada Inc)

Intrajejunal: Tenormin tablet (AstraZeneca Canada Inc)

4.Draw an equal volume of water and a little air into the syringe and shake to mix thoroughly.
Other info: Human and animal studies indicate absorption occurs in the jejunum, therefore jejunal administration will unlikely
alter the therapeutic effect of atenolol.(1)
Rectal: rectal gel

Administration: Plasma concentrations higher with rectal gel studied in rats & dogs than with suppositories. Insufficient
evidence to recommend rectal administration.(8)

atomoxetine Use an Enteral Closed System: No
Oral: Strattera capsule (Eli Lilly Canada Inc)

Preparation: Capsule contents can cause ocular irritation.(2)

atorvastatin Use an Enteral Closed System: No
Oral: Lipitor tablet (Pfizer Canada Inc)

Preparation: Do NOT crush or disperse tablets if pregnant (235); disperse tablet in 10 - 20 mL water over 2 - 10 minutes (235).
Although clinical resources suggest that atorvastatin tablets may be crushed or dispersed, the manufacturer does not
recommend such use of the product due to the lack of study data related to safety or efficacy when administered in this manner
(235, 255, 270).
Other info: Lipitor tablets are not a delayed-, extended-, or sustained -release formulation (270); the tablets are film coated (2,
270).
Stability: Use immediately after tablet has disintegrated; the drug is light sensitive (1, 270).
Intragastric: Lipitor Tablet (Pfizer Canada Inc)

Preparation: Common enteral drug administration references recommend dispersal of the tablet in 10 - 20 mL of water as the
preferred enteral administration technique (1, 235, 255). Crushing the tablet prior to mixing the powder with water for enteral
administration is also suggested by an Australian reference, but dispersal of the tablet in water is listed as the preferred option
(235). Dispersal of the tablet should result in the production of a fine, white, milky dispersion for administration via enteral tubes
that are at least 8 French in diameter (1). Do NOT crush or disperse tablet if pregnant (235).

Stability: Use immediately after tablet has disintegrated; the drug is sensitive to light (1, 270).
Intrajejunal: Lipitor tablet (Pfizer Canada Inc)

Preparation: Common enteral drug administration references recommend dispersal of the tablet in 10 - 20 mL of water as the
preferred enteral administration technique (1, 235, 255). Crushing the tablet prior to mixing the powder with water for enteral
administration is also suggested by an Australian reference, but dispersal of the tablet in water is listed as the preferred option
(235). Dispersal of the tablet should result in the production of a fine, white, milky dispersion for administration via enteral tubes
that are at least 8 French in diameter (1). Do NOT crush or disperse tablet if pregnant (235).
Administration: Same as intragastric administration (1, 255). No specific data on jejunal administration appears to exist;
monitor for safety and efficacy (1, 255).
Stability: Use immediately after tablet has disintegrated; the drug is sensitive to light (1, 270).

atovaquone/proguanil Use an Enteral Closed System: No
Oral: Malarone tablet (Galderma Canada Inc)

Preparation: Crush tablet, mix with condensed milk and adminster immediately.(2)
Administration: Absorption of tablet improved when administered with condensed milk or food.(2)

atropine Use an Enteral Closed System: No
Parenteral:
Sublingual: eye drops

Administration: Atropine 1% ophthalmic drops administered sublingually (1-2 drops once daily or BID) can be used to manage
sialorrhea. The maximum dose is unknown.(13,14,15)

azathioprine Use an Enteral Closed System: Yes
Oral: Imuran compounded liquid (Glaxosmithkline Inc)

Preparation: Use AHS compounded liquid. (6) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site
on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information on the safe handling of this and other
hazardous medications.
Intragastric: Imuran tablet (Glaxosmithkline Inc)

Intrajejunal: Imuran tablet (Glaxosmithkline Inc)

Preparation: Use AHS compounded liquid. (6) The compounded liquid contains Ora-Plus and Ora-Sweet as suspending
agents; these agents contain sorbitol, and increase the viscosity and osmolality of the preparation. (6, 192, 193). It has been
suggested that dilution of oral liquids with at least 10 - 30 mL of sterile water may be required to decrease product viscosity and
osmolality and increase patient tolerance when oral suspensions are administered into the small bowel; use of larger amounts
of sterile water may be required if osmotic diarrhea is suspected, as the total osmolality of the AHS compounded oral liquid is
unknown. (192, 193) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Administration: Same as intragastric administration.(1) Note above suggestion for dilution of the compounded oral liquid.
Other info: Conflicting information exists on the effect of small bowel delivery of azathioprine on total systemic exposure. (1,
194). While some references suggest that drug absorption occurs mainly via the epithelium of the stomach and ileum,
suggesting that jejunal delivery of the drug should not adversely affect dosing, this information was derived from a
pharmaceutical manufacturer and validation with human data was not provided. (1) In contrast, another author suggests that
absorption of azathioprine may increase by as much as 67% when administered directly into the jejunum. (194) Given the
significant potential for bone marrow suppression or hepatotoxicity associated with supratherapeutic levels of azathioprine,
close patient monitoring for clinical efficacy and toxicity are recommended if jejunal administration of azathioprine cannot be
avoided, particularly if other medications that could increase systemic exposure to azathioprine are being administered
concomitantly.

azithromycin Use an Enteral Closed System: No
Other: Zithromax tablet, oral suspension (Pfizer Canada Inc)

Preparation: Commercially available oral suspension.(2)
Parenteral:

baclofen Use an Enteral Closed System: No
Oral: Lioresal tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid (6) OR crush & mix with water, followed by adequate rinsing with water.(1)
Intragastric: Lioresal tablet, aqueous vehicle (Novartis Pharmaceuticals Canada Inc)

Intrajejunal: Lioresal tablet (Novartis Pharmaceuticals Canada Inc)

Rectal: tablet
Other info: There is very little published literature on the rectal absorption of baclofen, and what literature is available is
conflicting. Kriel and colleagues administered rectal baclofen, prepared as a suspension in tap water, to six healthy adult
women as part of a cross-over study. (252) Although three of the six women reported feeling drowsy for two to four hours after
rectal drug administration, venous blood sampling completed at 1, 2, 4, 8, and 24 hours after baclofen administration was
negative for baclofen (the assay had a lower limit of detectability of 0.05 mcg/mL). (252) The authors suggest that baclofen,
which is a zwitterion at physiologic pH, has at least one charged functional group at any given pH, and may rely, in part, on an
active transport mechanism for some of its enteral absorption, is likely to be poorly absorbed from the rectum. (252)
Selge and colleagues administered baclofen tablets coated in petroleum jelly via the rectum to two palliative patients lacking
enteral access who were suffering from severe spasticity. (253) One of their two patients experienced marked improvement in
spasticity (as assessed using the Modified Ashworth Scale); a serum baclofen level drawn two hours after the third dose of a tid
dosing schedule was 210 mcg/L. (253) However, the second patient failed to respond to rectal baclofen administered in the
same manner, and had subtherapeutic baclofen levels (< 20 mcg/mL) on day six of therapy despite regular tid dosing and dose
escalation to 20 mg tid. (253) Selge and colleagues suggest that the numerous factors affecting drug absorption from the
rectum, including drug position within the rectum, failure of drug to dissolve in the 1-3 mL of mucus usually present in the
rectum, and involuntary expulsion of drug from the rectum, may explain the variable outcomes achieved.
Walker and colleagues reported the case of a 66 year-old cancer patient with chronic hiccups responsive to oral baclofen. (254)
Hiccups recurred when oral medications were held due to swallowing difficulties; rectal administration of baclofen tablets had no
effect on the patient's hiccups. When the patient was able to resume oral baclofen therapy two days later, his hiccups resolved.
(254) No information on rectal administration technique is provided, and blood levels were not drawn. This paper is cited by
Care Beyond Cure, 4th edition, in their table on rectal drug administration, to support the recommendation not to administer
baclofen via the rectal route. (19)
Based on the limited and conflicting data available, intrathecal administration of baclofen or the use of therapeutic alternatives,
when available and appropriate, is recommended in preference to rectal administration . If no therapeutic alternatives exist and
intrathecal administration of baclofen is judged to be inappropriate, administration of baclofen tablets coated in a thin layer of
petroleum jelly may be more appropriate than administration of a aqueous suspension of baclofen. Close monitoring for
therapeutic efficacy and emergence of toxicity is recommended.
Stability: Use immediately. (252, 253)
Updated: 2018-October-26
Intrathecal: Lioresal Solution (Novartis Pharmaceuticals Canada Inc)

Administration: Commercially available intrathecal products are available.(2)

beclomethasone dipropionate oral Use an Enteral Closed System: No
suspension

benazepril Use an Enteral Closed System: No
Oral: Apo-Benazepril tablet (Sandoz)

Preparation: Use AHS compounded liquid. (6)

betahistine Use an Enteral Closed System: No
Oral: Serc tablet (Solvay Pharma Inc)

Preparation: Crush the tablets & disperse in water immediately before administration.(1)
Intragastric: Serc tablet (Solvay Pharma Inc)

9. Finally, flush the enteral tube with the recommmended volume of water.
Other info: Where possible, administer after feed.(1)
Intrajejunal: Serc tablet (Solvay Pharma Inc)

of efficacy.(1)
Other info: Where possible, administer after feed.(1)

bethanechol Use an Enteral Closed System: No
Oral: Duvoid tablet (Paladin)

Intragastric: Duvoid tablet (Paladin)

Intrajejunal: Duvoid tablet (Paladin)

of efficacy.(1)

bezafibrate Use an Enteral Closed System: No
Oral: Bezalip SR sustained-release tablet (Actavis)

Preparation: Do NOT crush/chew tablet.(2)

bicalutamide Use an Enteral Closed System: Yes
Oral: Casodex tablet (AstraZeneca Canada Inc)

Preparation: Crush & mix with water using a closed system where possible (e.g. crushing syringe). (1) Treat as a hazardous
drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional
information on the safe handling of this and other hazardous medications.
Intragastric: Casodex tablet (AstraZeneca Canada Inc)

Administration: 1. Stop enteral feed.
3. Place the tablet in a suitable crushing syringe and crush to a fine powder
4. Add a few millilitres of water and mix to forma a paste.
5. Add up to 15 mL of water and mix thoroughly, ensuring that there are no large particles of tablet.
7. Draw another 15 mL of water into the syringe and stir to ensure that any remaining drugs I rinsed from the container. Flush
this via the feeding tube (this will rinse the syringe and ensure total dose is administered)/
9. Re-start the feed, unless a prolonged break is required.(1)
Intrajejunal: Casodex tablet (AstraZeneca Canada Inc)

of efficacy.(1)

bisacodyl Use an Enteral Closed System: No
Oral: Dulcolax enteric coated tablet (Boehringer Ingelheim Canada Ltd)

Rectal: Dulcolax suppositories (Boehringer Ingelheim Canada Ltd)

Administration: Commercial suppositories available.(2)

bisoprolol Use an Enteral Closed System: No
Oral: tablet
Preparation: Crush & mix with water, follow with adequate rinsing with water.(1)
Other info: Human and animal studies show that bisoprolol is well absorbed from the gastrointestinal tract.(16)
of efficacy.(1)

bosentan Use an Enteral Closed System: No
Oral: Tracleer tablet (Janssen Inc.)

Preparation: Use AHS compounded liquid. (6) Bosentan tablets may also be dispersed in water for immediate administration,
although the precautions required in order to avoid inadvertent exposure to this hazardous medication may make such an
administration method impractical. (235, 281) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on
Insite (https://insite.albertahealthservices.ca/pmmc/Page17382.aspx) for additional information on the safe handling of this and
other hazardous medications.
Other info: Women who are, or may become, pregnant, should not handle crushed or broken tablets.
Updated: 2019-May-23
Intragastric: Tracleer tablet (Janssen Inc.)

Preparation: Use AHS compounded liquid. (6) Compounding recipes for slightly more concentrated bosentan suspensions (i.e.
6.25 mg/mL) in a variety of commercially-available suspending agents have also been published. (282-284) Alternatively, the
oral tablets may be dispersed in 5 - 25 mL of water for immediate administration via gastric enteral tube. (235, 281-288)
Dispersion of tablets within the barrel of an enteral syringe may be preferred in order to minimize occupational exposure to this
hazardous drug. (235) Note that bosentan is only sparingly soluble in water (281); administration of tablets dispersed in water
without having first been crushed into a fine powder should be reserved for gastric tubes of at least 14 French in diameter in
order to minimize the risk of enteral tube obstruction. (196) Regardless of preparation technique, enteral tubes should be
flushed with an appropriate amount of water before and after administration of this medication in order to minimize the risk of
enteral tube obstruction. (196) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (https:
//insite.albertahealthservices.ca/pmmc/Page17382.aspx) for additional information on the safe handling of this and other
Other info: Women who are, or may become, pregnant, should not handle crushed or broken tablets.

bromocriptine mesylate Use an Enteral Closed System: No
Oral: tablet
Preparation: May disperse tablets in water.(1)
of efficacy.(1)

budesonide Use an Enteral Closed System: No
Oral: Entocort capsule (Tillotts Pharma)

Preparation: Tests have been performed on the enteric coated granules which support sprinkling them on a spoon of
applesauce. The pellets must NOT be chewed and the entire contents must be swallowed within 30 minutes.(17)
Rectal: Entocort enema (Tillotts Pharma)

Administration: Commercially available enema: Entocort Enema.(2)

buPROPion Use an Enteral Closed System: No
Oral: Wellbutrin XL extended release tablet (Biovail Pharmaceuticals Canada)

Preparation: Do NOT crush, divide or chew.(2) Crushing or chewing the ER preparation destroys the slow-release activity of
the product.(18)
Oral: Wellbutrin SR, Zyban sustained release tablet (Biovail Pharmaceuticals Canada)
Preparation: The manufacturer recommends NOT to crush, divide or chew. Crushing or chewing the SR preparation destroys
the slow-release activity of the product. Cutting or splitting the SR preparation in half will increase the rate of drug release in the
first 15 minutes. If the tablet is split, the unused half should be discarded unless used within 24 hours.(18)
Stability: The unused half should be discarded unless used within 24 hours.(18)

busulfan Use an Enteral Closed System: Yes
Oral: Myleran tablet (Glaxosmithkline Inc)

Intragastric: Myleran tablet (Glaxosmithkline Inc)

Preparation: Use AHS compounded. (6) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on
Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information on the safe handling of this and other
3.Shake the medication bottle thoroughly to ensure adequate mixing.
4.Draw the medication suspension into an appropriate size and type of syringe.
Intrajejunal: Myleran tablet (Glaxosmithkline Inc)

of efficacy.(1)

cabergoline Use an Enteral Closed System: No
Oral: Dostinex tablet (Pfizer Canada Inc)

Preparation: Tablets do not disperse readily in water, but will disperse completely to give a clear solution if shaken in 10 mL of
water for 5 minutes.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Intragastric: Dostinex tablet (Pfizer Canada Inc)

Preparation: Tablets do not disperse readily in water (235), but one reference suggests that some forms of cabergoline may
disperse completely to give a clear solution if shaken in 10 mL of water for 5 minutes; this suspension reportedly flushes via an
8Fr NG tube without blockage (1). Alternatively, the oral tablet may be crushed and mixed with water for administration,
although such a practice may present an exposure risk, particularly to healthcare workers who are pregnant or who are
attempting to conceive (235). Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications. Consider the use of therapeutic alternatives; rotigotine transdermal patch may be an alternative for patients with
Parkinson's disease (235).
Intrajejunal: Dostinex tablet (Pfizer Canada Inc)

Preparation: Tablets do not disperse readily in water (235), but one reference suggests that some forms of cabergoline may
disperse completely to give a clear solution if shaken in 10 mL of water for 5 minutes; this suspension reportedly flushes via an
8Fr NG tube without blockage (1). Alternatively, the oral tablet may be crushed and mixed with water for administration,
although such a practice may present an exposure risk, particularly to healthcare workers who are pregnant or who are
attempting to conceive (235). Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications. Consider the use of therapeutic alternatives; rotigotine transdermal patch may be an alternative for patients with
Parkinson's disease (235).
of efficacy.(1)

caffeine Use an Enteral Closed System: No
Oral: caffeine citrate powder, oral solution

Oral: caffeine base powder, oral solution

Intragastric: caffeine citrate powder, oral solution

3.Draw required dose of liquid preparation into the appropriate size and type of enteral syringe.
Intrajejunal: caffeine citrate powder, oral solution

Administration: There are no specific data available on jejunal administration. Administer using the intragastric method.
Monitor for increased side effects or loss of efficacy.(1)
Parenteral: caffeine citrate


calcitriol Use an Enteral Closed System: No
Oral: oral solution

Preparation: Use AHS compounded liquid ONLY IF commercial liquid is NOT available AND alfacalcidol oral solution is
unsuitable, as preparation of the calcitriol liquid requires staff members to withdraw contents of Rocaltrol capsules using a
needle and syringe (risk of needle stick injury). (6, 226)
Updated: 2018-July-20

calcium carbonate Use an Enteral Closed System: No
Oral:
Preparation: Use AHS compounded liquid (6), or crush the tablet and mix with water, applesauce, or yogurt. (235)
Alternatively, the patient could be converted to and equivalent dose of a commercially available liquid calcium supplement.
Intragastric:
Preparation: Use AHS compounded liquid. (6) Alternatively, the patient could be converted to an equivalent dose of a low-
osmolality commercially available liquid calcium supplement preparation. If other alternatives are not available, one clinical
reference suggests that oral tablets could be crushed to a fine powder and mixed with at least 30 mL of water for administration
via larger-bore enteral tubes. (235) If crushing the tablets is attempted, proper flushing of the enteral tube before and after
administration is particularly important to ensure that the calcium does not come into contact with enteral feeding solution within
the tube, which could increase the risk of enteral tube obstruction. (1, 196)
Administration: 1.Stop the enteral feed.
3.Draw the medication liquid into an appropriate size and type of syringe.
5.Finally, flush carefully with the recommended volume of water.
6.Restart the feed.
Intrajejunal:
Preparation: Use AHS compounded liquid (6), or consider administration of an equivalent dose of a commercially available, low
osmolality liquid product.
Administration: Same as intragastric administration. Calcium salts are absorbed in the jejunum. (1) Jejunal administration of
liquid or effervescent tablets should not affect the bioavailability. (1) If administering a liquid preparation, choose a product with
low osmolality to avoid adverse effects. (1)

calcium polystyrene sulfonate Use an Enteral Closed System: No
Oral: Resonium powder (Sanofi-Aventis)

Preparation: The resin is given by mouth as a suspension in a little water, or for greater palatability, the resin may be made into
a paste with some sweetened vehicle, but not orange juice or other fruit juices that are known to contain potassium. The amount
of fluid usually ranges from 3 to 4 mL per gram of resin.(2)
Intragastric: Resonium powder (Sanofi-Aventis)

Preparation: The amount of fluid required usually ranges from 3 to 4 mL per gram of resin. If there is difficulty with swallowing,
it may be given through a gastric tube, 2 to 3 mm in diameter.(2)
Rectal: Resonium powder (Sanofi-Synthelabo Canada Inc)

Administration: Retain for 9 hours if possible then follow emulsion with cleansing enema. Rectal administration may yield less
effective results compared to oral administration. May be used with oral therapy.(8)

capTOPRIL Use an Enteral Closed System: No
Oral: tablet
Administration: Same as intragastric administration. No specific data exists. Therefore monitor for increased side-effects or
loss of efficacy.(1)
Rectal:
Administration: Oral absorption rapid. Cannot recommend rectal administration.(8)

carbamazepine Use an Enteral Closed System: No
Oral: Tegretol suspension (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid when commercial product is not available.(6) Chewable tablets are available
commercially.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Intragastric: Tegretol suspension (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid when commercial product is not available.(6) Dilute suspension or compounded
liquid with an equal volume of sterile water & administer mixture immediately (see below). (1, 195) Flush tubing with sterile
water following administration to prevent clogging and increase delivery of the entire dose to the distal end of the feeding tube.
(1) If giving more than 400 mg daily, or if the patient had previously been stabilized on the controlled-release formulation, divide
total daily dose into four equal doses. (1, 195). Note that adverse effects (i.e. bloating, cramping, diarrhea) due to the sorbitol
content of the liquid are highly likely with total daily doses in excess of 800 mg daily; additional dilution with sterile water may or
may not reduce patient symptoms. (1, 193) If the patient develops symptoms likely to be due to excessive sorbitol intake (i.e.
bloating, cramping, diarrhea), consideration could be given to converting the patient to crushed regular-release tablets (see
below). (192, 193, 196) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
3. Shake the medication bottle thoroughly to ensure adequate mixing.
4. Draw the medication suspension into an appropriate size and type of enteral syringe.
5. Draw an equal volume of sterile water and a little air into the syringe and shake to mix thoroughly.
OR, if using regular-release carbamazepine tablets (192, 193, 196):

1. Stop enteral feed.
3. Crush the regular-release tablet into a fine powder and mix with 30 - 60 mL of sterile water to form a slurry.
4. Draw the medication suspension into an appropriate size and type of enteral syringe.
5. Rinse container used to prepare suspension with sterile water, and draw the rinse water up into the enteral syringe.
7. Finally, flush the feeding tube with the recommended volume of water.
8. Re-start the feed, unless a prolonged break is required.
Other info: Careful monitoring for therapeutic efficacy and toxicity, as well as carbamazepine levels, is recommended,
particularly because there are inconsistent reports of carbamazepine adsorbing to polyvinyl chloride feeding tubes or interacting
with enteral feeding solutions. (1, 192, 193, 195)
Intrajejunal: Tegretol suspension (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid when commercial product is not available.(6) Dilute suspension or compounded
liquid with an equal volume of sterile water & administer mixture immediately. (1, 195) Flush tubing with sterile water following
administration to prevent clogging and increase delivery of the entire dose to the distal end of the feeding tube.(1) If giving
more than 400 mg daily, or if the patient had previously been stabilized on the controlled-release formulation, divide total daily
dose into four equal doses. (1, 195). Note that adverse effects (i.e. bloating, cramping, diarrhea) due to the sorbitol content of
the liquid are highly likely with total daily doses in excess of 800 mg daily; additional dilution with sterile water may or may not
reduce patient symptoms. (1, 193) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.
Administration: Same as intragastric administration of diluted suspension. Note that administration of finely-crushed
immediate-release tablets mixed with sterile water is not recommended for jejunal administration; for jejunal administration the
drug should be fully dissolved and the preparation diluted to achieve a final osmolarity of approximately 285 mOsm/L. (196)
Other info: Careful monitoring for therapeutic efficacy and toxicity, as well as carbamazepine levels, is recommended. (1, 193,
195)
Rectal: Tegretol suspension, capsules (Novartis Pharmaceuticals Canada Inc)

Preparation: Tegretol 100 mg/5mL suspension has been administered rectally in 400 mg aliquots to 7 patients presenting to an
Australian hospital with seizures (256). Note that 6 of the 7 patients also received IV anticonvulsants acutely to terminate their
seizures (256) and acute therapy with proven treatment alternatives is recommended for initial seizure management. Treat as a
Administration: The suspension does give rise to strong defecatory urge (19), although none of the 7 patients in an Australian
case series defecated their carbamazepine doses (256). One palliative care resource recommends placing crushed tablets
inside a size 00 gelatin capsule to eliminate the urge to defecate, although no supporting clinical data is provided (19). It has
been suggested that rectal administration of carbamazepine must be retained for at least 2 hours to approximate oral
bioavailability, but again, no citations are provided to support this statement (19). If rectal administration of carbamazepine is
attempted for maintenance therapy, close monitoring of serum concentrations, and clinical monitoring for signs of efficacy or
toxicity, is recommended .(19, 256) Total absorption between oral and rectal similar, but absorption rate may be slower rectally.
(8)

carVEDILOL Use an Enteral Closed System: No
Oral: tablet
3.Avoid a prolonged break to reduce incidence of profound hypotension
Administer after feed.(1)

cefixime Use an Enteral Closed System: No
Oral: Suprax oral suspension (Sanofi-Aventis)

Preparation: Use commercially available oral suspension.(2)
Intragastric: Suprax oral suspension (Sanofi-Aventis)

Preparation: Do not dilute suspension.(1)
3.Draw the medication solution into an appropriate size and type of syringe.
6.Re-start the feed unless a prolonged break is required.(1)
Intrajejunal: Suprax oral suspension (Sanofi-Aventis)

Preparation: Do not dilute suspension.(1)
Administration: No specific data exists, therefore monitor for increased side-effects or loss of efficacy. Flush well before and
after dosing to reduce the osmolarity of the suspension.(1)

cefuroxime Use an Enteral Closed System: No
Oral: Ceftin tablet, oral suspension (Glaxosmithkline Inc)

Preparation: Tablets may be easily dispersed in water.(1) Commercially available oral suspension.(2)
Intragastric: Ceftin tablet, oral suspension (Glaxosmithkline Inc)

Preparation: Use suspension or tablet.(1)
Tablets may be easily dispersed in water; this may be easier than the suspension to administer via nasogastric tube. The
suspension may be too viscous to administer via fine bore feeding tubes.(1)
Administration: Oral Suspension:(1)
1. Stop the enteral feed.
4.Draw the medication into an appropriate size and type of syringe.
7.Re-start the feed, unless prolonged break is required.
Tablets:(1)
3. Place the tablet in the barrel of an appropriate size and type of syringe.
4. Draw 10mL of water into the syringe and allow the tablet to disperse, shaking if necessary.
6. Draw another 10mL of water into the oral syringe and also flush this via the feeding tube.
Intrajejunal: Ceftin tablet, oral suspension (Glaxosmithkline Inc)

Preparation: Use suspension or tablet.(1)Tablets may be easily dispersed in water; this may be easier than the suspension to
administer via nasogastric tube. The suspension may be too viscous to administer via fine bore feeding tubes.(1)
of efficacy.(1)
Parenteral:

celecoxib Use an Enteral Closed System: No
Oral: Celebrex capsule (Pfizer Canada Inc)

Preparation: The contents of the capsules pour easily from an opened capsule and mix easily with 10 mL of water to form a
milky suspension, although manual dexterity is required.(1) Can be mixed with pudding or apple sauce immediately prior to oral
administration.(1, 211) Alternatively, the AHS compounded liquid may be used. (6)
Updated: 2018-June-21
Oral: Celebrex oral suspension (Pharmacia)

Intragastric: Celebrex Capsule (Pfizer Canada Inc)

Preparation: The contents of the capsules pour easily from an opened capsule and mix easily with 10 mL of water to form a
milky suspension that flushes down an 8 Fr NG tube without blockage. (1) However, this requires a degree of manual dexterity
owing to the small size of the capsules. (1) Consideration could be given to administering the AHS compounded liquid via NG
tube as well, however note that this compounded liquid is hyperosmolar and contains sorbitol, so monitoring for signs of
intolerance (bloating, flatulence, osmotic diarrhea) as the patient's daily sorbitol load increases.
Other info: At least two oncology trials report administering celecoxib via PEG tube, although preparation and administration
instructions are unfortunately not provided in the study reports. (212, 213)

cephalexin Use an Enteral Closed System: No

Stability: Use immediately after dispersing tablet in water.(1)

Administration: Cephalexin is thought to be absorbed from the duodenum so administration via a jejunostomy tube may
produce reduced plasma concentrations. Use higher end of dose range. Administer using the intragastric method.(1)
Stability: Use immediately after dispersing tablet in water.(1)

cetirizine Use an Enteral Closed System: No
Oral: oral solution

Preparation: Use commercially available oral solution.(2)

chloral hydrate Use an Enteral Closed System: No
Oral: Noctec syrup

Preparation: Commercially available ora syrup.(2)
Intragastric: Noctec syrup

Preparation: Use commercial syrup.(2)
Intrajejunal: Noctec syrup

Preparation: Use commercial syrup.(2)

chlorambucil Use an Enteral Closed System: Yes
Oral: tablet
Preparation: Use AHS compounded liquid.(6) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on

chloroquine Use an Enteral Closed System: No
Oral: tablet
Administration: Same as intragastric administration; ensure that tube is flushed well.(1)
Rectal: compounded suppositories

Administration: Poorly designed studies. Efficacy has not been established using compounded suppositories.(8)

chlorpheniramine Use an Enteral Closed System: No
Oral: Chlor-Tripolon tablet (Bayer Inc)

Preparation: Tablets can be crushed and mixed with water. Chlorpheniramine is soluble 1:5 in water.(1)
Intragastric: Chlor-Tripolon tablet (Bayer Inc)

Preparation: Tablets can be crushed and mixed with water.(1)
6.Restart the feed, unless a prolonged break is required.(1)
Intrajejunal: Chlor-Tripolon tablet (Bayer Inc)

Preparation: Tablets can be crushed and mixed with water. (1)

chlorpromazine hydrochloride Use an Enteral Closed System: No
Oral: Teva-Chlorpromazine tablet (Teva Canada Ltd.)

Preparation: Crushing the tablets is not recommended, as exposure to this product can lead to contact dermatitis and
sensitization. (1, 235) Since the tablets contain insoluble excipients, the tablets do not disperse well if mixed with water. (280)
Extemporaneous oral liquid compounding recipes have been published in the pharmacy literature. (158,280) However, one of
the published recipes is not considered suitable for inclusion in the AHS Recipe Database due to difficulties in obtaining key
ingredients. (158) The alternative oral suspension recipe is much simpler to compound, but the resulting suspension reportedly
causes an "anesthetic numbing" of the oropharynx that lasts for 2 to 3 hours following administration; this may pose a safety risk
to patients with dysphagia. (280) The use of therapeutic alternatives, where possible, is recommended.
Rectal: suppositories
Administration: Suppositories not commercially available in Canada.(2) Commercial suppositories (containing glycerin,
glyceryl monopamitate, monosterate, coconut oil, and palm kernel oil) are available in the USA.(19)

chlorthalidone Use an Enteral Closed System: No
Oral: tablet (Alliance)

Preparation: Tablet disintegrates within 2 minutes when placed in 10mL of water.(1)
Intragastric: tablet (Alliance)

Preparation: Tablet disintegrates within 2 minutes when placed in 10mL of water; the pale yellow dispersion flushes via an 8Fr
the total dose is administered).
Intrajejunal: tablet (Alliance)

of efficacy.(1)

cholecalciferol (vitamin D3) Use an Enteral Closed System: No
Oral: tablet, oral solution

Preparation: Commercially available liquid.(2)
Intragastric: tablet, oral solution

Preparation: Use commercial liquid.(2)
4.If necessary, dilute with 5mL enteral feed.
Intrajejunal: tablet, oral solution


cholesterol oral suspension Use an Enteral Closed System: No


cholestyramine Use an Enteral Closed System: No
Oral: Questran sachet (Bristol-Myers Squibb Canada)

Preparation: Contents of sachet should be mixed with 150 mL fluid.(1)
Other info: Contains sucrose 3.79 g/sachet.(1)
Intragastric: Questran sachet (Bristol-Myers Squibb Canada)

Preparation: Contents of sachet mixed with 100 mL of water forms a cloudy dispersion that is not viscous and will draw into a
syringe and flush via an 8Fr nasogastric tube without risk of blockage.(1)
Administration: 1 Stop enteral feed.
3.Ensure dose is administered 4 hours after any other medication.
4.Empty the sachet into an appropriate container, add 100 mL of water and stir to mix throroughly.
6.Finally, flush with recommended volume of water.
Intrajejunal: Questran sachet (Bristol-Myers Squibb Canada)

Preparation: Contents of sachet mixed with 100 mL of water forms a cloudy dispersion that is not viscous and will draw into a
syringe.(1)
Administration: Clinical effectiveness of cholestyramine is not affected by jejunal administration. Same as intragastic
administration.(1)

cilazapril Use an Enteral Closed System: No
Oral: Inhibace tablet (Roche)

Preparation: No Data available.

cimetidine Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) OR use alternative product (AHS Provincial Formulary level 1 therapeutic
interchange to raniditine)
Preparation: Use AHS compounded liquid (6) OR use alternative product (AHS Provincial Formulary level 1 therapeutic
interchange to raniditine)
4. Draw the medication dose into an appropriate size and type of syringe.
Drug on NIOSH List:

cinacalcet Use an Enteral Closed System:
Oral: Sensipar tablet (Amgen Canada Inc)

Preparation: Sensipar tablets are film-coated, without an enteric coating or delayed- or sustained-release mechanism. (180)
Although the effects of splitting or crushing Sensipar tablets on stability or efficacy were not evaluated by the manufacturer
during drug development, several case reports describing administration of crushed tablets via gastrostomy tube have been
published. (179, 181).
Administration: In a case report involving a pediatric patient with chronic kidney disease, 30 mg Sensipar tablets were
crushed and mixed with 10 mL of water. A 5 mL portion of the resulting suspension was then administered via gastrostomy
tube in order to achieve a 15 mg dose. The part dose was administered immediately following preparation, and the remainder
was discarded. The tablets were not split in order to obtain two 15 mg doses as the prescribing information indicates that the
tablet should not be divided. (179) The case report provides laboratory results for the patient on this regimen demonstrating
response to therapy. Based on this information, it may be possible to crush Sensipar tablets and mix the crushed tablet with
water immediately prior to administration for patients unable to swallow tablets whole tablets when no therapeutic alternatives
are available.
Updated: 2017-March-13
Intragastric: Sensipar tablet (Amgen Canada Inc)

Preparation: Sensipar tablets are film-coated, without an enteric coating or delayed- or sustained-release mechanism. (180)
Although the effects of splitting or crushing Sensipar tablets on stability or efficacy were not evaluated by the manufacturer
during drug development, several case reports describing administration of crushed tablets via gastrostomy tube have been
published. (179, 181).
Administration: In a case report involving a pediatric patient with chronic kidney disease, 30 mg Sensipar tablets were
crushed and mixed with 10 mL of water. A 5 mL portion of the resulting suspension was then administered via gastrostomy
tube in order to achieve a 15 mg dose. The part dose was administered immediately following preparation, and the remainder
was discarded. The tablets were not split in order to obtain two 15 mg doses as the prescribing information indicates that the
tablet should not be divided. (179) The case report provides laboratory results for the patient on this regimen demonstrating
response to therapy.
A second case report describes crushing of cinacalcet tablets (brand not specified) for administration via PEG tube.
Unfortunately, information on the method of administration is not provided. However, laboratory results demonstrating a
response to therapy are provided. (181)

ciprofloxacin Use an Enteral Closed System: No
Oral: Cipro tablet (Bayer Inc)

Preparation: Crush tablet & mix with 15 mL of sterile or distilled water for each 500 mg tablet,(1) or use AHS compounded
liquid(6) or commercially available oral suspension.(2)
Oral: Cipro Oral Suspension liquid (Bayer Inc)

Preparation: For ORAL USE ONLY. DO NOT USE the COMMERCIAL PRODUCT for NG ADMINISTRATION as it clogs
feeding tubes. (1)
**Use AHS compounded recipe for NJ, NG, or tube feeds.**
Oral: Cipro XL Extended-release tablet (Bayer Inc)

Preparation: DO NOT split, crush, or chew tablets, as this would disrupt the extended-release mechanism of the tablet (2). If
the tablets cannot be swallowed whole, consider converting the patient to immediate-release ciprofloxacin tablets, immediate-
release AHS compounded oral liquid, or intravenous ciprofloxacin, as appropriate.
Intragastric: Cipro tablet (Bayer Inc)

Preparation: Crush tablet & mix with 15 mL of sterile or distilled water for each 500 mg tablet,(1) or use AHS compounded
liquid.(6) Do NOT use commercial oral suspension for feeding tubes. (1, 255) Continuous feed: hold feed at least 2 hours
before and 2 hours after drug administration. (235, 255) Intermittent feed: administer drug at least 2 hours before tube feed. (1)
Administration: 1.Stop enteral feed two hours prior to medication administration.

3.Allow a break in feeding if possible.
9.Re-start feed two hours following medication administration.(1)
Intrajejunal: Cipro tablet (Bayer Inc)

Preparation: Crush tablet & mix with15 - 25 mL of sterile or distilled water for each 500 mg tablet,(1, 255) or use AHS
compounded liquid.(6) Do NOT use commercial oral suspension for feeding tubes. (1, 255) Continuous feed: hold feed at least
2 hours before and 2 hours after drug administration. (235, 255) Intermittent feed: separate drug administration from feeding by
2 hours. (255)
Administration: Do NOT use the commercially-available liquid, as it clogs feeding tubes. (1,255) Administer using the
intragastric method. (1) Case report evidence suggests that ciprofloxacin is absorbed from the duodenum and jejunum. (1, 9,
235, 255) However, the peak level following jejunal administration was significantly lower than that seen with oral administration.
(9, 235, 255, 257, 258) Therefore, administration of doses at the upper end of dose range is recommended; intravenous
administration or use of a therapeutic alternative may be preferable to avoid therapeutic failure, particularly for severe infections
or organisms at high risk of developing resistance. (1, 235, 255) Monitor for increased side-effects or loss of efficacy.(1, 255)
Otic: eye drops

Administration: Ciprofloxacin 0.3% eye drops can be safely administered in the ears as either BID or TID dosing.(20)
Parenteral:

cisapride Use an Enteral Closed System: No
Oral: Apo-cisapride tablet (Apotex)


citalopram Use an Enteral Closed System: No
Oral: Celexa tablet (Lundbeck Canada Inc)

Preparation: Crush thoroughly & mix with water.(1)
Other info: Due to its lipophilic nature and high permeability, citalopram is likely absorbed throughout the intestine. An
intravenous infusion is available from Lundbeck on a named-patient basis. Contact the manufacturer for further details.(1)
Intragastric: Celexa tablet (Lundbeck Canada Inc)

Preparation: Crush thoroughly & mix with water; flush.(1)
3.Add crushed tablet to 10 mL of water and shake to slowly disintegrate into a fine dispersion that flushes via an 8Fr NG without
blockage.
Intrajejunal: Celexa tablet (Lundbeck Canada Inc)

Preparation: Crush thoroughly & mix with water; flush.(1)
of efficacy.(1)

clarithromycin Use an Enteral Closed System: No
Oral: Biaxin XL Extended-release tablet (BGP Pharma ULC, Novopharm Ltd)

Preparation: Do NOT crush, chew, or break the XL tablet, as this will disrupt the extended-release mechanism(2). Consider
converting patients who cannot swallow intact Biaxin XL tablets to the immediate-release tablets, to the commercially-available
oral suspension, or to other macrolides, if therapeutically appropriate (2, 235).
Oral: Biaxin immediate-release tablet (BGP Pharma ULC, Novopharm Ltd)

Preparation: Use the commercially-available oral liquid for patients unable to swallow intact tablets (2, 235). One clinical
reference suggests that the immediate-release, film-coated tablets could be crushed and mixed with yoghurt or apple puree
immediately prior to administration (235). However, given the unpleasant taste of this medication, disrupting the film coating on
the tablet may be poorly tolerated.
Intragastric: Biaxin oral suspension (BGP Pharma)

Preparation: DO NOT administer via feeding tubes smaller than 9 French Gauge in diameter, as the oral suspension product is
viscous and granular in consistency; clogging of the enteral tube has been reported (1, 235, 259). Administration of an
alternative macrolide, or an alternative antibiotic, either enterally or parenterally, may be considered if therapeutically
appropriate (1). A single clinical reference suggests that crushing the immediate-release, film-coated tablets (Biaxin BID) and
mixing the finely-ground powder with water may be suitable for administration via enteral tubes (235); this recommendation is
not specific to a type of enteral tube, film coatings are often difficult to crush into a fine powder, and loss of drug dose during
medication preparation may be problematic, particularly for infections caused by organisms with a high MIC. If tube bore is
sufficiently large, dilute the oral suspension with at least an equal volume of water and administer mixture immediately (1, 235).
Flushing the tubing with at least 30 to 50 mL of sterile water following medication administration is recommended in order to
prevent clogging (1, 235)
5.Draw at least an equal volume of water and a little air into the syringe and shake to mix thoroughly.
6.Flush the medication dose down the feeding tube with the recommended volume of water.
Other info: The authors of a small pharmacokinetic study involving 16 critical care patients (without significant renal, hepatic or
gastrointestinal dysfunction) found that administration of 500 mg of clarithromycin suspension via a nasogastric tube resulted in
clarithromycin and 14-OH-clarithromycin pharmacokinetic parameters similar to those reported in other adult subjects (260).
Intrajejunal: Biaxin oral suspension (BGP Pharma)

Preparation: DO NOT administer the oral suspension via feeding tubes smaller than 9 French Gauge in diameter, as this
product is viscous and granular in consistency; clogging of the enteral tube has been reported (1, 259). Administration of an
alternative macrolide, or an alternative antibiotic, either enterally or parenterally, may be considered if therapeutically
appropriate (1). A single clinical reference suggests that crushing the immediate-release, film-coated tablets (Biaxin BID) and
mixing the finely-ground powder with water may be suitable for administration via enteral tubes (235); this recommendation is
not specific to jejunal tubes, film coatings are often difficult to crush into a fine powder, and loss of drug dose during medication
preparation may be problematic, particularly for infections caused by organisms with a high MIC. If tube bore is sufficiently
large, dilute the oral suspension with at least an equal volume of water and administer mixture immediately (1, 235). Flushing
the tubing with 30 to 50 mL of sterile water following administration of the suspension is recommended in order to prevent
clogging (1, 235)
Administration: Same as intragastric administration. No specific data on jejunal administration of clarithromycin was identified
during a literature search (1). In addition, the consistency of the oral suspension makes it unsuitable for administration via small
bore tubes typically used for postpyloric enteral access. If no therapeutic alternatives exist, monitor patient closely for
increased side-effects or loss of efficacy (1).

clindamycin Use an Enteral Closed System: No
Oral: Dalacin capsule, oral suspension (Pharmacia)

Preparation: Use commercially available oral suspension OR open & mix contents of the capsule with water.(1)
Intragastric: Dalacin capsule, oral suspension (Pharmacia)

Preparation: Use commercially available oral suspension OR open & mix contents of the capsule with water. The powder
mixes easily with water and flushes via an 8Fr NG tube without blockage.(1)
Intrajejunal: Dalacin capsule, oral suspension (Pharmacia)

Preparation: Use commercially available oral suspension OR open & mix contents of the capsule with water. The powder
mixes easily with water.(1)
Administration: There are no specific data available on jejunal administration. Administer using the intragastric method.(1)
Parenteral:

cloBAZam Use an Enteral Closed System: No
Oral: tablet
of efficacy.(1)

clodronate Use an Enteral Closed System: No
Oral: Bonefos capsule (Berlex Canada Inc)

Preparation: Do NOT open capsule, not for NG tube.(21)

clomipRAMine Use an Enteral Closed System: No


clonazePAM Use an Enteral Closed System: No
Oral: Rivotril tablet (Roche)

Preparation: Use AHS compounded liquid (6) OR crush & mix with water, followed by adequate rinsing with water.(1) Treat as
a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp)
for additional information on the safe handling of this and other hazardous medications.
Intragastric: Rivotril tablet (Roche)

3 .Place the tablet in the barrel of an appropriate size and type of syringe.
4. Draw 10 mL of water into the syringe & allow the tablet to disperse, shaking if necessary.
6. Draw another 10 mL of water into the syringe and also flush this via the feeding tube.
8. Re-start feed, unless a prolonged break is required.(1)
Intrajejunal: Rivotril tablet (Roche)

of efficacy.(1)
Rectal: rectal suspension

Administration: Rectal suspension was well tolerated when administered to a small number of patients. Rapid absorption, but
bioavailability unknown.(8,19) No compounding recipe is available.

clonidine Use an Enteral Closed System: No
Oral: tablet
of efficacy.(1)
Rectal:
Administration: High bioavailability. Onset similar to oral. Therapeutic levels were achieved when administered ~20 minutes
before anesthesia. Clonidine, given preoperatively in children, may be a useful alternative to midazolam.(8)

clopidogrel Use an Enteral Closed System: No
Oral: Plavix tablets (75 mg) (Sanofi-Synthelabo Canada Inc)

Stability: Use within 30 minutes of being crushed.(1)
Intragastric: Plavix tablets (75 mg) (Sanofi-Synthelabo Canada Inc)

Intrajejunal: Plavix tablets (75 mg) (Sanofi-Synthelabo Canada Inc)

Administration: No specific data exists. Administer using the intragastric method.(1)
Rectal:
Administration: Well absorbed orally. Cannot recommend rectal administration at this time.(8)

clozapine Use an Enteral Closed System: No
Oral: tablet
3.Shake the suspension for 10 seconds.
4.Draw required dose into an appropriate size and type of syringe.
Administration: No data on jejunal administration.(1)

codeine phosphate Use an Enteral Closed System: No
Oral: Codeine Contin Controlled-release tablet (Purdue Pharma)

Preparation: Do NOT crush/chew CR tablet. All strengths may be halved, except the 50mg tablet (2). If the tablets are halved,
the resulting half tablets should be swallowed whole (2). If patients cannot swallow Codeine Contin tablets or half-tablets whole,
consider converting the patient to a therapeutic alternative, such as multiple daily divided doses of an immediate-release
codeine product (which could be crushed, if necessary), or to a different opioid analgesic administered enterally, parenterally, or
transdermally, as therapeutically appropriate (235).
Other info: Specific site of absorption is not documented.(1)

Intragastric: Codeine Contin Controlled-release tablet (Purdue Pharma)

Preparation: DO NOT crush Codeine Contin tablets; this product is NOT suitable for enteral administration (2). Consider
converting patient to a therapeutic alternative, such as multiple divided daily doses of codeine phosphate oral liquid (1, 235,
255); transdermal or parenteral administration of other opioid analgesics may also be considered, if therapeutically appropriate.
If the decision is made to administer codeine phosphate liquid via jejunal tube, consider diluting the product at least 1:1 with
sterile water, and monitor for therapeutic response or emergence of unexpected adverse effects (1, 255).
Other info: Specific site of absorption is not documented (1).
Intrajejunal: Codeine Contin Controlled-release tablet (Purdue Pharma)

Preparation: Do NOT crush Codeine Contin tablets; this product is NOT suitable for enteral administration (2). Consider
converting patient to a therapeutic alternative, such as multiple divided daily doses of codeine phosphate oral liquid (1, 235,
255); transdermal or parenteral administration of other opioid analgesics may also be considered, if therapeutically appropriate.
If the decision is made to administer codeine phosphate liquid via jejunal tube, consider diluting the product with 3 to 4 times the
volume with sterile water to reduce the osmolality of the product, and monitor for therapeutic response or emergence of
unexpected adverse effects (1, 255).
Rectal:
Administration: At least one study has suggested that codeine injection can be used for rectal administration and is rapidly
absorbed (22). However, absorption is dependent on pH and absorption location within the rectum (22). First-pass metabolism
of codeine to morphine is required for therapeutic effect of this agent; rectally-administered medication may bypass hepatic first-
pass metabolism entirely depending on where the drug enters the rectal circulatory system, resulting in variability in clinical
response (22). Based on this information, rectal administration of commercially-available opioid rectal suppositories, such as
morphine, oxycodone, or hydromorphone rectal suppositories, as therapeutically appropriate, is recommended in preference to
rectal administration of codeine injection.

colchicine Use an Enteral Closed System: No
Oral: tablet
Preparation: Tablets will disperse within 2 minutes when placed in 10mL of water to give a coarse dispersion.(1) Treat as a
Preparation: Tablets will disperse within 2 minutes when placed in 10mL of water to give a coarse dispersion that breaks up
further when drawn into the syringe. Flushes via an 8Fr NG tube without blockage.(1) Treat as a hazardous drug. Refer to the
Preparation: Tablets will disperse within 2 minutes when placed in 10mL of water to give a coarse dispersion that breaks up
further when drawn into the syringe.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite
(http://insite.albertahealthservices.ca/17382.asp) for additional information on the safe handling of this and other hazardous
medications.
of efficacy.(1)

colestipol Use an Enteral Closed System: No
Oral: Colestid tablet (Pfizer Canada Inc)

Oral: Colestid granules (Pfizer Canada Inc)

Preparation: With cereals, soups & fruits: the granules or orange granules may be taken with milk in hot or regular breakfast
cereals, or in soups with a high fluid content. May also be added to fruits that are pulpy such as crushed pineapple, pears,
peaches, or fruit cocktail. NOT recommended for use in feeding tubes as granules are hygroscopic. (23)
Administration: With beverages:
1. Add the prescribed amount of granules or orange granules to a glass (100 mL or more) of water, milk, flavored drink, juice
(orange, tomato, pineapple, etc.), or carbonated beverage. A heavy or pulpy juice may minimize complaints relative to
consistency. An unsweetened juice may improve palatability.
2. Stir the mixture until the medication is completely suspended. The granules and orange granules will not dissolve in the
liquid.
3. After drinking the mixture, rinse the glass with a small amount of additional beverage to make sure all the medication is taken.
(23)

cortisone acetate Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) OR crush & mix with water, followed by adequate rinsing with water.

cyanocobalamin Use an Enteral Closed System: No

Parenteral:

cyclobenzaprine Use an Enteral Closed System: No
Administration: No specific data exists, therefore monitor for increased side-effects and loss of efficacy.(24)

cycloPHOSPHAMIDE Use an Enteral Closed System: Yes
Oral: injectable prepared for oral use, tablet

Preparation: Do NOT crush tablets. Use AHS compounded liquid.(6) Treat as a hazardous drug. Refer to the Hazardous
Intragastric: injectable prepared for oral use, tablet

Intrajejunal: injectable prepared for oral use, tablet

Administration: If clinically appropriate; same as intragastric administration.(1)

cycloSPORINE Use an Enteral Closed System: No
Oral: Neoral liquid (Novartis Pharmaceuticals Canada Inc)

Preparation: Use Neoral liquid.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.
Intragastric: Neoral liquid (Novartis Pharmaceuticals Canada Inc)

medications.
3.Use appropriate 60 mL feeding tube syringe (syringe may contain PVC), dilute Neoral dose with at least 2 – 3 times the
dosing volume
4.Administer immediately after cyclosporine solution diluted
6.Re-start feed.(1)
Stability: Use immediately after diluting the solution.(1)
Intrajejunal: Neoral liquid (Novartis Pharmaceuticals Canada Inc)

medications.
Monitor for levels and adjust accordingly.(1)
Stability: Use immediately after diluting the solution.(1)
Parenteral:
Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.
ca/17382.asp) for additional information on the safe handling of this and other hazardous medications.

dabigatran Use an Enteral Closed System: No
Oral: Pradaxa capsule (Boehringer Ingelheim Canada Ltd)

Preparation: Do NOT open the capsules and take the pellets alone as the oral bioavailability may be increased by 75%.(25)

daclatasvir Use an Enteral Closed System: No
Oral: Daklinza tablet (Bristol Laboratories of Canada)

Preparation: Manufacturer recommends NOT crushing/chewing tablet due to unpleasant taste.(4)

dantrolene Use an Enteral Closed System: No
Oral: Dantrium capsule (Methapharm Inc)


dapsone Use an Enteral Closed System: No
Oral: tablet
Administration: There are no specific data available on jejunal administration. However, time to peak levels would indicate that
absorption does not occur in the stomach. Administer using the intragastric method.(1)

darifenacin Use an Enteral Closed System: No
Oral: Enablex sustained-release tablet (Merus Labs)

Preparation: Do NOT crush/chew/split tablet.(2)

darunavir Use an Enteral Closed System: No
Oral: Prezista tablet, oral suspension (Janssen-Ortho Inc)

Preparation: Tablets may be crushed/chewed if necessary.(4)
Intragastric: Prezista tablet, oral suspension (Janssen-Ortho Inc)

Administration: There is a case report with 1 patient on administering darunavir through a nasograstroduodenal tube.(26)

darunavir/cobicistat Use an Enteral Closed System: No
Oral: Prezcobix film-coated tablet (Janssen-Ortho Inc)

Preparation: Tablet should be swallowed whole without crushing.(4)

dasatinib Use an Enteral Closed System: Yes
Oral: Sprycel tablet (Bristol-Myers Squibb Canada)

Preparation: The core tablet is surrounded by a film coating to prevent exposure of personnel to the active drug substance.
Tablets may be dissolved in juice or lemonade & administered via a feeding tube.(27) Treat as a hazardous drug. Refer to the
Other info: Use a closed system.

deferasirox Use an Enteral Closed System: No
Oral: Exjade dispersible tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Disperse tablet by stirring in water, orange juice, or apple juice until a fine suspension is obtained. (203) Doses of
<1g should be dispersed in 100 mL of liquid and doses of >1g in 200 mL of liquid. (203) After swallowing the suspension, any
residue should be resuspended in a small volume of liquid and swallowed. (203) Tablets must not be chewed, split, crushed or
swallowed. (203)
Oral: Jadenu tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Jadenu tablets may be crushed and administered by sprinkling the full dose on a soft food (e.g. yogurt or
applesauce). (203) Commercial crushers with serrated surfaces should be avoided for crushing a single 90 mg tablet due to
loss of material in the crusher. (203) The dose should be immediately and completely consumed, and followed with a glass of
water. The dose should not be stored for future use.
Intragastric: Exjade dispersible tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Disperse tablet in 100 mL (for doses <1g) to 200 mL (for doses > 1g) of water until a fine dispersion is produced.
(203) Dispersion in milk is NOT recommended because of the increased time required to achieve a fine dispersion. (1, 203)
Tablets must NOT be chewed, split, crushed or swallowed whole. (1, 203)
3.Allow 1-hour break.
4.Place the tablet into an appropriate container; add 100mL of water and allow the tablet to disperse; add another 100mL of
water if required to achieve a suitable dispersion. Draw this into an appropriate syringe.
6.Add a further 15mL of water to rinse the container (to ensure the full dose is administered); draw into an appropriate syringe
and flush down the feeding tube.
Intragastric: Jadenu tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: No specific data regarding the administration of deferasirox film-coated tablets via feeding tube was identified
during a search of the literature. (203) Therapeutic alternatives include converting to Exjade or parenteral administration of
deferoxamine.
Intrajejunal: Exjade dispersible tablet (Novartis Pharmaceuticals Canada Inc)

Administration: There are no specific data available on jejunal administration. (1) In addition, the large dispersion volume is
likely to be problematic for jejunal administration. Consider parenteral administration of deferoxamine.

deferiprone Use an Enteral Closed System: No
Oral: Ferriprox tablet, oral solution (Apotex)

Preparation: Commercially available oral solution.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling
site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information on the safe handling of this and other
Intragastric: Ferriprox tablet, oral solution (Apotex)

Preparation: Use commercial oral solution.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on
3.Draw dose of oral solution into appropriate size and type of syringe.
4.Administer dose via feeding tube.
Intrajejunal: Ferriprox tablet, oral solution (Apotex)

Preparation: Use commercial oral solution.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on

deflazacort Use an Enteral Closed System: No
Oral: Calcort tablet (Sanofi-Aventis)

Preparation: Tablets can be crushed or they will disintegrate rapidly when placed in 10 mL of water, to produce a fine white
dispersion.(1)
Intragastric: Calcort tablet (Sanofi-Aventis)

dispersion that flushes down an 8Fr NG tube without blockage. A prolonged break in feeding is not required.(1)
3.Measure 10 mL of water into a measuring pot.
4.Add the crushed tablet & allow to dissolve.
7.Rinse the measure & administer this also to ensure that the total dose is given.
9.Re-start feed.(1)
Intrajejunal: Calcort tablet (Sanofi-Aventis)

dispersion. A prolonged break in feeding is not required.(1)
Monitor for increased side effects of loss of efficacy.(1)

desloratadine Use an Enteral Closed System: No
Oral: Aerius tablet, oral syrup (Bayer Inc)

Preparation: Use commercially available oral syrup.(2)
Intragastric: Aerius tablet, oral syrup (Bayer Inc)

Intrajejunal: Aerius tablet, oral syrup (Bayer Inc)

Administration: There are no specific data.(1)

desloratadine/pseudoephedrine Use an Enteral Closed System: No
Oral: Aerius Dual Action 12 Hour extended-release tablet (Bayer Inc)

Preparation: Do NOT crush/chew/break tablet.(2)

desmopressin Use an Enteral Closed System: No
Oral: DDAVP tablet (Ferring Inc)

Intragastric: DDAVP tablet (Ferring Inc)

Preparation: Tablet disintegrates within 5 minutes when placed in 10mL of water, the resulting dispersion flushes via an 8Fr
Intrajejunal: DDAVP tablet (Ferring Inc)

Administration: There are no specific data available to support jejunal administration; owing to the site of absorption it is
possible that bioavailability may be reduced. If indicated use the intragastric method and monitor for loss of efficacy.(1)
Intranasal: DDAVP spray, solution (Ferring Inc)

Preparation: Commercially available as either DDAVP Nasal Spray or DDAVP Rhinyle.(2)

desvenlafaxine Use an Enteral Closed System: No
Oral: Pristiq extended-release tablet (Pfizer Canada Inc)

Preparation: Do NOT crush/chew/break tablet.(2)

dexamethasone Use an Enteral Closed System: No


5.Drawn an equal volume of water into the syringe and also flush this via the feeding tube.

Rectal: injectable
Administration: Parenteral formulation can be administered via a rectal drip.(1)
Parenteral:

dexlansoprazole Use an Enteral Closed System: No
Oral: Dexilant delayed-release capsule (Takeda)

Preparation: May sprinkle contents of capsule onto applesauce and swallow immediately without chewing granules.(2)

dextroamphetamine Use an Enteral Closed System: No
Oral: Dexedrine capsule (Glaxosmithkline Inc)

Preparation: For swallowing difficulties: open capsule, mix pellets with applesauce, do not chew, use immediately.(29) Do NOT
crush pellets. NOT for NG tube (pellets become sticky).(28,29)
Oral: Dexedrine tablet (Glaxosmithkline Inc)

Preparation: Crush tablet, mix with water, flush with water.(28)
Rectal: compounded suppositories

Preparation: No compounding recipe available.
Administration: Rectal use was effective in one patient with GI obstruction.(7)

diazepam Use an Enteral Closed System: No
Oral: tablet
Administration: Liquid Administration:(1)
1.Stop enteral feed.
8.Re-start the feed, unless a prolonged break is required.
Administration: Tablet Administration:(1)
8.Re-start feed, unless a prolonged break is required.
Rectal: Diastat rectal gel (Valeant Canada)

Preparation: Commercially available rectal gel.(2)
Administration: Rectal burning lasting up to 15 minutes noted in up to 60% of patients receiving parenteral drug rectally. Drug
peaks within 20 minutes.(8)
Parenteral:

diazoxide Use an Enteral Closed System: No
Oral: Proglycem capsules (Schering Canada Inc)


dichloroacetic acid Use an Enteral Closed System: No
Oral: powder

diclofenac (extended release tablets) Use an Enteral Closed System: No
Oral: Voltaren SR tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Do NOT crush. Use AHS compounded liquid.(6)
Intragastric: Voltaren SR suppository (Novartis Pharmaceuticals Canada Inc)

Intrajejunal: Voltaren SR tablet (Novartis Pharmaceuticals Canada Inc)

Rectal: Voltaren suppository (Novartis Pharmaceuticals Canada Inc)

Administration: Commercial suppositories available.(2) Efficacy was found in one study. The rectal gel (not commercially
available) is considered pharmacokinetically superior to the suppository & generally less irritating.(8)

diclofenac sodium/misoprostol Use an Enteral Closed System: No
Oral: Arthrotec tablet (Pfizer Canada Inc)

Preparation: Do NOT crush.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.

dicyclomine Use an Enteral Closed System: No
Oral: Bentylol oral syrup (Aptalis Pharma)

Preparation: Commercially available oral syrup has been discontinued.(2) AHS hyoscine 2 mg/mL oral suspension may be a
suitable alternative for some clinical scenarios. (191)
Intragastric: Bentylol oral syrup (Aptalis Pharma)

3.Shake the medcation bottle throuhgly to ensure adequate mixing.
Intrajejunal: Bentylol oral syrup (Aptalis Pharma)


didanosine (slow release) Use an Enteral Closed System: No
Oral: Videx EC capsule (Bristol-Myers Squibb Canada)

Preparation: Do NOT crush/chew/open. Commercial oral product may be available through the Special Access Program.(4)

diflunisal Use an Enteral Closed System: No
Oral: Diflunisal tablet (AA Pharma)

Preparation: Film coated tablet; manufacturer recommends that the tablet be swallowed whole, NOT crushed or chewed.(2)

digoxin Use an Enteral Closed System: No
Oral: Toloxin oral solution (Pharmascience Inc)

Preparation: Commercially available oral solution.(2)
Other info: Parenteral route is available; see parenteral entry.(1)
Intragastric: Lanoxin oral solution (Pharmascience Inc)

Preparation: Use commercial product.(2)
Intrajejunal: Lanoxin oral solution (Pharmascience Inc)

Preparation: Use commercial product.(2)
Administration: Administer using the above method. Case reports have suggested that digoxin absorption is not compromised
when administered via jejunostomy tube, although other authors have suggested that administration via the jejunal route my
result in therapeutic failure due to the potential for drug administration beyond the site of absorption in the proximal small
intestines.(1, 194) If administered by this route, therapeutic drug monitoring should be performed in addition to clinical
monitoring for efficacy and toxicity. (1)
Rectal:
Administration: Good oral absorption & bioavailability. Cannot recommend rectal administration at this time.(8)
Parenteral:

diltiazem Use an Enteral Closed System: No
Oral: Tiazac Capsule (extended release) (Valeant Canada)

Preparation: Tiazac® capsules may be opened and the beads mixed with a spoonful of soft food (e.g., applesauce, etc.) or a
small amount of water (31). Patients should be advised not to chew the food, as chewing or crushing the beads will interfere
with the controlled delivery of the drug (31). The food should be swallowed immediately without chewing and followed with a
glass of cool water to ensure complete swallowing of the capsule content. If the beads are to be suspended in water, they
should be dispersed only, and should not be allowed to sit in solution in an attempt to dissolve them (31).
Oral: Tiazac XC Tablet (extended release) (Valeant Canada)

Preparation: Tiazac XC tablets should not be halved unless administering both halves to the same patient (32). Do not crush
or chew the whole tablet or the half-tablets (2, 32).
Oral: immediate release tablet

Preparation: Use AHS compounded liquid (6, 235) OR crush & mix with water, followed by adequate rinsing with water (235).
One clinical reference suggests that the crushed tablet could be mixed with a spoonful of yoghurt or apple puree for those
patients who cannot swallow thin fluids (235).
Stability: Use immediately after crushing tablet (235)
Oral: Sandoz Diltiazem Extended-release & controlled-delivery capsule (Sandoz Canada)

Preparation: Manufacturer does NOT recommend opening the capsules since no studies have been done (161). However, only
The AHS Drugs and Therapeutics

the pellets within the capsule have the release mechanism (161).
Committee (DTC) supports extrapolating alternate modes of oral drug

administration data (e.g. opening capsule for sprinkling) between
brand name and generic drug products based on pharmacokinetic
principles and bioequivalence; it is considered acceptable practice
within AHS to open generic diltiazem modified release capsules and
administer their contents in a similar manner as the brand name
capsule (263). Do not crush the pellets (263).
Oral: pms-Diltiazem CD Controlled release capsule (Pharmascience Inc)

Preparation: Manufacturer states that there are no contraindications for opening the capsules (162). No stability or safety
The AHS Drugs and

studies on opening the capsules and sprinkling the contents onto food (162).
Therapeutics Committee (DTC) supports extrapolating alternate

modes of oral drug administration data (e.g. opening capsule for
sprinkling) between brand name and generic drug products based on
pharmacokinetic principles and bioequivalence; it is considered
acceptable practice within AHS to open generic diltiazem modified
release capsules and administer their contents in a similar manner as
the brand name capsule (263). Do not crush the pellets (263).
Oral: Apo-Diltiaz Immediate-release tablet (Apotex)

Preparation: Manufacturer has no information on crushing tablets. The tablets are film-coated, but the coating is to ensure that
the tablets are shiny, smooth, and easy to swallow (163).
Oral: Apo-Diltiaz CD Controlled-delivery capsules (Apotex)

Preparation: Manufacturer states that the extended-release mechanism is in the pellets and not the capsule-shell (163). Thus,
The AHS Drugs and Therapeutics Committee

do not chew/crush the pellets (163).
(DTC) supports extrapolating alternate modes of oral drug

administration data (e.g. opening capsule for sprinkling) between
brand name and generic drug products based on pharmacokinetic
principles and bioequivalence; it is considered acceptable practice
within AHS to open generic diltiazem modified release capsules and
administer their contents in a similar manner as the brand name
capsule (263). Do not crush the pellets (263).
Oral: ACT Diltiazem T Extended-release capsules (Teva Canada Ltd.)
The AHS Drugs and Therapeutics Committee (DTC) supports

Preparation:
extrapolating alternate modes of oral drug administration data (e.g.

opening capsule for sprinkling) between brand name and generic drug
products based on pharmacokinetic principles and bioequivalence; it is
considered acceptable practice within AHS to open generic diltiazem
modified release capsules and administer their contents in a similar
manner as the brand name capsule (263). Do not crush the pellets
(263).
Intragastric: Immediate-release tablet

Preparation: Use AHS compounded liquid (6, 235, 255) OR crush & mix with water, followed by adequate rinsing with water (1,
235, 255).
Administration: Patients previously stabilized on a modified-release, daily diltiazem preparation may be converted to an
equivalent or lower (to account for potential changes in bioavailability between dosage forms) daily dose of immediate-release
diltiazem tablets, divided into three or four daily doses; further titration of the patient's diltiazem doses should be based on
clinical response (1, 235, 255). Note that administration of modified-release diltiazem pellets via enteral feeding tubes is not
supported by standard clinical references (1, 235, 255), and is not considered acceptable practice within AHS (263).

10. A prolonged break in feeding is not required for enteral absorption of this medication.
Intrajejunal: Immediate-release tablet

Preparation: Use AHS compounded liquid (6, 235, 255) OR crush & mix with water, followed by adequate rinsing with water (1,
235, 255).
Administration: Same as intragastic administration. No specific data on jejunal administration of diltiazem appears to exist;
consider changing to an alternative therapy (1). If administering as above, monitor for increased side-effects or loss of efficacy
(1, 255). Note that administration of modified-release diltiazem pellets via enteral feeding tubes is not supported by standard
clinical references (1, 235, 255), and is not considered acceptable practice within AHS (263).
Other info:

Rectal:
Administration: Cannot recommend rectal administration at this time.(8)
Parenteral:

dimenhydrinate Use an Enteral Closed System: No
Oral: Gravol tablets, capsules, chewable tablets, oral liquid (Church & Dwight Canada Corp)
Preparation: Use commercially available products.(2)
Intrajejunal: Gravol tablet (Church & Dwight Canada Corp)

Administration: No specific data exists, therefore monitor for increased side-effects and loss off efficacy.(1)
Other info: If commercial oral liquid is used, consider diluting prior to jejunal administration to reduce osmolarity.(1)
Rectal: Gravol suppository (Church & Dwight Canada Corp)

Preparation: Suppositories are commercially available: 25mg, 100mg.(2)
Parenteral:

dinoprostone Use an Enteral Closed System: No
Oral: tablet

diphenoxylate HCl/ atropine sulfate Use an Enteral Closed System: No
Oral: Lomotil tablet (Goldshield)

Preparation: Tablets disperse in 10 mL of water within 5 minutes when agitated to give very fine white dispersion.(1)
Intragastric: Lomotil tablet (Goldshield)

Preparation: Tablets disperse in 10 mL of water within 5 minutes when agitated to give very fine white dispersion that flushes
down an 8 Fr NG tube without blockage.(1)
Intrajejunal: Lomotil tablet (Goldshield)

Preparation: Tablets disperse in 10 mL of water within 5 minutes when agitated to give very fine white dispersion.(1)

dipyridamole Use an Enteral Closed System: No
Oral: tablet

disopyramide Use an Enteral Closed System: No
Oral: capsule
Preparation: Use AHS compounded liquid (6) OR Open & mix capsule contents with water, followed by adequate rinsing with
water.(1)

divalproex Use an Enteral Closed System: No
Oral: Epival, Novo-Divalproex enteric coated tablet (BGP Pharma ULC, Novopharm Ltd)
Preparation: Do NOT crush. Coating provides protection for the mucous membrane in the stomach & the coating protects the
tablet from the stomach acidity.(33) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite
medications.

docusate sodium Use an Enteral Closed System: No
Oral: Docusol oral solution (Typharm)

Intragastric: Docusol oral solution (Typharm)

Preparation: Use commercially available product.(2)
Intrajejunal: Docusol oral solution (Typharm)

Administration: Same as intragastric administration. Administration directly into the jejunum will not affect the pharmacological
response.(1)

dolasetron Use an Enteral Closed System: No
Oral: Anzemet tablet (Sanofi-Synthelabo Canada Inc)

Preparation: Use AHS compounded liquid OR crush & mix with water, followed by adequate rinsing with water.(6)

dolutegravir Use an Enteral Closed System: No
Oral: Tivicay tablet (ViiV Healthcare)

Preparation: Tablets may be crushed and added to semi-solid food or liquid. Consume immediately.(4)

domperidone Use an Enteral Closed System: No
Oral: tablet
Rectal: suppository
Preparation: Commercial suppositories are NOT available in Canada.(2)

donepezil Use an Enteral Closed System: No
Oral: Aricept tablet (Pfizer Canada Inc)

Preparation: Tablets can be crushed & suspended in water immediately prior to administration. Tablets disintegrate within 5
minutes when placed in 10 mL of water to give a fine dispersion.(1)
Oral: Aricept RDT rapidly disintegrating tablet (Pfizer Canada Inc)

Preparation: RDT should be placed on the tongue & allowed to disintegrate before swallowing with water.(2)
Intragastric: Aricept tablet (Pfizer Canada Inc)

minutes when placed in 10 mL of water to give a fine dispersion which flushes via a 8Fr NG tube without blockage.(1)
Intrajejunal: Aricept tablet (Pfizer Canada Inc)

minutes when placed in 10 mL of water to give a fine dispersion.(1)
Administration: Same as intragastric administration. No specific data exists. If administering as above, monitor for increased
side-effects or loss of efficacy.(1)

doxazosin Use an Enteral Closed System: No
Oral: Cardura tablet (Pfizer Canada Inc)

Preparation: Tablets can be crushed & mixed with water immediately prior to administration.(1)
Intragastric: Cardura tablet (Pfizer Canada Inc)

Intrajejunal: Cardura tablet (Pfizer Canada Inc)


doxepin Use an Enteral Closed System: No
Oral: capsule
Preparation: Capsules may be opened and the contents mixed with water.(1)
Intragastric: capsule
Intrajejunal: capsule
Rectal: capsule
Administration: Patients reported feeling more comfortable following rectal administration of capsules. Adjust dose according
to response.(8)
Buccal: Mouthrinse
Preparation: Doxepin Oral Mouthrinse recipe available through AHS.(6)

doxycycline Use an Enteral Closed System: No
Oral:
Preparation: Use AHS compounded liquid.(6) Crushing the tablet or opening the capsule is not recommended as this drug may
be irritating and can cause sensitization. (2, 235) For patients with swallowing difficulties, or in emergency situations, when
adequate supplies of the compounded oral suspension are unavailable, instructions on softening doxycycline hyclate
tablets to facilitate preparation of doxycycline liquid that may be further mixed with milk, chocolate milk, chocolate pudding,
apple juice, or apple puree are available. (235, 249) Use of a mask and gloves is recommended if manipulating doxycycline
dosage forms. (235)
Intragastric: capsule, tablet

Preparation: Use AHS compounded liquid.(6) Crushing the tablet or opening the capsule is not recommended as this drug may
be irritating and can cause sensitization. (2, 235) If the AHS compounded liquid is unavailable, it may be possible to disperse
plain doxycycline tablets in 10 - 20 mL of water within the barrel of an enteral syringe. (235) However, note that not all brands
of doxycycline hyclate tablets disperse well in water. (235) An administration technique to facilitate administration of crushed
tablets has also been proposed that involves soaking plain doxycycline tablets in water prior to crushing the tablet within the
water bath. (235) Case reports involving enteral administration of doxycycline are available in the medical literature, but details
on administration technique are lacking. (250, 251)
Administration:
If administering the AHS compounded liquid (preferred) (1):
1. Stop enteral feed. See note in "Miscellaneous information" with respect to evaluating whether a prolonged break in feeding is
required.
3. Dilute medication with an appropriate amount of water and draw the medication into an appropriate size and type of syringe.
5. Flush with the recommended volume of water.
6. Restart the feed as appropriate.
If attempting to administer the plain tablet dispersed in water (not preferred, due to increased operator risk of exposure) (235):
1. Stop enteral feed. See note in "Miscellaneous information" with respect to evaluating whether a prolonged break in feeding
is required.
3. Remove the plunger and place the tablet into an enteral syringe. Replace the plunger.
4. Draw 10 to 20 mL of water into the enteral syringe and allow the tablet to disperse. This may take several minutes. Shake
gently if required.
5. Give the dispersed tablet immediately into the enteral feeding tube.
6. Rinse the enteral syringe with a further 10 mL of water to ensure the entire dose is given.
7. Flush with the recommended volume of water.
8. Restart the feed as appropriate.
Other info: Although administration with food or milk does not usually affect absorption of doxycycline (1,2,235,249),
administration with antacids or products that contain high concentrations or iron, calcium, aluminum or magnesium may reduce
doxycycline absorption if administered within two hours of the drug. (1,2,235) Therefore, administration of doxycycline during a
break in feeding is preferred, if possible, particularly as the acuity of the illness increases. (1) Alternatively, the higher end of the
dosage range should be used, or, depending on the clinical situation, therapeutic alternatives should be sought. (1)
Intrajejunal: capsule, tablet

Preparation: The AHS compounded liquid could be used, but dilution is required due to the osmolality of the excipients.(6)
Monitor for signs of gastrointestinal intolerance, such as bloating, cramping, and diarrhea, that may indicate intolerance to the
hyperosmolar suspending vehicles. (192,193) Crushing the tablet or opening the capsule is not recommended as this drug may
be irritating and can cause sensitization. (2, 235) If the AHS compounded liquid is unavailable, it may be possible to disperse
plain doxycycline tablets in 10 - 20 mL of water within the barrel of an enteral syringe. (235) However, note that not all brands
of doxycycline hyclate tablets disperse well in water. (235) An administration technique to facilitate administration of crushed
tablets has also been proposed that involves soaking plain doxycycline tablets in water prior to crushing the tablet within the
water bath. (235)
Administration: As peak absorption may occur in the duodenum, it is possible that bioavailability may be reduced by the
jejunal administration. Use an alternative antibiotic, if possible, or monitor closely for loss of efficacy. Administer using the
intragastric method.(1)
Other info: Although administration with food or milk does not usually affect absorption of doxycycline (1,2,235,249),
administration with antacids or products that contain high concentrations or iron, calcium, aluminum or magnesium may reduce
doxycycline absorption if administered within two hours of the drug. (1,2,235) Therefore, administration of doxycycline during a
break in feeding is preferred, if possible, particularly as the acuity of the illness increases. (1) Alternatively, the higher

doxylamine-pyridoxine Use an Enteral Closed System: No
Oral: Diclectin tablet (Duchesnay Inc)

Preparation: Do NOT crush/split tablet.(2)

droperidol Use an Enteral Closed System: No
Rectal: parenteral solution

Administration: Expected duration of action is only 2-4 hours, so rectal dosing is impractical.(8)

duloxetine Use an Enteral Closed System: No
Oral: Cymbalta capsule (Eli Lilly Canada Inc)

Preparation: For oral use in patients with swallowing difficulties, open the capsule & carefully mix the pellets in ~2
tablespoonsful of applesauce. Do not chew. Use immediately.(35) Cannot be mixed with chocolate pudding or other soft foods
without compromising the integrity of the enteric coating and causing the drug to be destroyed by stomach acid. (182)
Stability: Use immediately
Intragastric: Cymbalta capsule (Eli Lilly Canada Inc)

Administration: DO NOT administer via enteral feeding tubes. (1, 34, 35, 182) Recommendations have been published in
which clinical pharmacists advise that duloxetine should not be given through enteral feeding tubes because the pellets may
obstruct the tubes.(34,35) In addition, in vitro studies conducted by Eli Lilly indicate that the enteric coated pellets from
Cymbalta capsules tend to clump together when diluted in water or apple juice and accumulate at the junction between the tip of
the administration syringe and the entry point of the feeding tubes, resulting in clogging of the tube. (182) These aggregated
particles could not be dislodged by attempting to flush the tube. Clogging was observed even with 20 French silicone
gastrostomy tubes. (182) Patients with feeding tubes should be converted to an alternative therapy.
Nasogastric: Cymbalta capsule (Eli Lilly Canada Inc)

Administration: DO NOT administer via enteral feeding tubes. (1, 34, 35, 182) Recommendations have been published in
which clinical pharmacists advise that duloxetine should not be given through enteral feeding tubes because the pellets may
obstruct the tubes.(34,35) In addition, in vitro studies conducted by Eli Lilly indicate that the enteric coated pellets from
Cymbalta capsules tend to clump together when diluted in water or apple juice and accumulate at the junction between the tip of
the administration syringe and the entry point of the feeding tubes, resulting in clogging of the tube. (182) These aggregated
particles could not be dislodged by attempting to flush the tube. Clogging was observed with both silicone and polyurethane 14
French nasogastric tubes. (182) Patients with feeding tubes should be converted to an alternative therapy.

dutasteride Use an Enteral Closed System: No
Oral: Avodart capsule (GlaxoSmithKline)

Preparation: Do NOT open capsule since contact with the capsule contents may result in irritation of the oropharyngeal
mucosa. Dutasteride is absorbed through the skin; therefore, women and children must avoid contact with leaking capsules. If
contact is made with leaking capsules, the contact area should be washed immediately with soap and water.(2) Treat as a
Other info: Call physician to get order changed to finasteride.(1)

efavirenz Use an Enteral Closed System: No
Oral: Sustiva capsule, tablet (Dupont Pharma)

Preparation: Splitting tablets is NOT recommended.(36) Three 200-mg capsules may be opened and the contents may be
added to 2-teaspoons of applesauce, grape jelly, yogurt, or infant formula.(150)
Administration: The following procedure was used to administer sprinkles with food vehicles:(150)
1. The capsule was held vertically with the cap facing up.
2. The cap was pulled away from the body of the capsule carefully, and the contents were sprinkled and mixed with the food in
a 100-mL container.
3. The mixture was administered with a spoon as soon as possible but no morethan 30 minutes after mixing.
4. After administration of the efavirenz–food mixture, the container was rinsed three times with 50 mL of water, and the subject
swallowed each rinse.
5. After the three rinses, subjects consumed an additional 90 mL of water.
Intragastric: Sustiva capsule (Dupont Pharma)

Preparation: Open capsule & mix with 5 mL MCT oil or 15 mL Orasweet.(36)
Intrajejunal: Sustiva capsule (Dupont Pharma)

Preparation: Open capsule & mix with 5 mL MCT oil or 15 mL Orasweet.(36)

efavirenz/emtricitabine/tenofovir Use an Enteral Closed System: No
Oral: Atripla tablet (Bristol-Myers Squibb And Gilead Sciences)

Preparation: Tablets can be crushed and dissolved in 5mL of water and then diluted to 20mL with Ora-Sweet. Use solution
within 24 hours to ensure drug stability. Pharmacokinetics will be altered when tablets are crushed.(37)
Stability: Use solution within 24 hours to ensure drug stability.(37)
Drug on NIOSH List:

eltrombopag Use an Enteral Closed System:
Oral: Revolade tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: The manufacturer recommends that Revolade tablets should not be crushed and mixed with food or liquids.
(2,189) The tablets are not enteric-coated and do not possess sustained-release properties. (189) However, no studies have
been conducted to evaluate the efficacy, safety, or bioequivalence of altered tablets compared to intact tablets, and tablets that
are crushed or split may stain surfaces exposed to the tablet particles or powder. (189) No compounding recipes for an oral
suspension were located during an extensive search of the compounding literature available to the Drug Information Service.
Novartis Pharmaceuticals markets eltrombopag unit-dose powder for oral suspension in the United States under the brand
name Promacta.(178) If no therapeutic alternatives can be located for patients requiring eltrombopag suspension, practitioners
may wish to attempt to obtain Promacta suspension via Health Canada's Special Access Programme.
Updated: 2017-August-11

elvitegravir Use an Enteral Closed System: No
Oral: Vitekta tablet (Gilead Sciences)

Preparation: No data on crushing tablet.(4)

elvitegravir/cobicistat/emtricitabine/tenofovi Use an Enteral Closed System: No
r Stribild tablet (Gilead Sciences)

Oral:
Preparation: Tablet may be crushed and administered with food or enteral nutrition. (184)
Nasogastric: Stribild tablet (Gilead Sciences)

Preparation: Tablets may be crushed and suspended in enteral feeding solution. (184)

emtricitabine Use an Enteral Closed System: No
Oral: Emtriva capsule (Gilead Sciences)

Preparation: Capsules may be opened and mixed with water.(4)

emtricitabine/tenofovir/rilpivirine Use an Enteral Closed System: No
Oral: Complera tablet (Gilead Sciences)

Preparation: Splitting of crushing tablet is NOT recommended.(4)

enalapril Use an Enteral Closed System: No
Oral: Vasotec tablet (Merck Frosst Canada Ltd)

Intragastric: Vasotec tablet (Merck Frosst Canada Ltd)

Intrajejunal: Vasotec tablet (Merck Frosst Canada Ltd)

side-effects or loss of efficacy. Rat studies show enalapril is well absorbed from the jejunum in a concentration dependent
mechanism, with lower concentrations being better absorbed than higher concentrations.(1)

entacapone Use an Enteral Closed System: No
Oral: Comtan tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Tablets disintegrate when shaken in 10 - 20 mL of water for 5 - 10 minutes, to give a bright orange, yellow, or
green cloudy dispersion. The dispersion will stain equipment, as well as the patient's mouth (saliva, lips, gums, tongue,
dentures, etc.). (1, 235, 243) Disperse the tablets in water immediately prior to dosing, and rinse the cup or oral dispenser well.
(1, 235) If the patient cannot swallow thin fluids, the tablets may be crushed into a fine yellow or greenish powder immediately
prior to administration; mix the powder with solid, semi-solid, or liquid food products (yoghurt or apple puree has been
suggested) immediately prior to administration. (235, 243) Use a dedicated tablet crusher to prepare the medication due to the
potential for staining. (235)
Stability: Disperse the tablets in water, or crush tablets, immediately prior to dosing. (1, 235, 243)
Intragastric: Comtan tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Tablets disintegrate when shaken in 10 mL of water for 5 minutes, to give a bright orange, cloudy dispersion that
flushes via an 8Fr NG tube without blockage. The dispersion will stain, so crushing tablets to a dry powder should be avoided.
Disperse the tablets in water immediately prior to dosing.(1)
Stability: Disperse the tablets in water immediately prior to dosing.(1)
Intrajejunal: Comtan tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Tablets disintegrate when shaken in 10 mL of water for 5 minutes, to give a bright orange, cloudy dispersion. The
dispersion will stain, so crushing tablets to a dry powder should be avoided. Disperse the tablets in water immediately prior to
dosing.(1)
Stability: Disperse the tablets in water immediately prior to dosing.(1)
Drug on NIOSH List:

entecavir Use an Enteral Closed System:
Intragastric: Baraclude tablet (Bristol-Myers Squibb Canada)

Preparation: Treat as a hazardous drug. A single clinical resource recommends dispersing the tablet in 10 - 20 mL of water
within the barrel of an enteral syringe. (235) The capped enteral syringe may require gentle agitation in order to minimize
adherence of the drug to the walls of the syringe. (235) Note that a literature search failed to identify any published information
relating to therapeutic outcomes achieved using this method. If no therapeutic alternatives are available, monitor patients
carefully for signs of clinical efficacy or emerging toxicity/therapeutic failure.
Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional
Administration: 1. Stop the enteral feed. Since administration of this product on an empty stomach is recommended (2),
stopping continuous enteral feeds two hours prior to administration of entecavir via NG tube is recommended. (235)
2. Flush the enteral tube with the recommended volume of water.
3. Remove the plunger of an enteral syringe and place the tablet into the syringe. Replace the plunger.
4. Draw 10 - 20 mL of sterile water into the enteral syringe and allow the tablet to disperse, shaking if necessary.
5. Flush the dispersed tablet down the enteral tube.
6. Draw another 10 mL of sterile water into the enteral syringe and flush this water down the feeding tube.
7. Finally, flush the enteral tube with an adequate amount of sterile water.
8. Wait 2 hours before restarting continuous enteral feeds.

eprosartan Use an Enteral Closed System: No
Oral: Teveten tablet (Solvay Pharma Inc)

Preparation: The tablets do not disperse readily in water, but will crush, mix with water.(1)
Other info: Owing to lack of data, consider changing to irbesartan.(1)
Intragastric: Teveten tablet (Solvay Pharma Inc)

Preparation: The tablets do not disperse readily in water, but will crush, mix with water & flush via a fine-bore tube without
blockage.(1)
Intrajejunal: Teveten tablet (Solvay Pharma Inc)

Preparation: The tablets do not disperse readily in water, but will crush, mix with water & flush via a fine-bore tube without
blockage.(1)

ergocalciferol (vitamin D2) Use an Enteral Closed System: No
Oral: Erdol oral solution (Odan)

Preparation: Commercially available oral liquid.(2)
Intragastric: Erdol oral solution (Odan)

Preparation: Use commercial liquid.
Administration: No data on enteral tube administration.(1)
Intrajejunal: Erdol oral solution (Odan)

Preparation: Use commercial liquid.
Administration: No data on enteral tube administration.(1)

erythromycin Use an Enteral Closed System: No
Oral: erythromycin
ethylsuccinate
Preparation: The commercially-available suspension has been removed from the Canadian marketplace and no compounding
recipe is available at this time. (2, 191) Consideration could be given to parenteral administration of the medication, as an
injectable form is also available. (2, 191) Alternatively, consideration could be given to converting the patient to azithromycin or
clarithromycin oral suspensions, if therapeutically appropriate for the indication in question.
Intragastric: erythromycin ethylsuccinate

Preparation: The commercially-available suspension has been removed from the Canadian marketplace and no compounding
clarithromycin oral suspensions, if therapeutically appropriate for the indication in question. Unfortunately, available oral dosage
forms are unsuitable for administration via enteral feeding tubes. (1)
Intrajejunal: erythromycin
ethylsuccinate oralcommercially-available
Preparation: The suspension suspension has been removed from the Canadian marketplace and no compounding
clarithromycin oral suspensions, if therapeutically appropriate for the indication in question. Unfortunately, available oral dosage
forms are unsuitable for administration via enteral feeding tubes. (1)

Administration: Efficacy has not been established.(8)
Parenteral:

escitalopram Use an Enteral Closed System: No
Oral: Cipralex tablet (Lundbeck Canada Inc)

Preparation: Crush tablet & mix with water, flush with water.(1)
Other info: Commercial oral drops through Lundbeck (not available in Canada)(2) can be used for enteral tube administration.
Stability: Use immediately; if not used within 15 minutes- discard and remake.(1)

esomeprazole Use an Enteral Closed System: No
Oral: Nexium tablet (AstraZeneca Canada Inc)

Preparation: Nexium MUPS™ tablets may be dispersed in half a glass of non-carbonated water. No other liquids should be
used as the enteric coating may be dissolved.(2)
Administration: Nexium MUPS™ tablets: Place the tablet in half a glass of non-carbonated water. Stir until the tablets
disintegrate and drink the liquid with the pellets immediately or within 30 minutes. Rinse the glass with half a glass of water and
drink. The pellets must not be chewed or crushed.(2)
Other info: Take 1 hour before food because food decreases and delays absorption.(1)
Stability: Use within 30 minutes (but preferably immediately).(1,2)
Oral: Nexium granules (AstraZeneca Canada Inc)

Preparation: Sachets of Nexium granules may be administered orally to patients with difficulty swallowing tablets. (2)
Alternatively, Nexium MUPS™ tablets may be dispersed in water for patients with swallowing difficulties. (2) Note that Nexium
granules are not currently listed on the AHS formulary. (177)
Administration: The contents of each sachet should be emptied into a container containing 1 tablespoon (15 mL) of water. Stir
the contents and leave for a few minutes to thicken. Stir again and drink within 30 minutes. If any material remains after
drinking, add more water stir and drink immediately.
Stability: Use within several minutes to 30 minutes. (2)
Oral: Mylan-Esomeprazole tablet (Mylan Pharmaceuticals ULC)

Preparation: Mylan-Esomeprazole is acid labile and therefore is administered orally as a MUPS™ tablet. The MUPS™ tablet
consists of many enteric-coated granules compressed into a tablet. The tablets may be dispersed in half a glass of non-
carbonated water; no other liquids should be used as the enteric coating may be dissolved. (2)
Administration: Mylan-Esomeprazole: Place the tablet in half a glass of non-carbonated water. Stir until the tablets disintegrate
and drink the liquid with the pellets immediately or within 30 minutes. Rinse the glass with half a glass of water and drink. The
pellets must not be chewed or crushed. (2)
Stability: Use within 30 minutes (but preferably immediately). (2)
Intragastric: Nexium tablet (AstraZeneca Canada Inc)

Preparation: Esomeprazole is acid labile and therefore is administered orally as a MUPS™ tablet or as a pH-appropriate
suspension. (2) The MUPS™ tablet consists of many enteric-coated granules compressed into a tablet. The sachet consists of
enteric-coated granules and inactive excipient granules that are dispersed in water to form an oral suspension. (2) Either the
MUPS tablet or the Nexium Granules may be administered via gastric tube (2). However, Nexium granules are not currently on
the AHS formulary. (177) Do not administer either Nexium formulation through tubes smaller than 8 French in diameter; the
AHS compounded omeprazole or lansoprazole suspension should be used for patients with feeding tubes smaller than 8
French in diameter. (2,177)
Administration: Nexium MUPS™ tablets: Dispersed tablets can also be administered via naso-gastric feeding tubes (8-20
French) using a 25 to 60 mL disposable syringe. The type of syringe used should ensure a secure fit with the feeding tube.
Each NEXIUM tablet should be dispersed in 50 mL of water and passed through the tube into the stomach. After administering
the suspension, the naso-gastric tube may be flushed with an additional 25-50 mL of water to clear the syringe and tube. In
larger naso-gastric feeding tubes (i.e. 14 French or larger), the dispersion volume may be reduced to 25 mL. (2)
Stability: Use within 30 minutes (preferably immediately). (1, 2)

Intragastric: Nexium granules (AstraZeneca Canada Inc)

Preparation: Nexium granules may be administered via naso-gastric or gastric tubes with diameters of 8 - 20 French. (2).
However, patients with feeding tubes with diameters smaller than 8 French should receive AHS compounded omeprazole or
lansoprazole suspension in order to avoid clogging the tube. (177). Nexium granules are not currently on the AHS formulary;
use Nexium MUPS dispersible tablets instead. (177)
Administration: For patients who have a naso-gastric or gastric tube in place, the contents of the sachet can be added to a
syringe containing 15 mL of water. Immediately shake the syringe and leave for a few minutes to thicken. Shake the syringe and
inject through the nasogastric or gastric tube within 30 minutes. Refill the syringe with an equal amount of water and shake and
flush any remaining contents from the nasogastric tube into the stomach. (2)
Stability: Use within 30 minutes (but preferably immediately) (1,2)
Intrajejunal: Nexium tablet (AstraZeneca Canada Inc)

Preparation: Esomeprazole is acid labile and therefore is administered orally as a MUPS™ tablet or as a pH-appropriate
suspension. (2) The MUPS™ tablet consists of many enteric-coated granules compressed into a tablet. (2) Nexium tablets may
be dispersed in water for administration via enteral tubes between 8 and 20 French in diameter (2, 177). Do not administer
Nexium formulation through tubes smaller than 8 French in diameter; the AHS compounded omeprazole or lansoprazole
suspension should be used for patients with feeding tubes smaller than 8 French in diameter. (2,177)
Administration: Although NOT LICENSED via this route, intrajejunal administration of the enteric coated microgranules is
unlikely to affect the pharmacokinetic response to esomeprazole.(1) However, note that Nexium MUPS™ tablets are not
suitable for administration via tubes less than 8 French in diameter. (2, 177). For patients with tubes less than 8 French in
diameter, use AHS compounded omeprazole or lansoprazole suspension if therapy with an enteral PPI formulation is desired.
(177) Alternatively, therapy with intravenous pantoprazole could be considered.
Nexium MUPS™ tablets: Dispersed tablets can also be administered via naso-gastric feeding tubes (8-20 French) using a 25
to 60 mL disposable syringe. The type of syringe used should ensure a secure fit with the feeding tube. Each NEXIUM tablet
should be dispersed in 50 mL of water and passed through the tube into the stomach. After administering the suspension, the
naso-gastric tube may be flushed with an additional 25-50 mL of water to clear the syringe and tube. In larger naso-gastric
feeding tubes (i.e. 14 French or larger), the dispersion volume may be reduced to 25 mL. (2)
Stability: Use within 30 minutes (but preferably immediately).(1,2)

Nasogastric: Mylan-Esomeprazole tablet (Mylan Pharmaceuticals ULC)

Preparation: Mylan-Esomeprazole is acid labile and therefore is administered orally as a MUPS™ tablet.(2) The MUPS™
tablet consists of many enteric-coated granules compressed into a tablet.(2) Mylan-Esomeprazole tablets may be dispersed in
non-carbonated water only (other liquids may disrupt the enteric coating) and administered to patients with feeding tubes
between 8 - 20 French in diameter. (177)
Administration: Mylan-Esomeprazole tablets: Dispersed tablets can be administered via naso-gastric feeding tubes (8-20
French) using a 25 to 60 mL disposable syringe. The type of syringe used should ensure a secure fit with the feeding tube.
Each esomeprazole delayed release tablet should be dispersed in 50 mL of water and passed through the tube into the
stomach. After administering the suspension, the naso-gastric tube may be flushed with an additional 25-50 mL of water to clear
the syringe and tube. In larger naso-gastric feeding tubes (i.e. 14 French or larger), the dispersion volume may be reduced to 25
mL.
Stability: Use within 30 minutes (but preferably immediately). (2)

ethacrynic acid Use an Enteral Closed System: No
Oral: Edecrin tablet (Acton Pharma)

Parenteral:

ethambutol Use an Enteral Closed System: No
Oral: tablet
Preparation: Crush & mix with water; the coating takes a few minutes to dissolve.(1)
Updated: 2018-January-23
9. Finally, flush the enteral tube with the recommended volume of water.

ethinyl estradiol Use an Enteral Closed System: Yes
Oral: tablet
Preparation: Uncoated tablets such as these can be crushed; the manufacturer has no data.(1) Treat as a hazardous drug.
Vaginal: Nuvaring ring (slow release) (Merck Canada)

Preparation: Commercially available product.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site
Topical: patches
Preparation: Use transdermal patches where clinically appropriate.(2) Treat as a hazardous drug. Refer to the Hazardous

ethosuximide Use an Enteral Closed System: No
Oral: Zarontin oral syrup (Parke-Davis)

Preparation: Commercially available oral syrup.(2)
Intragastric: Zarontin oral syrup (Parke-Davis)

Preparation: Slightly viscous liquid; mixes easily with water to reduce resistance to flushing.(1)
Intrajejunal: Zarontin oral syrup (Parke-Davis)

Preparation: Slightly viscous liquid; mixes easily with water to reduce resistance to flushing.(1)
of efficacy.(1)

etidronate Use an Enteral Closed System: No
Oral: tablet
Preparation: Crush & mix with water, flush with water. Do not mix with food.(1)
3.Allow a 2 hour break.
9.Add another 15 mL of water to the mortar and stir to ensure that any remaining drug is rinsed from the container. Draw this
10.Finally, flush the enteral tube with the recommended volume of water.
11.Wait for at least 2 hours before restarting the feed.(1)

etoposide Use an Enteral Closed System: Yes

Preparation: Oral liquids based on published compounding recipes are prone to precipitation. Use the 20 mg/mL injectable
product orally.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.



etravirine Use an Enteral Closed System: No
Oral: Intelence tablet (Janssen-Ortho Inc)

Preparation: Tablets may be dispese in a glass of water. Consume immediately.(4)
Intragastric: Intelence tablet (Janssen-Ortho Inc)

Preparation: Tablets may be dispese in a glass of water. Consume immediately.(4)
Administration: There is a case report with 1 patient on administering etravirine through a PEG tube.(38)

everolimus Use an Enteral Closed System: Yes
Oral: Afinitor oral tablets, DISPERZ tablets (Novartis Pharmaceuticals Canada Inc)
Preparation: **NOTE: Oral tablets and the DISPERZ tablets are NON-interchangeable.(2,146) Treat as a hazardous drug.
Oral Tablets:
Tablets may be dispersed in 30 mL of water by gently stirring until the tablet is fully disintegrated. (Approximately 7 minutes)
DISPERZ Tablets (for oral suspension) should be administered as a suspension only and should NOT be swallowed whole,
chewed, or crushed. Administer the suspension immediately after preparation. Discard suspension if not administered after 60
minutes of preparation.
Instructions for oral suspension:
Administration: Method 1-Using an oral syringe:
1. Place the prescribed dose of AFINITOR* DISPERZ into a 10 mL syringe. Do not exceed a total of 10 mg per syringe. If higher
doses are required, prepare an additional syringe. Do not break or crush tablets.
2.Draw approximately 5 mL of water and 4 mL of air into the syringe.
3. Place the filled syringe into a container (tip up) for 3 minutes, until the AFINITOR* DISPERZ tablets are in suspension.
4. Gently invert the syringe 5 times immediately prior to administration.
5. After administration of the prepared suspension, draw approximately 5 mL of water and 4 mL of air into the same syringe,
and swirl the contents to suspend remaining particles. Administer the entire contents of the syringe.
Method 2-Using a small drinking glass:

1. Place the prescribed dose of AFINITOR* DISPERZ into a small drinking glass (maximum size 100 mL) containing
approximately 25 mL of water. Do not exceed a total of 10 mg of AFINITOR* DISPERZ per glass. If higher doses are required,
prepare an additional glass. Do not break or crush tablets.
2. Allow 3 minutes for suspension to occur.
3. Stir the contents gently with a spoon, immediately prior to drinking.
4. After administration of the prepared suspension, add 25 mL of water and stir with the same spoon to re-suspend remaining
particles. Administer the entire contents of the glass.
Stability: Use immediately. Discard suspension if not administered within 60 minutes.(2,146)
Intragastric: Afinitor oral tablets, DISPERZ tablets (Novartis Pharmaceuticals Canada Inc)
Administration: Both oral tablets and DISPERZ tablets may be used for enteral feeding. Either formulations must be dispersed
completely in a glass of water and then administered immediately prior to administration into the enteral tube using an oral
syringe. To ensure removal of the drug, subsequent rinsing with water is required.
To avoid interactions and incompatibilities with enteral nutrition, the feeding tube should be flushed with at least 15 mL of water
before and after the administration of everolimus.(146)
Intrajejunal: Afinitor oral tablets, DISPERZ tablets (Novartis Pharmaceuticals Canada Inc)
Administration: Both oral tablets and DISPERZ tablets may be used for enteral feeding. Either formulations must be dispersed
completely in a glass of water and then administered immediately prior to administration into the enteral tube using an oral
syringe. To ensure removal of the drug, subsequent rinsing with water is required.
To avoid interactions and incompatibilities with enteral nutrition, the feeding tube should be flushed with at least 15 mL of water
before and after the administration of everolimus.(146)

ezetimibe Use an Enteral Closed System: No
Oral: Ezetrol tablet (Merck Canada)

Preparation: Tablets disperse in 10 mL of water within 5 minutes if shaken.(1)
Intragastric: Ezetrol tablet (Merck Canada)

Preparation: Tablets disperse in 10 mL of water within 5 minutes if shaken. The fine white dispersion flushes via 8Fr NG tube
without blockage.(1)
Intrajejunal: Ezetrol tablet (Merck Canada)

Preparation: Tablets disperse in 10 mL of water within 5 minutes if shaken to form a fine white dispersion.(1)

famciclovir Use an Enteral Closed System: No
Oral: Famvir tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Crush & mix with water, rinsewith water.(1,39)
Stability: Use immediately after crushing tablet.(1,39)
Intragastric: Famvir tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Crush & mix with water, flush with water.(1,39)
Intrajejunal: Famvir tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Crush & mix with water, flush with water.(1,39)

famotidine Use an Enteral Closed System: No
Oral: tablet

fampridine Use an Enteral Closed System: No
Oral: Fampyra sustained-release tablet (Biogen Idec Canada Inc)

Preparation: Do NOT split/crush/chew tablet.(2)

felodipine Use an Enteral Closed System: No
Oral: Plendil tablet (AstraZeneca Canada Inc)

Preparation: Do NOT crush extended release tablets.(40)

fenofibrate Use an Enteral Closed System: No
Oral: Lipidil Supra tablet (Fournier Pharma Inc)

Preparation: Splitting or crushing of the tablet should be performed just prior to administration.(41)
Stability: Use immediately after crushing or splitting.(41)
Oral: Lipidil EZ tablet (Fournier Pharma Inc)

Preparation: Splitting or crushing of the tablet should be performed just prior to administration.(42)
Oral: Lipidil Micro capsule (Solvay Pharma Inc)

Preparation: Opening the capsule should be performed just prior to administration.(43)

fentanyl Use an Enteral Closed System: No
Buccal & Sublingual: Fentora Effervescent tablets (Teva Canada Ltd.)

Preparation: Do not split Fentora tablets (2). Do not suck, chew, or swallow tablet, as this will result in increased loss of drug
via significant first pass metabolism when absorbed via the gastrointestinal tract; serum levels and therapeutic response will be
reduced (2).
Administration: Place entire tablet in buccal cavity or sublingual space (2). Do NOT split tablet (2).
The tablet should be left between the cheek and gum until it has disintegrated, which usually takes approximately 14-25 minutes
(2). After 30 minutes, if remnants from the tablet remain, they may be swallowed with a glass of water (2).
Stability: Use immediately after removing from blister (2).
Intranasal: mucosal atomizer device & syringe

Administration: Intranasal fentanyl has been used to manage moderate to severe pain, especially in the neonatal and pediatric
population. Practice guidelines and protocols are available through Insite and SharePoint (44,45,46, 265). When administered
intranasally, the commercially-available injectable product (50 mcg/mL) should be administered with a mucosal atomizer device
to maximize intranasal delivery of the drug (45, 46, 265). The intranasal route is recommended for patients weighing 50 kg or
more due to the limited surface area available for absorption relative to the volume of drug to be administered; increased loss of
drug to the nasopharynx, resulting in decreased drug absorption and inadequate analgesic response, is likely (45, 264).
Other info: The absorptive capacity of the nasal mucosa is limited; the volume of medication administered per nostril should be
no more than 1 mL in adults (ideally, no more than 0.5 mL) in order to avoid loss of the drug to the nasopharynx with
subsequent deactivation (264, 269). Based on this information, a maximum possible single dose of 100 mcg (1 mL of the 50
mcg/mL injection per nostril) may be delivered in one dose; the intranasal route may therefore not be suitable for larger patients
requiring single weight-based doses close to or in excess of 100 mcg (264, 269).
Nasal mucosal atomizer devices have a "dead space" that needs to be taken into account when preparing medication doses for
administration (264); refer to the product information for the specific device being used.
Parenteral:
https://webappsint.albertahealthservices.ca/pharmacy/pm/pm_preview.asp?id=7806
Sublingual: fentanyl citrate injection (50 mcg/mL)

Administration: Fentanyl injection may be administered sublingually for the management of incident pain (173, 174). If
administered by this route, the injection should be retained sublingually for a minimum of 5 minutes to promote adequate
absorption, as drug lost through swallowing is subject to extensive first-pass metabolism (174). A protocol for using injectable
fentanyl sublingually for the management of incident pain is available from the Calgary Zone Long Term Care Formulary (174).
Alternatively, use of the commercially-available sublingual/buccal tablet (Fentora) may be appropriate.

fexofenadine/pseudoephedrine Use an Enteral Closed System: No
Oral: Allegra-D tablet (Aventis Pharma Inc)

Preparation: Do NOT crush. The fexofenadine layer is an immediate-release formulation; the pseudoephedrine layer is a
sustained-release formulation.(2)

finasteride Use an Enteral Closed System: Yes
Oral: Proscar tablet (Bayer Inc)

Preparation: Do NOT crush. Use a "closed system" to disperse tablet. Women should not handle crushed or broken tablets if
they are or may be pregnant owing to the potential risk to a male fetus.(47,48) Treat as a hazardous drug. Refer to the
Intragastric: Proscar tablet (Bayer Inc)

Intrajejunal: Proscar tablet (Bayer Inc)


flavoxate Use an Enteral Closed System: No
Oral: Urispas tablet (Shire Biochem Inc)

Preparation: The tablets do not disperse readily in water and are very hard to crush, but with persistence they can be ground
into a fine powder, which mixes well with water to form a milky dispersion.(1)
Intragastric: Urispas tablet (Shire Biochem Inc)

Preparation: The tablets do not disperse readily in water and are very hard to crush, but with persistance they can be ground
into a fine powder, which mixes well with water to form a milky dispersion that flushes via an 8Fr NG tube without blockage.(1)
Intrajejunal: Urispas tablet (Shire Biochem Inc)

Preparation: The tablets do not disperse readily in water and are very hard to crush, but with persistance they can be ground
into a fine powder, which mixes well with water to form a milky dispersion.(1)

flecainide Use an Enteral Closed System: No
Oral: tablet

Administration: Compounded suppository controlled tachycardia. Pharmacokinetic study showed good bioavailability &
absorption of microenema.(8)

fluconazole Use an Enteral Closed System: No
Oral: Diflucan capsule, oral suspension (Pfizer Canada Inc)

Preparation: If the commercial oral suspension is not available, use AHS compounded liquid.(6) Treat as a hazardous drug.
Intragastric: Diflucan capsule, oral suspension (Pfizer Canada Inc)

Intrajejunal: Diflucan capsule, oral suspension (Pfizer Canada Inc)


Preparation: Fluconazole suppository recipe is available from IJPC.(49) Treat as a hazardous drug. Refer to the Hazardous
Administration: Compounded suppositories can be used for candidiasis and were well tolerated. Absorption is slightly slower
with rectal administration compared to oral administration.(19)
Parenteral:

flucytosine Use an Enteral Closed System: No
Oral: capsule
Preparation: Use AHS compounded liquid & treat as hazardous drug.(6)

fludrocortisone Use an Enteral Closed System: Yes
Oral: Florinef tablet (Paladin Laboratories Inc)

Preparation: Fludrocortisone is practically insoluble in water. However, the usual dose of 100 mcg will dissolve in 2.5 mL of
water. Tablet disintegrates within 2 minutes when placed in 10 mL of water.(1)
Stability: Disperse tablet in water immediately prior to administration.(1)
Intragastric: Florinef tablet (Paladin Laboratories Inc)

water. Tablet disintegrates within 2 minutes when placed in 10 mL of water; the fine dispersion settles quickly but flushes via an
8Fr NG tube without blockage.(1)
Intrajejunal: Florinef tablet (Paladin Laboratories Inc)

water. Tablet disintegrates within 2 minutes when placed in 10 mL of water; the fine dispersion settles quickly.(1)

fluorouracil Use an Enteral Closed System: Yes

Administration: Drug was combined with pre-operative radiotherapy.(8)

fluoxetine Use an Enteral Closed System: No


3. Draw required dose of liquid preparation into the appropriate size and type of enteral syringe.

Rectal: capsule, oral suspension

Administration: Rectal administration via a capsule form was well tolerated. Rectal route requires higher doses than oral route
since bioavailability is lower with rectal administration. Precise conversion ratio has not been established.
20 mg fluoxetine in 30 mL sterile water was administered rectally in one patient & although she experienced some clinical
response, as the dosage was increased, abdominal cramping increased to intolerable levels.(19)

flupenthixol dihydrochloride Use an Enteral Closed System: No
Oral: Fluanxol tablet (Lundbeck Canada Inc)

Preparation: Tablets do not disperse readily owing to the sugar coating, but will disintegrate if shaken in water for 5 minutes to
give a pale pink, very fine dispersion.(1)
Other info: Depot injection available.(2)
Intragastric: Fluanxol tablet (Lundbeck Canada Inc)

give a pale pink, very fine dispersion that flushes via an 8Fr NG tube without blockage.(1)
Intrajejunal: Fluanxol tablet (Lundbeck Canada Inc)

give a pale pink, very fine dispersion.(1)

fluphenaZINE Use an Enteral Closed System: No
Oral: Moditen tablet (Sanofi-Synthelabo Canada Inc)

Preparation: Tablets do not disperse readily owing to the sugar coating, but disintegrate if shaken in water for 5 minutes to give
a pale pink, very fine dispersione.(1)
Other info: Depot injection available.(2)
Intragastric: Moditen tablet (Sanofi-Synthelabo Canada Inc)

a pale pink, very fine dispersion that flushes via an 8Fr NG tube without blockage.(1)
Intrajejunal: Moditen tablet (Sanofi-Synthelabo Canada Inc)

a pale pink, very fine dispersion.(1)

flutamide Use an Enteral Closed System: Yes
Oral: tablet
Preparation: Bulky tablets do not disintegrate readily, but will disperse if shaken in water for 5-10 minutes.(1) Treat as a
Preparation: Bulky tablets do not disintegrate readily, but will disperse if shaken in water for 5-10 minutes; this dispersion
flushes via an 8 Fr tube without blockage.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on
Preparation: Bulky tablets do not disintegrate readily, but will disperse if shaken in water for 5-10 minutes.(1) Treat as a

fluvastatin Use an Enteral Closed System: No
Oral: Lescol capsule (Novartis Pharmaceuticals Canada Inc)

Preparation: Open capsule; the powder pours out easily & mixes readily with 10 mL of water to form a pale yellow, milky
dispersion.(1)
Oral: Lescol XL extended release tablet (Novartis Pharmaceuticals Canada Inc)

Intragastric: Lescol capsule (Novartis Pharmaceuticals Canada Inc)

dispersion that flushes easily down an 8Fr NG tube.(1)
4.Add 15 mL of water
5.Stir to disperse the powder
6.Draw into an appropriate syringe and administer via the feeding tube.
8.Draw up this dispersion and flush down the tube. This will ensure that the whole dose is given.
Intrajejunal: Lescol capsule (Novartis Pharmaceuticals Canada Inc)

dispersion.(1)

fluvoxamine maleate Use an Enteral Closed System: No
Oral: Faverin tablet (Solvay Pharma Inc)

Preparation: Faverin tablets can be crushed and mixed with water, although the manufacturers have no data to support
administration via enteral feeding tubes.(1)

folic acid Use an Enteral Closed System: No



Parenteral:

fosamprenavir Use an Enteral Closed System: No
Oral: Telzir tablet (Glaxosmithkline Inc)

Preparation: Commercially available liquid available.(2)
Intragastric: Telvir oral suspension (Glaxosmithkline Inc)

Intrajejunal: Telvir oral suspension (Glaxosmithkline Inc)

of efficacy.(1)

fosinopril Use an Enteral Closed System: No
Oral: Monopril tablet (Squibb)

Preparation: Fosinopril is freely soluble in water, but data is limited consider changing to alternative ACE inhibitors.(1)
Intragastric: Monopril tablet (Squibb)

Preparation: Fosinopril is freely soluble in water, but data is limited consider changing to alternative ACE inhibitors.(1)
6.Draw another 10 mL of water into the syringe and also flush this via the feeding tube (this will rinse the syringe and ensure

furosemide Use an Enteral Closed System: No
Oral: Lasix oral solution (Sanofi-Synthelabo Canada Inc)

Preparation: Use commercially available product (20 mg/mL). For small doses, use AHS compounded liquid (0.5 mg/mL).(6)
Intragastric: Lasix oral solution (Sanofi-Synthelabo Canada Inc)

Intrajejunal: Lasix oral solution (Sanofi-Synthelabo Canada Inc)

Administration: Furosemide is absorbed well following jejunal administration. Administer using the intragastric method of
administration.(1)
Rectal: Lasix compounded suppository

Administration: Absorption can be erratic and incomplete. Diuretic effect noted in both studies.(8)
Parenteral:

gabapentin Use an Enteral Closed System:
Oral: Neurontin capsule (Pfizer Canada Inc)

Preparation: Use AHS compounded liquid (6) OR open capsule, mix with water, & flush with water.(50)
Intragastric: Neurontin capsule (Pfizer Canada Inc)

4.Add 15 mL of water
5.Stir to disperse the powder
6.Draw into an appropriate syringe and administer via the feeding tube.
8.Draw up this dispersion and flush down the tube. This will ensure that the whole dose is given.
Intrajejunal: Neurontin capsule (Pfizer Canada Inc)

Administration: Animal studies show that gabapentin is absorbed throughout the small intestine, with most absorption
occurring in the duodenum. Therefore, intrajejunal administration may result in decreased absorption. Monitor for loss of
efficacy.(1)
Rectal:
Administration: Rectal administration unreliable & not recommended. Consider alternative antiepileptic.(8)

galantamine Use an Enteral Closed System: No
Oral: Reminyl ER capsule (Janssen-Ortho Inc)

Preparation: Open capsule carefully to avoid damaging pellets. Sprinkling pellets on applesauce or yogurt retains extended
release properties for up to 10 minutes. No information on feeding tube administration.(51)
Stability: Use within 10 minutes of opening capsule.(51)
Oral: Reminyl tablet (Janssen-Ortho Inc)

Preparation: Film coating does not affect release of medication from tablet. Tablets will disperse within 5 minutes when placed
in 10mL of water to give a fine dispersion.(1)
Intragastric: Reminyl tablet (Janssen-Ortho Inc)

in 10mL of water to give a fine dispersion that settles quickly but flushes easily via an 8Fr NG tube without blockage.(1)
Intrajejunal: Reminyl tablet (Janssen-Ortho Inc)

in 10mL of water to give a fine dispersion that settles quickly.(1)
Administration: Same as intragasrtic administration. No specific data exists. If administering as above, monitor for increased

gamma hydroxybutyrate Use an Enteral Closed System: No
Oral: powder
Preparation: No data currently available. Consider alternative.(52)

ganciclovir Use an Enteral Closed System: Yes
Oral: Cytovene injectable prepared for oral use (Hoffmann-La Roche Limited)
Parenteral:

gliclazide Use an Enteral Closed System: No
Oral: Diamicron tablet (Servier Canada Inc)

Preparation: Crush & disperse in water immediately prior to administration.(1)
Oral: Diamicron MR MR tablet (Servier Canada Inc)

Preparation: Do not crush Diamicron MR tablets.(2)
Intragastric: Diamicron tablet (Servier Canada Inc)

Intrajejunal: Diamicron tablet (Servier Canada Inc)


glimepiride Use an Enteral Closed System: No
Oral: Amaryl tablet (Hoechst Marion Roussel)

Preparation: Tablets disperse within 5 minutes when placed in 10 mL of water, to form a very fine dispersion.(1)
Intragastric: Amaryl tablet (Hoechst Marion Roussel)

Preparation: Tablets disperse within 5 minutes when placed in 10 mL of water, to form a very fine dispersion that flushes down
an 8Fr NG tube without blockage.(1)
Intrajejunal: Amaryl tablet (Hoechst Marion Roussel)

Preparation: Tablets disperse within 5 minutes when placed in 10 mL of water, to form a very fine dispersion.(1)

glyburide Use an Enteral Closed System: No
Oral: tablet (APS)

Preparation: APS brand tablets disperse in water within 5 minutes to give a very fine dispersion.(1)
Intragastric: tablet (APS)

Preparation: APS brand tablets disperse in water within 5 minutes to give a very fine dispersion that flushes down an 8Fr NG
tube without blockage.(1)
6.Draw another 10 mL of water into the oral syringe and also flush this via the feeding tube (this will rinse the syringe and
ensure that the total dose is administered).

glycopyrrolate Use an Enteral Closed System: No
Oral: Cuvposa Oral solution (Pediapharm Inc.)

Preparation: Use the commercially-available oral solution product (Cuvposa). (2) Administer at least on hour before or two
hours after meals. (2)
Alternatively, two AHS compounded oral liquids are available for use when the commercially-available oral solution is
unavailable. (6)
Stability: Discard Cuvposa bottles 60 days after opening the bottle. (2)
Intrajejunal: Cuvposa Oral solution (Pediapharm Inc.)

Administration: No specific information on administration of this product via enteral feeding tube was located in common
enteral medication administration references, or during a search of the primary medical literature. (1, 235) The site of
absorption within the gastrointestinal tract is unknown. (1) However, it is unclear whether administration of this medication into
the small intestine would be successful, as the oral absorption of this product from the gastrointestinal tract is known to be poor,
variable, and erratic (average oral bioavailability in patients with an intact gastrointestinal tract: 3 - 25%). (244, 245). In
addition, the stability of glycopyrrolate in questionable in environments where the pH exceeds 6, as the drug undergoes ester
hydrolysis. (244) Finally, the osmolality of the commercially-available oral solution is unknown, but the solution is expected to
be hyperosmolar based on the nonmedicinal ingredient list (the product contains glycerin, propylene glycol, cherry flavor, and
sorbitol). (2) Parenteral administration of this product is recommended, if possible. If the clinical decision is made to attempt
administration of this medication into the small bowel, careful monitoring for loss of therapeutic efficacy or the emergence of
adverse effects is recommended. (1)
Stability: Discard Cuvposa bottles 60 days after opening the bottle. (2)
Parenteral:

granisetron Use an Enteral Closed System: No
Oral: tablet
Tablet does not disintegrate readily but disperses in 10mL if water if shaken for 5 minutes.(1)
Tablet does not disintegrate readily but disperses in 10mL if water if shaken for 5 minutes; this fine dispersion flushes via an 8Fr
Preparation: Use AHS compounded liquid OR crush & mix with water, followed by adequate rinsing with water.(6)Tablet does
not disintegrate readily but disperses in 10mL if water if shaken for 5 minutes.(1)

haloperidol Use an Enteral Closed System: No
Oral: tablet
Preparation: There is no documented interaction with food. Haloperidol is compatible with water, apple, orange and tomato
juice, as well as cola, soups and pudding.(1)
7 Finally, flush with the recommended volume of water.
Rectal:
Administration: Not recommended.(19)
Parenteral:
haloperidol: http://intraweb01.albertahealthservices.ca/pharmacy/pm/pm_preview.asp?id=8900
haloperidol decanoate (LA): http://intraweb01.albertahealthservices.ca/pharmacy/pm/pm_preview.asp?id=8901

hydrALAZine Use an Enteral Closed System: No
Oral: Apo-hydralazine tablet, injectable prepared for oral use (Apotex)

Preparation: Use AHS compounded liquid (6) OR Crush tablet, mix with water, flush with water.(1) Apotex has not conducted
studies on crushing tablets. However, there is nothing about the tablet that would indicated that crushing would be a problem.
(53)
Intragastric: Apo-hydralazine tablet (Apotex)

Intrajejunal: Apo-hydralazine tablet (Apotex)

Rectal:
Parenteral:

hydrochlorothiazide Use an Enteral Closed System: No
Oral: tablet
Administration: The total quantity of drug absorbed across the jejunum & ileum was similar to literature values reported
following oral absorption & since hydrochlorothiazide is absorbed in the jejunum & ileum, it should be absorbed when given via
a jejunostomy tube. Intrajejunal is an acceptable administration route.(54)

hydrocortisone Use an Enteral Closed System: No
Oral: tablet
Rectal: enema, foam/aerosal

Preparation: Rectal route is used for topical treatment only. Commercially available products: (1) enema: Cortenema, (2)
foam/aerosal: Cortifoam.(2)
Parenteral:

HYDROmorphone Use an Enteral Closed System: No
Oral: HYDROmorph Contin controlled release capsule (Purdue Pharma)

Preparation: Hydromorph Contin capsules may be opened and the contents may be sprinkled onto soft foods for swallowing.
(2) Alternatively, convert patient to commercially available oral syrup in divided daily doses. (2)
Intragastric: oral syrup (Pharmascience Inc)

Preparation: Do NOT attempt to administer the contents of HYDROmorph Contin capsules via feeding tubes owing to the high
risk of blockage. (1, 171). Potential alternatives may include converting the patient to M-Eslon (for patients with gastric tubes; 1,
170, 171), topical sustained-release opiates such as the fentanyl or buprenorphine patches (1), or divided daily doses of the
commercially-available hydromorphone oral liquid or other immediate-release opioid product (1).
Intrajejunal: oral syrup

Preparation: Use commercially available product, dilute prior to intrajejunal administration. Do NOT attempt to administer
contents of modified release capsules via the feeding tube owing to the high risk of blockage.(1, 171)
Administration: Hydromorphone is likely absorbed from the upper GIT, therefore jejunal administration may affect
bioavailability – monitor for loss of efficacy.(55,56)
Rectal: tablet
Administration: Can be given rectally. Tends to have less adverse effects than parenteral administration (form unspecified).(8)
Parenteral:

hydroxychloroquine Use an Enteral Closed System: No
Oral: compounded liquid


hydroxyurea Use an Enteral Closed System: Yes
Oral: Hydrea capsule (Squibb Canada)

Other info: Hydroxyurea is cytotoxic. Suitable protective clothing should be worn.
Intragastric: Hydrea capsule (Squibb Canada)

Administration: When possible use extemporaneous preparation to minimize operator exposure to powder. 1.
Stop enteral feed.
Intrajejunal: Hydrea capsule (Squibb Canada)


hydrOXYzine Use an Enteral Closed System: No
Oral: Atarax oral syrup (Erfa Canada Inc)

Preparation: Use commercially available 2 mg/mL syrup.(2)
Intragastric: Atarax oral syrup (Erfa Canada Inc)

Intrajejunal: Atarax oral syrup (Erfa Canada Inc)

Administration: Same as intragastric administration. No specific data exists. If administering as above consider diluting the
liquid preparation immediately prior to administration to reduce osmolarity. Monitor for increased side-effects or loss of efficacy.
(1)

hyoscine butylbromide Use an Enteral Closed System: No
Oral: Buscopan tablet (Boehringer Ingelheim Canada Ltd)

Intragastric: Buscopan tablet (Boehringer Ingelheim Canada Ltd)

Alternatively, two foreign clinical resources suggest that hyoscine butylbromide injection (Buscopan), which contains the same
drug salt as Buscopan tablets, and minimal excipients (sodium chloride and sterile water for injection) could be administered via
enteral feeding tube in place of crushed tablets. (1,2,235)
Intrajejunal: Buscopan tablet (Boehringer Ingelheim Canada Ltd)

Alternatively, two foreign clinical resources suggest that hyoscine butylbromide injection (Buscopan), which contains the same
drug salt as Buscopan tablets, and minimal excipients (sodium chloride and sterile water for injection) could be administered via
enteral feeding tube in place of crushed tablets. (1,2,235)
Administration: No data available. However, jejunal administration is unlikely to affect therapeutic response. Consider
changing to parenteral therapy (see parenteral entry) if enteral absorption is compromised.(1)
Parenteral:

ibuprofen Use an Enteral Closed System: No
Oral: Advil oral liquid (Wyeth Canada)

Preparation: Use commercially available product.(2) Suspensions prepared by dispersing tablets in water may have reduced
absorption, therefore commercial liquids are recommended.(1)
Intragastric: Advil oral liquid (Wyeth Canada)

Preparation: Use commercially available product; dilute with an equal volume of water immediately prior to administration
where possible. Use commercially available product. Suspensions prepared by dispersing tablets in water may have reduced
absorption, therefore commercial liquids are recommended. A prolonged break in feeding is not required.(1)
Intrajejunal: Advil oral liquid (Wyeth Canada)

Preparation: Use commercially available product. Suspensions prepared by dispersing tablets in water may have reduced
absorption, therefore commercial liquids are recommended. Commercial suspensions should be diluted prior to administration
intrajejunally.(1) A prolonged break in feeding is not required.(1)
Administration: Animal studies have shown that ibuprofen is mostly absorbed from the small intestine, with less absorption
occurring in the stomach. No specific data, therefore monitor for increased side-effects or loss of efficacy.(1)
Rectal: Advil oral liquid (Wyeth Canada)

Administration: There is limited pharmacokinetics data for rectal use of ibuprofen. There is lower bioavailability compared to
oral administration.(57) Rectal administration has been used for postoperative pain in pediatrics.(58) However, it is important to
consider the volume required may be too high to be retained in the rectum. Rectal use of ibuprofen was limited to 3 days in the
study. Consider therapeutic alternative, especially if the indication is fever reduction.
Parenteral:

imatinib Use an Enteral Closed System: Yes
Oral: Gleevec tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Treat as hazardous drug. For patients unable to swallow whole imatinib tablets, the tablets may be dispersed in
water or apple juice (50 mL for every 100 mg tablet or 200 mL for every 400 mg tablet).(2, 59) Do NOT use orange juice or cola
products due to stability and compatibility issues. (200) The mixture should be stirred with a spoon and consumed immediately
after tablet disintegration. (2, 59) The glass used to disperse the tablet should be rinsed, and the rinse liquid should also be
consumed. (2, 59) Alternately, use AHS compounded liquid. (6) Refer to the Hazardous Medication Handling site on Insite
medications.
Stability: Use immediately after complete disintegration.(2,59)
Intragastric: Gleevec compounded liquid (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid; treat as hazardous drug. (6) Refer to the Hazardous Medication Handling site on
hazardous medications. Note that, while administration of Gleevec tablets dissolved in water or apple juice (see "oral" route
entry) would potentially be acceptable for intragastric administration, the AHS compounded liquid is recommended here in order
to reduce the exposure risk of front-line staff members.
Administration: No detailed information relating to recommended administration techniques to provide imatinib via enteral
feeding tube was located in the literature. The following administration technique is suggested based on information available
for the enteral administration of other medications available as suspensions. (1) Based on information provided in the Gleevec
product monograph, a prolonged break in enteral feeding to facilitate drug absorption does NOT appear to be necessary. (2)
Note that further dilution of the compounded suspension with sterile water immediately prior to enteral administration as
indicated in the suggested procedure below is necessary in order to reduce the viscosity (and therefore increase drug delivery
through the enteral tube) and osmolality (and therefore improve tolerability) of the compounded liquid. (196)
Suggested administration technique:

4. Draw the medication liquid into an appropriate size and type of syringe.
5. Draw an equal volume of water and a little air into the syringe and shake to mix thoroughly.
8. Re-start the feed.
Other info: A case report describing the administration of imatinib via nasogastric tube is available in the primary literature.
(200, 201) Unfortunately, the case report does not provide any information on preparation used or administration procedure.
(201)
Intrajejunal: Gleevec compounded liquid (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid; treat as hazardous drug. (6) Refer to the Hazardous Medication Handling site on
hazardous medications. Note that, while administration of Gleevec tablets dissolved in sterile water (see "oral" route entry)
would potentially be preferable to using the AHS compounded liquid from an osmolality perspective, the AHS compounded
liquid is recommended here in order to reduce the exposure risk of front-line staff members.
Administration: No detailed information relating to recommended administration techniques to provide imatinib via enteral
feeding tube was located in the literature. The following administration technique is suggested based on information available
for the enteral administration of other medications available as suspensions. (1) Based on information provided in the Gleevec
product monograph, a prolonged break in enteral feeding to facilitate drug absorption does NOT appear to be necessary. (2)
Note that further dilution of the compounded suspension with sterile water immediately prior to enteral administration as
indicated in the suggested procedure below may be necessary in order to reduce the viscosity (and therefore increase drug
delivery through the enteral tube) and osmolality (and therefore improve tolerability) of the suspension when administered into
the small bowel. (196)
Suggested administration technique:

4. Draw the medication liquid into an appropriate size and type of syringe.
8. Re-start the feed.
Other info: A case report describing regression of a gastrointestinal stromal tumor and healing of an associated
gastrocutaneous fistula within 30 days of starting a regimen of "enteral" imatinib is available in the literature. (199) Despite
several discrepancies in the case report relating to the type of enteral tube placed and the exact administration route of the
imatinib, it seems likely based on the patient characteristics described in this report that the patient received a suspension of
imatinib administered via an enteral tube exiting in the duodenum or the proximal jejunum. (199) Unfortunately, administration
instructions were not provided in the case report. (199)
Rectal: Gleevec tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Treat as hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Administration: A single case report describes rectal administration of the intact tablets in a 52 year-old woman with
gastrointestinal obstructions related to her gastrointestinal stromal tumor. (200, 202) The patient had previously participated in a
pharmacokinetic study following oral administration, and consented to provide multiple blood samples following administration of
her fourth rectal dose of imatinib in order to allow comparison of the AUC obtained following rectal administration. (202) The
AUC achieved in this patient after four doses of imatinib rectally (dosed as 400 mg rectally bid) was ~ 40% of the patient's
previously-documented oral AUC. (202) Based on this information, the authors suggest that administering double the
recommend oral imatinib dose via the rectal route may be feasible for patients unable to take the medication orally due to
obstruction of the GI tract. (202)

imipramine Use an Enteral Closed System: No
Oral: tablet
3.Draw the medication oral solution into the appropriate size and type of enteral syringe.

indapamide Use an Enteral Closed System: No
Oral: tablet
Preparation: Tablets can be crushed and mixed with water immediately prior to administration.(1)
7. Finally, flush with the recommended volume of water

indinavir Use an Enteral Closed System: No
Oral: Crixivan capsule (Merck Frosst Canada Ltd)

Preparation: Use AHS compounded liquid OR open & mix contents with water, followed by adequate rinsing with water.(6)
Stability: Use immediately after opening capsule.

indomethacin Use an Enteral Closed System: No
Oral: Indocid capsule (Merck Frosst Canada Ltd)

Preparation: Use AHS compounded liquid or open capsule, mix with water, and flush.(6)
Rectal: Ratio-Indomethacin, Sandoz-Indomethacin suppository

Preparation: Commercially available suppositories: 50mg and 100mg.(2)
Administration: Local irritation has been noted in one case of suppository usage. Incomplete absorption when compared with
oral formulations.(8)
Parenteral:

ipratropium Use an Enteral Closed System: No
Sublingual: Atrovent nasal spray (Boehringer Ingelheim Canada Ltd)

Preparation: Ipratropium 0.03% or 0.06% nasal spray can be administered sublingually to manage sialorrhea:(14,15,60,61)
Administration:
- Ipratropium 0.03% 2 sprays sublingually QHS or TID
- Ipratropium 0.06% 2 sprays sublingually TID

irbesartan Use an Enteral Closed System: No
Oral: Avapro tablet (Bristol Laboratories of Canada)

Preparation: Tablets disperse in 10 mL water within 2-5 minutes to give fine milky dispersion with some larger particles.(1)
Intragastric: Avapro tablet (Bristol Laboratories of Canada)

Preparation: Tablets disperse in 10 mL water within 2-5 minutes to give fine milky dispersion with some larger particles; these
break up when drawn into the syringe and flush down an 8Fr NG tube without blockage.(1)
6.Draw another 10 mL of water into the syringe an also flush this via the feeding tube.
Intrajejunal: Avapro tablet (Bristol Laboratories of Canada)

Preparation: Tablets disperse in 10 mL water within 2-5 minutes to give fine milky dispersion with some larger particles; these
break up when drawn into the syringe.(1)

iron (ferrous sulfate) Use an Enteral Closed System: No
Oral: oral drops

Preparation: Oral drops are commercially available.(2)
Intragastric: oral drops

Preparation: Add an equal amount of water to the commerical product to dilute before administration.(1)
Other info: Due to acidic pH (=4), certain iron oral liquid preparations may cause clumping when mixed with enteral feeding
formula. If an alternative formulation is not available, the enteral feed should be stopped 1-2 hours before and after drug
administration, or 30mL of water should be flushed through the tube before and after drug administration.(1)
Intrajejunal: oral drops

Preparation: Add an equal amount of water to the commerical product to dilute before administration.(1)
Administration: Human and animal data show that the site of absorption of iron is the duodenum and proximal jejunum.
Therefore, the intrajejunal administration of iron will likely result in decreased absorption; the dose should be titrated to
response or the parenteral route should be considered. Administer using the intragastric method.(1)
Other info: Due to acidic pH (=4), certain iron oral liquid preparations may cause clumping when mixed with enteral feeding
formula. If an alternative formulation is not available, the enteral feed should be stopped 1-2 hours before and after drug
administration, or 30mL of water should be flushed through the tube before and after drug administration.(1)

iron (heme iron polypeptide) Use an Enteral Closed System: No
Oral: Proferrin tablet (Colorado Biolabs Inc)

Preparation: Manufacturer states tablet may be crushed.(62)
Intragastric: Proferrin tablet (Colorado Biolabs Inc)

Preparation: No data for NG administration; Manufacturer states tablet may be crushed.(62)
Intrajejunal: Proferrin tablet (Colorado Biolabs Inc)

Preparation: Manufacturer states tablet may be crushed.(62)
Administration: Jejunal administration is likely to result in reduced absorption; the dose should be titrated to response or the
parenteral route should be considered.(1)

isoniazid Use an Enteral Closed System: No
Oral: PDP-Isoniazid oral syrup (Pendopharm)

Preparation: Use commercially available product, if not available then use AHS compounded liquid.(6)
Intragastric: PDP-Isoniazid oral syrup (Pendopharm)

3.Allow a 1 hour break if practical.
Intrajejunal: PDP-Isoniazid oral syrup (Pendopharm)


isosorbide dinitrate Use an Enteral Closed System: No
Oral: tablet (Alpharma)

Preparation: Crushing the tablet is not recommended; use a therapeutic alternative (i.e. sublingual nitroglycerin tablets or
spray, nitroglycerin patch, parenteral nitroglycerin).(1)

isosorbide-5-mononitrate Use an Enteral Closed System: No
Oral: Imdur extended release tablet (AstraZeneca Canada Inc)


isotretinoin Use an Enteral Closed System: No
Oral: Accutane capsule (Roche)

Preparation: Treat as a hazardous drug. Methods for patients with difficult swallowing:(147,148)
1) Place softgel capsule in a small container and add warm (~37◦C) water or milk to cover capsule. Wait 2-3 minutes until
capsule is soft and then drink the water or milk with the capsule.
2) Puncture the softgel capsule with a needle or cut with scissors. Squeeze capsule contents into 5-10 mL of warm milk or tube
feed. Draw mixture into an oral syringe and then give via feeding tube. Then flush feeding tube with at least 30 mL of milk or
tube feed formula.
3) Puncture the softgel capsule with a needle or cut with scissors. Draw contents into an oral syringe. Draw 1-5 mL of medium-
chain triglyceride, soyean, or safflower oil into the same syringe. Mix gently and administer via feeding tube. Then flush feeding
tube with at least 30 mL of milk or tube feed formula.
**Due to various risks associated with handling and modifying the capsules, administration method 1 would appear to be
associated with the lowest exposure risk. Refer to the Hazardous Medication Handling site on Insite (http://insite.

itraconazole Use an Enteral Closed System: No
Oral: Sporanox oral solution (Janssen-Ortho Inc)

Intragastric: Sporanox oral solution (Janssen-Ortho Inc)

3.Allow a 2 hour break before administering dose.
7.Do not restart the feed for at least 1 hour.(1)
Intrajejunal: Sporanox oral solution (Janssen-Ortho Inc)

Administration: No data available. Consider using parenteral.(1)
Drug on NIOSH List:

ivermectin Use an Enteral Closed System:
Intragastric: Stromectol tablet (Merck Frosst Canada Ltd)

Administration: At least five case reports involving the administration of ivermectin by nasogastric tube for the treatment of
Strongyloides stercoralis have been published. (227-231) Unfortunately, none of the case reports provide details of the
preparation used or the nasogastric administration technique employed. An Australian reference recommends that Stromectol
tablets be dispersed in 20 mL of water within an enteral syringe; the tablet should disperse within 1 minute but settles quickly,
requiring shaking of the syringe to redisperse the tablet immediately prior to administration of the dose. (235)
No information on the necessity of a break in enteral feeding is provided in the published case reports; whether or not a break in
enteral feeding is required may depend on the indication and would need to be considered carefully given the lack of published
data. (232-234) An Australian reference suggests that no break in enteral feeding is required for administration of ivermectin.
(235)
Other info: Note that paralytic ileus, which can occur with Strongyloides stercoralis hyperinfection, will significantly impair
ivermectin absorption from the gastrointestinal tract; consultation with an Infectious Diseases specialist to discuss therapeutic
alternatives is recommended should paralytic ileus develop. (227-229; 235)
Stability: Use immediately.
Rectal: tablet
Preparation: Three case reports describe preparation of a compounded ivermectin enema formulation for rectal administration
for treatment of Strongyloides stercoralis hyperinfection associated with severe gastroparesis. (227-229) Note that enteral
ivermectin administration was continued in addition to rectal administration in all three case reports. (227-229) Two
extemporaneous formulations have been described:
Ivermectin in Ora-Plus: Crush ivermectin tablets and mix the required dose (200 mcg/kg/day) in Ora-Plus to achieve a total
volume of 30 mL. (227, 228)
Ivermectin in carboxymethylcellulose 1.5%: Crush ivermectin 12 mg in a mortar until it is a fine powder. Wet the powder with a
small quantity of carboxymethylcellulose 1.5% until a homogeneous mixture is achieved. Add small proportions of
carboxymethylcellulose up to a final volume of 30 mL. (229)
Other info: Published clinical experience with extemporaneous preparation of ivermectin retention enemas appears to be
limited to three case reports. (227-229) All three patients continued to receive enteral ivermectin with or without other oral
agents while receiving rectal ivermectin administered daily. (227-229) Two patients improved, while a third passed away. (227
-229) Healthcare workers considering rectal administration of ivermectin to treat Strongyloides stercoralis hyperinfection are
encouraged to consider therapeutic alternatives and to review the original case reports.
Stability: Use immediately due to a lack of published stability data. (229)

ketamine Use an Enteral Closed System: No
Oral: oral solution

Preparation: Use AHS compounded liquid (prepared from injection OR powder).(6)
Intragastric: oral solution

Intrajejunal: oral solution

Administration: There are no specific data available on jejunal administration.(1)

Administration: When formulated as a suppository (using a fatty excipient) at an approximate dose of 10mg/kg, it may be used
for sedation during induction of pediatric anesthesia. Onset of action is 7-10 minutes.(63)
Parenteral:

ketoconazole Use an Enteral Closed System: No
Oral: Apo-Ketoconazole tablet (Apotex)

Intragastric: Apo-Ketoconazole tablet (Apotex)

3.Wait 30 minutes before administering dose.
4.Place the tablet in the barrel of an appropriate size & type of syringe.
9.Do not re-start feed for at least 2 hours.(1)
Intrajejunal: Apo-Ketoconazole tablet (Apotex)

Administration: Not suitable for jejunal use.(1)

ketoprofen Use an Enteral Closed System: No
Rectal: suppository
Administration: Commercially available suppositories: 50mg and 100mg. Bioavailability is comparable to capsule preparation.
(2)

ketorolac Use an Enteral Closed System: No
Oral: Toradol tablet (Roche)

Preparation: Tablets disperse if shaken in 10 mL of water for 5 minutes to give a fine dispersion.(1)
Intragastric: Toradol tablet (Roche)

Preparation: Tablets disperse if shaken in 10 mL of water for 5 minutes to give a fine dispersion that settles quickly but flushes
down an 8Fr NG tube without blockage.(1)
Intrajejunal: Toradol tablet (Roche)

Preparation: Tablets disperse if shaken in 10 mL of water for 5 minutes to give a fine dispersion that settles quickly.(1)

L-arginine Use an Enteral Closed System: No
Oral: powder, injection

Intragastric: powder, injection

Intrajejunal: powder, injection


L-isoleucine Use an Enteral Closed System: No
Oral: oral solution


L-leucine Use an Enteral Closed System: No
Oral: oral solution


L-valine Use an Enteral Closed System: No
Oral: oral solution


labetalol Use an Enteral Closed System: No
Oral: tablet
water into the syringe and also flush this via the feeding tube.
Parenteral:

lacosamide Use an Enteral Closed System: No
Oral: Vimpat tablet (UCB)

Preparation: Tablets may be dispersed in water for administration, or may be crushed and mixed with a spoonful or yogurt or
apple sauce for administration to patients with dysphagia. (64, 65, 235) Unfortunately, lacosamide oral syrup is not currently
marketed in Canada. (2)
Stability: Use immediately after crushing or dispersing tablet. (64, 65, 235)
Updated: 2019-May-7
Intragastric: Vimpat tablet (UCB)

Preparation: The tablet may be crushed and mixed with water, or may be dispersed in 10 - 20 mL of water within the barrel of
an enteral syringe prior to administration. (64, 65, 235) Alternatively, if the feeding tube is for short-term use only, treatment
with parenteral therapy could be considered, depending on the clinical scenario. Refer to AHS Provincial Parenteral
Monograph:
Other info: Commercial oral syrup has been administered via gastrostomy tube. Unfortunately, the commercial product isn’t
marketed in Canada.(2)
Stability: Use immediately after crushing or dispersing tablet. (64, 65, 235)
Updated: 2019-May-7
Parenteral: Vimpat Solution for Injection (UCB)

Updated: 2019-May-7

lactose Use an Enteral Closed System: No
Oral: powder
Intragastric: powder
2.Flush the enteral feeding tube with the recommended volume of water..
3.Place the liquid into into an appropriate size & type of syringe.
4.Draw twice the volume of water & a little air into the syringe and shake to mix thoroughly.
Intrajejunal: powder

lactulose Use an Enteral Closed System: No
Oral: oral syrup (PMS)

Preparation: Use AHS compounded liquid (dilute lactulose syrup volume with 2-3 times the volume of distilled or sterile water).
(6)
Intragastric: oral syrup (PMS)

(6)
4.Draw twice the volume of water and a little air into the syringe and shake to mix thoroughly.
Other info: Acts locally in the colon, therefore no loss of efficacy with intragastric vs intrajejunal administration.(1)
Intrajejunal: oral syrup (PMS)

(6)
Other info: Acts locally in the colon, therefore no loss of efficacy with intragastric vs intrajejunal administration.(1)

lamivudine Use an Enteral Closed System: No
Oral: 3TC tablet, oral solution (ViiV Healthcare)

Preparation: Use commercially available liquid OR tablets may be crushed/split.(4)
Intragastric: 3TC oral solution (ViiV Healthcare)

Preparation: Use commercially available liquid.(1)
3.Draw the medication solution into the appropriate size and type of enteral syringe.
Intrajejunal: 3TC tablet, oral solution (ViiV Healthcare)

Preparation: Use commercially available liquid.(1)

lamivudine/zidovudine Use an Enteral Closed System: No
Oral: Combivir tablet (ViiV Healthcare)

Preparation: Tablets may be crushed and disintegrated into water, grape juice, or orange juice. May have bitter taste.(4) Treat
as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.
asp) for additional information on the safe handling of this and other hazardous medications.
Intragastric: Combivir tablet (ViiV Healthcare)

Administration: There are two case series surrounding the use of a G-tube for the administration of lamivudine/zidovudine. In
one case series, 6 children received lamivudine/zidovudine via a G-tube to ensure adherence.(26) Another case series involved
9 children and concluded that the pharmacokinetics of G-tube administration is comparable to oral administration.(66) In
addition, there is a case report with 1 patient on administering lamivudine/zidovudine via a nasograstroduodenal tube.(67)

lamotrigine Use an Enteral Closed System: No
Oral: Lamictal tablet (Glaxosmithkline Inc)

Preparation: Use AHS compounded liquid (6) OR disperse the tablets in 10 mL of water.(1)
Intragastric: Lamictal tablet (Glaxosmithkline Inc)

Preparation: Use AHS compounded liquid (6) OR disperse the tablets in 10 mL of water; the resulting dispersion flushes down
Intrajejunal: Lamictal tablet (Glaxosmithkline Inc)

Preparation: Disperse the tablets in 10 mL of water; note that there is a risk of tube occlusion with this method.(1) AHS
compounded liquid is unlikely to be appropriate for jejunal administration due to the large volumes required, as well as the high
osmolality and low pH of the suspending vehicle. (6)
Administration: Same as intragastic administration. No specific data exists. If administering as above, monitor for increased
Rectal: Lamictal tablet (Glaxosmithkline Inc)

Preparation: Lamotrigine suspension for rectal administration via a small catheter consists of crushing a 100mg tablet in 6mL of
room temperature tap water followed by two 2mL syringe-tubing rinses.(68)
Administration: Rapid absorption into the bloodstream, therefore rectal administration may be an alternative to oral. Variable
bioavailability, not absorbed to same extent as oral.(8)

lansoprazole Use an Enteral Closed System: No
Oral: Prevacid FasTabs dispersible tablets (Takeda)

Preparation: Use commercially available product. FasTab tablets should not be broken, cut or chewed. FasTab tablets are not
designed to be swallowed intact or chewed. (187)
Administration: FasTab tablets are designed for administration to patients who cannot swallow intact capsules or tablets. The
FasTab tablets are not designed to be swallowed intact or chewed. There are two administration options (187):
1) Place tablet on the tongue and allow it to disintegrate with or without water until the particles can be swallowed. The tablet
typically disintegrates in less than 1 minute.
2) For administration via oral syringe, FasTabs can be administered as follows:

- Place a 15 mg tablet in an oral syringe and draw up approximately 4 mL of water, or place a 30 mg tablet in an oral syringe
and draw up approximately 10 mL of water.
- Shake gently to allow for a quick dispersal.
- After the tablet has dispersed, administer the contents within 15 minutes.
- Refill the syringe with approximately 2 mL (5 mL for the 30 mg tablet) of water, shake gently, and administer any remaining
contents.
Other info: Phenylketonurics: Contains Phenylalanine 2.5 mg per 15 mg tablet & 5.1 mg per 30 mg Tablet.(2)
Stability: Use immediately, or within 15 minutes if the tablet is dispersed in water for administration. (1,187)
Oral: Prevacid delayed-release capsule (Takeda)

Preparation: Use AHS compounded liquid.(6) For oral use, lansoprazole delayed-release capsules can be opened, & the intact
granules contained within can be sprinkled on one tablespoon of applesauce & swallowed immediately. The granules should not
be chewed or crushed. The granules have also been shown in vitro to remain intact for up to 30 minutes when exposed to
apple, cranberry, grape, orange, pineapple, prune, tomato, & V-8 vegetable juice.(187)
Other info: Use for phenylketonuric patients or when small doses are required, e.g. pediatrics.
Oral: Apo-Lansoprazole Delayed-release capsule (Apotex)

Preparation: Capsules may be opened, and the intact granules sprinkled on 1 tablespoon of applesauce for patients with
difficulties swallowing the intact capsule. Swallow granules mixed with applesauce immediately. Do not crush or chew
granules. (188)
Intragastric: Prevacid FasTabs dispersible tablets (Takeda)

Preparation: Use commercially available product. FasTabs can be dispersed in water; the granules settle quickly but can be
drawn into a syringe & administered via NG tubes of at least 8 French gauge without blockage.(1,2) Note that Prevacid
FasTabs are no longer listed on the AHS formulary; esomeprazole MUPS, or the AHS omeprazole or lansoprazole
compounded liquids are formulary alternatives, depending on patient and enteral tube characteristics. (177)
Administration: To administer Prevacid FasTabs via NG tubes of at least 8 French gauge (2):
- Place a 15 mg tablet in a syringe and draw up 4 mL of water, or place a 30 mg tablet in a syringe and draw up 10 mL of water.
- Shake gently to allow for a quick dispersal.
- After the tablet has dispersed, inject through the nasogastric tube into the stomach within 15 minutes.
- Refill the syringe with approximately 5 mL of water, shake gently, and flush the nasogastric tube.
Stability: Use within 15 minutes of dispersing the tablet in water. (2)
Intragastric: Prevacid delayed-release capsule (Takeda)

Preparation: Use AHS compounded liquid (6) or follow administration instructions found below.
Administration: For patients who have a nasogastric tube (at least 16 French gauge or larger) in place, lansoprazole delayed-
release capsules can be opened and the intact granules mixed in 40 mL of apple juice or water and injected through the
nasogastric tube into the stomach. (187) After administering the granules, the nasogastric tube should be flushed with additional
apple juice or water to clear the tube.(187) For patients with nasogastric tubes <16 French gauge, AHS formulary alternatives
include esomeprazole MUPS, or the AHS omeprazole or lansoprazole compounded suspensions, depending on patient and
enteral tube characteristics.
OR
1.Stop the enteral feed.

4.Add 15 mL of sodium bicarbonate 8.4%.
5.Stir to dissolve granules.
6.Draw into the syringe and administer via the feeding tube.
7.Add a further 15 mL of water to the medicine pot; stir to ensure that any drug remaining in the pot is mixed with water.
8.Draw up the dispersion and flush down the tube. This will ensure that the whole dose is give.
9. Flush the tube with the recommended volume of water.
10. Restart the feed, unless a prolonged break is required.(1)
Intrajejunal: Prevacid FasTabs dispersible tablets (Takeda)

Preparation: Use commercially available product. FasTabs can be dispersed in water for administration via intrajejunal feeding
tube according to the instructions provided for nasogastric administration provided the jejunal feeding tube is at least 8 French
gauge. For smaller feeding tubes, use of the compounded liquid is required. Note that Prevacid FasTab is no longer listed on
the AHS formulary; formulary alternatives include esomeprazole MUPS, or AHS omeprazole or lansoprazole compounded
suspension, depending on patient and enteral tube characteristics. (177)
Administration: Lansoprazole is absorbed in the small bowel; therefore, jejunal administration is not expected to reduce
bioavailability.(1)
Stability: Use within 15 minutes of dispersing tablet in water. (187)
Intrajejunal: Prevacid FasTabs delayed-release capsules (Takeda)

Preparation: Use AHS compounded liquid. (6,177, 187)
Administration: Lansoprazole is absorbed in the small bowel; therefore, jejunal administration is not expected to reduce
bioavailability.(1)
Drug on NIOSH List:

ledipasvir/sofosbuvir Use an Enteral Closed System:
Oral: Harvoni tablet (Gilead Sciences)

Preparation: Harvoni tablets are not enteric-coated and do not possess a sustained-release mechanism. The tablets can be
disintegrated in water, juice, or milk with minor stirring and pressure with a spoon. However, the stability of Harvoni tablets in
these liquids is unknown at this time. Futhermore, there are no studies evaluating the pharmacokinetic parameters of the
disintegrated or crushed Harvoni tablet versus the whole tablet. Similarly, splitting Harvoni tablets has not been studied. In
addition, a disintegrated or crushed Harvoni tablet may have an unpleasant taste. (172)

leflunomide Use an Enteral Closed System: No
Oral: Arava tablet (Aventis Pharma Inc)

Preparation: Tablets disperse if shaken in 10 mL of water for 5 minutes to form a cloudy dispersion.(1) Treat as a hazardous
Intragastric: Arava tablet (Aventis Pharma Inc)

Preparation: Tablets disperse if shaken in 10 mL of water for 5 minutes to form a cloudy dispersion that flushes via an 8Fr tube
without blockage.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Intrajejunal: Arava tablet (Aventis Pharma Inc)

Preparation: Tablets disperse if shaken in 10 mL of water for 5 minutes to form a cloudy dispersion.(1) Treat as a hazardous

letrozole Use an Enteral Closed System: Yes
Oral: Femara tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Treat as hazardous drug. Requires special handling to limit exposure to health risks.(2)
Drug on NIOSH List:

leucovorin Use an Enteral Closed System:
Oral: tablet
Preparation: To prepare an oral solution, add 5 mg tablets to an 8 ounce (approximately 240 mL) glass of water and let stand
for 5 minutes, then stir the solution with a spoon. (147,190) Tablets should readily go into solution. (147,190) When prepared
in this manner, the potency of the solution has been reported to be retained for up to 2 hours. (147) However, because the
brand of leucovorin tablet studied is no longer available, immediate administration of the solution is recommended.
Alternatively, the tablets may be crushed and mixed with a soft food such as applesauce or pudding. (190)
Stability: Use within 2 hours, but preferably immediately due to limited stability data (147,190)

levetiracetam Use an Enteral Closed System: No
Oral: Keppra tablet (UCB Pharma)

Preparation: Use AHS compounded liquid (6) OR regular release tablets disperse in 10 mL of water if shaken for 5 minutes.(1)
In one study, subjects received a single 500 mg dose of levetiracetam, either crushed & mixed with 4 oz applesauce (Motts) or
120 mL of a common ENF (Sustacal ® enteral nutrition formula). Concomitant crushing & mixing of levetiracetam tablets with
food or an ENF did not affect drug absorption significantly. The reduction in Cmax is similar to that seen when it is taken with
meals (20%).(70)
Intragastric: Keppra tablet (UCB Pharma)

Preparation: Use AHS compounded liquid (6) OR regular release tablets disperse in 10 mL of water if shaken for 5 minutes.
This forms a milky, even dispersion that flushes down an 8Fr NG tube without blockage.(1,69) In one study, subjects received a
single 500 mg dose of levetiracetam, either crushed & mixed with 4 oz applesauce (Motts) or 120 mL of a common ENF
(Sustacal ® enteral nutrition formula). Concomitant crushing & mixing of levetiracetam tablets with food or an ENF did not affect
drug absorption significantly. The reduction in Cmax is similar to that seen when it is taken with meals (20%).(70)
2.Flush the enteral feeding feeding tube with the recommended volume of water.
4.Draw 10 mL of water into the syringe & allow the tablet to dissolve, shaking if necessary.
6.Draw another 10 mL of wter into the syringe & also flush this via the feeding tube.
Intrajejunal: Keppra tablet (UCB Pharma)

Preparation: Use AHS compounded liquid (6) OR regular release tablets disperse in 10 mL of water if shaken for 5 minutes.
This forms a milky, even dispersion that flushes down an 8Fr NG tube without blockage.(1,69) In one study, subjects received a
single 500 mg dose of levetiracetam, either crushed & mixed with 4 oz applesauce (Motts) or 120 mL of a common ENF
(Sustacal ® enteral nutrition formula). Concomitant crushing & mixing of levetiracetam tablets with food or an ENF did not affect
drug absorption significantly. The reduction in Cmax is similar to that seen when it is taken with meals (20%).(70)
Administration: Same as intragastric administration. No specific data for jejunal use exists. The manufacturer's representative
from UCB Canada Inc., stated that as the drug is absorbed within 1 hour orally, it is thought to be absorbed in the stomach; but
the effectiveness of the drug via the jejunal route cannot be ruled out. It is up to the physician to make this choice & to monitor
levels to assess effectiveness.(1)
Rectal: Keppra tablet (UCB Pharma)

Administration: Tablets have been given rectally to manage neuropathic pain in 3 patients. Levetiracetam was adequately
absorbed after rectal administration.(19)
Parenteral:
Subcutaneous: Levetiracetam Injection injectable (Hospira)

Preparation: Dilute in 100 mL of normal saline (164, 165). Note that the concentration of the current injectable product
available via Health Canada's Special Access Programme (Hospira's levetiracetam 100 mg/mL injection) differs in concentration
from the concentration that has been administered in two case reports (500 mg/mL).
Administration: Administer over 30 minutes via a subcutaneous catheter (164, 165).

levodopa Use an Enteral Closed System: No
Oral: powder
Intragastric: powder

levodopa/benserazide HCl Use an Enteral Closed System: No
Oral: Prolopa capsule (Hoffmann-La Roche Limited)

Preparation: Do NOT open capsules as levodopa is readily oxidized & the accuracy of the dose cannot be guaranteed.(71)

levodopa/carbidopa Use an Enteral Closed System: No
Oral: Sinemet CR tablet (Bristol Laboratories of Canada)

Preparation: Do NOT crush or cut in half (tablet no longer scored).(1,2)
Oral: Sinemet tablet, compounded suppository (Merck Frosst Canada Ltd)

Preparation: Use AHS compounded liquid OR crush & mix with water, followed by adequate rinsing with water.(6) Formulation
has changed so brand-name tablets are NO longer scored for half-tablet dosing.(2)
Oral: Teva-Levocarbidopa tablet (Teva Canada Ltd.)

Preparation: Use AHS compounded liquid OR crush & mix with water, followed by adequate rinsing with water.(6) These
tablets are scored for half-tablet dosing.(2)
Intragastric: Sinemet tablet, compounded suppository (Merck Frosst Canada Ltd)

Intragastric: Teva-Levocarbidopa tablet (Teva Canada Ltd.)

Intrajejunal: Sinemet tablet (Merck Frosst Canada Ltd)

Administration: Bioavailability should be unaffected by jejunal delivery of levodopa; time to peak may be shorter.(1)
Intrajejunal: Teva-Levocarbidopa tablet (Teva Canada Ltd.)

Administration: Bioavailability should be unaffected by jejunal delivery of levodopa; time to peak may be shorter.(1)
Rectal: Sinemet rectal suspension (Merck Frosst Canada Ltd)

Preparation: Use AHS compounded rectal suspension (6) OR Crush & pulverize 10 tablets of 100/25 mg or 250/25 mg
levodopa-carbidopa. Mix fine powder with 10 mL of water/glycerol (glycerin) mixture (Mixed in portions of 50:50). Add 1 g citric
acid to lower pH to 2.3-2.4. The resulting strength is 1 tablet per mL of the final mixture (24 hour stability). Authors theorize lack
of efficacy may be due to rectum alkalinity or bacteria degradation of levodopa. Lower pH of suspension to 2.3-2.4 using 1 g
citric acid & store in the refrigerator.(72)
Rectal: Teva-Levocarbidopa tablet (Teva Canada Ltd.)

Preparation: Use AHS compounded liquid OR crush & mix with water, followed by adequate rinsing with water.(6) These
tablets are scored for half-tablet dosing.(2)
Administration: See Sinemet information.
Drug on NIOSH List:

levodopa/carbidopa/entacapone Use an Enteral Closed System:
Oral: Stalevo tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: A single article providing anecdotal, practice-based evidence suggests that tablets may be crushed and dispersed
in 15 mL of water immediately prior to administration for patients with difficulties swallowing intact tablets. (219)
Administration: Two institutional protocols available from NHS facilities in the United Kingdom suggest that crushed tablets
may be mixed with honey, jam, or orange juice immediately prior to administration in order to mask the bitter taste. (221,222)
However, references to support these statements are not available for verification, and an equal number institutional protocols
recommending that patients be changed to other preparations in the event that Stalevo tablets cannot be swallowed whole were
also located. (223-225)
Other info: Crushed tablets may stain the patient's saliva, lips, gums, tongue, and dentures. (220)
Stability: Use immediately due to stability concerns related to the levodopa and carbidopa components. (218)

levofloxacin Use an Enteral Closed System: No
Oral: Levaquin tablet (Janssen-Ortho Inc)

Preparation: Use AHS compounded liquid or crush, mix with water, flush with water.(6) Tablet crushing in an open device such
as a tablet crusher or pestle and mortar can result in a 15-25% reduction in the dose delivered.(1)
Intragastric: Levaquin tablet (Janssen-Ortho Inc)

Preparation: Use AHS compounded liquid or crush, mix with water, flush with water.(6) Hold feed for 2 hours prior to & post
administration of dose, due to interaction with cations in the feeds.(1)
3.Allow a 2 hour break if practical.
11.Wait for at least 2 hours before restarting the feed.(1)
Intrajejunal: Levaquin tablet (Janssen-Ortho Inc)

Preparation: Use AHS compounded liquid or crush, mix with water, flush with water.(6) Hold feed for 2 hours prior to & post
administration of dose, due to interaction with cations in the feeds.(1)
Administration: There are no specific data on jejunal administration of levofloxacin. Consider an alternative antibiotic.
Administer using the above method; use the higher end of the dose range. Monitor for increased side-effects or loss of efficacy.
(1)

levothyroxine Use an Enteral Closed System: Yes
Oral: Synthoid tablet (Abbott Laboratories Limited)

Preparation: Use AHS compounded liquid or crush tablet, mix with water, flush with water.(6)
Intragastric: Synthoid tablet (Abbott Laboratories Limited)

Other info: Co-administration of levothyroxine with enteral nutrition is known to decrease bioavailability, which may lead to
hypothyroidism. Withholding enteral nutrition has not been shown to improve bioavailability. A temporary increase in dose may
be required while the patient is receiving EN. Close monitoring of thyroid levels is recommended.(1)
Intrajejunal: Synthoid tablet (Abbott Laboratories Limited)

Administration: Same as intragastric administration. No specific data exists. Levothyroxine is absorbed from the duodenum,
jejunum, and ileum. Bypass of the duodenum may result in decreased absorption of levothyroxine, which may lead to
hypothyroidism. Close monitoring of thyroid levels is recommended.(1)
Other info: Co-administration of levothyroxine with enteral nutrition is known to decrease bioavailability, which may lead to
hypothyroidism. Withholding enteral nutrition has not been shown to improve bioavailability. A temporary increase in dose may
be required while the patient is receiving EN. Close monitoring of thyroid levels is recommended.(1)
Rectal: Synthoid compounded suppository (Abbott Laboratories Limited)

Preparation: When formulated as a suppository (at a dose 1.8 times higher than a tablet for oral use), it can be used to manage
patients with hypothyroidism. This was a small scale study with 6 patients.(73) No compounding recipe available.

linezolid Use an Enteral Closed System: No
Oral: Zyvoxam oral suspension (Pfizer Canada Inc)

Preparation: Use commercially available oral suspension or crush tablet & mix with water, followed with adequate rinsing with
water.(1)
Other info: Parenteral route is available; see parenteral entry.(1)
Intragastric: Zyvoxam oral suspension (Pfizer Canada Inc)

water.(1)
3.Shake & draw the medication suspension into the appropriate size and type of syringe
5. Finally, flush with the recommended volume of water
Intrajejunal: Zyvoxam oral suspension (Pfizer Canada Inc)

water.(1)
Administration: Absorption begins in the stomach although the majority of absorption takes place in the small intestine, so full
absorption may not occur if linezolid is delivered directly into the jejunum.(1)
Parenteral:
Drug on NIOSH List:

lisdexamfetamine dimesylate Use an Enteral Closed System:
Oral: Vyvanse capsule (Shire Pharma Canada ULC)

Preparation: Capsules may be opened and the entire contents emptied and mixed in a glass of water or orange juice, or mixed
with yogurt (for those patients who cannot swallow thin fluids). (2, 235, 242)
Administration: If the contents of the capsule include any compacted powder, a spoon may be used to break apart the powder
in the yogurt or liquid. (2) The contents should be mixed until completely dispersed. (2)The patient should consume the entire
mixture of yogurt or liquid immediately; it should not be stored. (2) The active ingredient dissolves completely once dispersed;
however, a film containing the inactive ingredients may remain in the glass or container once the mixture is consumed. (2) The
patient should not take anything less than one capsule per day and a single capsule should not be divided. (2)
Other info: The prolonged duration of action of Vyvanse is a result of lisdexamfetamine's properties as a prodrug, not due to
any extended-release properties of the formulation itself. (242)

lisinopril Use an Enteral Closed System: No
Oral: tablet
4. Draw the medication suspension into an appropriate size and type of syringe.
4. Draw 10 mL of water into the syringe and allow the tablet to disperse, shaking if necessary.
Rectal:

lithium Use an Enteral Closed System: No
Oral: PMS-Lithium Citrate oral syrup (Pharmascience Inc)

Preparation: Use commercially available lithium citrate syrup.(2) Each 5 mL of cherry-flavored syrup contains: lithium ion 8
mmoL (approximately equivalent to lithium carbonate 300 mg).(2) If commercial product is not available, use AHS compounded
liquid.(6)
Intragastric: PMS-Lithium Citrate oral syrup (Pharmascience Inc)

Preparation: Use commercially available lithium citrate syrup. If commercial product is not available, use AHS compounded
liquid.(6)
3.Draw the solution into the appropriate size and type of enteral syringe.
Intrajejunal: PMS-Lithium Citrate oral syrup (Pharmascience Inc)

Preparation: Use commercially available lithium citrate syrup. If commercial product is not available, use AHS compounded
liquid.(6)
Monitor for levels and adjust accordingly.(1)

loperamide Use an Enteral Closed System: No
Oral: Imodium tablet, oral solution, quick-dissolve tablet (McNeil Consumer Healthcare)
Preparation: Use commercially available oral solution, commercially-available quick-dissolve tablet, crush tablets and mix with
water prior to administration, or use AHS compounded liquid if no suitable alternatives are commercially available. (6, 235)
Note that the quick-dissolve tablets can be taken without fluid; it disintegrates within seconds on the surface of the tongue & is
then swallowed with the saliva.(246)
Intragastric:
Preparation: Use commercially-available liquid, AHS compounded liquid, or disperse quick-dissolve tablet in 10 - 20 mL of
water within the barrel of an enteral syringe. (1, 6, 235) Alternatively, it should be possible to crush plain loperamide tablets
and suspend the powder with water, or disperse the tablets in 10 - 20 mL of water, for administration via enteral feeding tubes.
(1, 235) Monitor patients closely for therapeutic efficacy and emergence of adverse effects. (1)
Administration:
If administering the oral liquid or crushing loperamide tablet:
3. Draw the medication solution into an appropriate size and type of syringe.
6. Restart the feed.
If dispersing quick-dissolve tablet or plain loperamide tablet within an enteral syringe:

3. Remove the plunger and place the tablet into an enteral syringe. Replace the plunger.
gently if required.
6. Draw an additional 10 mL of water into the enteral syringe and administer via the enteral feeding tube to ensure the entire
dose is administered to the patient.
Other info: A prolonged break in feeding is not required. (1, 235)
Stability: Administer dose immediately after preparation. (1, 235)
Intrajejunal:
Preparation: Use commercially-available liquid, AHS compounded liquid, or disperse quick-dissolve tablet within the barrel of
an enteral syringe for administration. (1, 235)
Administration: Administer as per "Intragastric" instructions. However, owing to the potential osmotic effects of the liquid
preparation, further dilution of the compounded or commercially-available liquid is required to ensure tolerability. (1) It may be
possible to avoid concerns related to hyperosmolality by administering the dispersed, quick-dissolve tablet. (192, 196, 247)
Stability: Administer dose immediately after preparation. (1, 235)

lopinavir/ritonavir Use an Enteral Closed System: No
Oral: Kaletra film-coated tablet, oral solution (Abbvie)

Preparation: Commercially available oral solution.(2) Do NOT crush/split/break tablets.(4)
Intragastric: Kaletra film-coated tablet, oral solution (Abbvie)

Administration: There is a case series surrounding the use of a G-tube for the administration of lopinavir/ritonavir in 9 children.
(67) In addition, there is a case report for administering lopinavir/ritonavir to a non-adherent, critically ill patient via a PEG tube.
(74)
Intrajejunal: Kaletra film-coated tablet, oral solution (Abbvie)

Administration: There is a case report with 1 patient on administering lopinavir/ritonavir through a J-tube.(75)

loratadine Use an Enteral Closed System: No
Oral: Claritin rapid-dissolve tongue tablet, oral syrup (Schering Canada Inc)
Preparation: Use commercially available oral syrup or place rapid-dissolve tongue tablet in the mouth (no water needed).(2)
Intragastric: Claritin oral syrup (Schering Canada Inc)

3.Draw the medication solution into an appropriate size & type of syringe.
Intrajejunal: Claritin oral syrup (Schering Canada Inc)

Administration: Same as intragastric administration. No specific data exists. If administering as above, further dilute the liquid
with an equal volume of water immediately prior to administration to reduce osmolarity. Monitor for increased side-effects or
loss of efficacy.(1)

lorazepam Use an Enteral Closed System: No
Oral: tablet
Administration: Same as intragastric administration. Studies in which lorazepam was administered via this route (n = 43) had
effective outcomes.(1)
Rectal: tablet, parenteral solution

Administration: Complete but prolonged absorption using the parenteral solution or tablets; a viable option for restlessness &
anxiety instead of IV lorazepam.(8)
Parenteral:

losartan potassium Use an Enteral Closed System: No
Oral: Cozaar tablet (Merck Frosst Canada Ltd)

Preparation: Use AHS compounded liquid (6) OR crush tablet, mix with 10 mL water to form a fine suspension.(1)
Intragastric: Cozaar tablet (Merck Frosst Canada Ltd)

Preparation: Use AHS compounded liquid (6) OR crush tablet, mix with 10 mL water to form a fine suspension that flushes
down an 8Fr NG tube without blockage, flush with water.(1)
Intrajejunal: Cozaar tablet (Merck Frosst Canada Ltd)

Preparation: Use AHS compounded liquid (6) OR crush tablet, mix with 10 mL water to form a fine suspension.(1)

lurasidone Use an Enteral Closed System: No
Oral: Latuda tablet (Sunovion)

Preparation: The manufacturer has no data for efficacy or stability of the tablets when split and therefore it can NOT be
recommended.(76)

magnesium glucoheptonate Use an Enteral Closed System: No
Oral: Rougier Magnesium oral liquid (Rougier Pharma)

Intragastric: Rougier Magnesium oral liquid (Rougier Pharma)


maraviroc Use an Enteral Closed System: No
Oral: Celsentri film-coated immediate release tablet (ViiV Healthcare)

Preparation: No data available for crushing/chewing tablet.(4)

mebendazole Use an Enteral Closed System: No
Oral: Vermox tablet (Janssen-Ortho Inc)

Preparation: No specific data on this product available.(1)

medroxyPROGESTERrone Use an Enteral Closed System: No
Oral: Provera tablet (Pfizer Canada Inc)

Preparation: The 5 mg & 100 mg tablets (only strengths tested) disperse in 10 mL of water within 5 minutes.(1) Treat as a
Intragastric: Provera tablet, compounded suppository (Pfizer Canada Inc)

Intrajejunal: Provera tablet, compounded suppository (Pfizer Canada Inc)


Administration: Pharmacokinetic study. Rectal absorption is slow and low; may have been due to suppository base.(8)

megestrol acetate Use an Enteral Closed System: Yes
Oral: Megace OS tablet, oral suspension (Bristol Laboratories of Canada)

Preparation: Commercially available solution available.(2) Tablets disintegrate rapidly when placed in 10 mL of water to give a
fine dispersion.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Stability: Disperse the tablets in water immediately prior to administration.(1)
Intragastric: Megace OS tablet (Bristol Laboratories of Canada)

Preparation: Tablets disintegrate rapidly when placed in 10 mL of water to give a fine dispersion that settles quickly but flushes
via an 8Fr NG tube without blockage.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite
medications.
Intrajejunal: Megace OS tablet (Bristol Laboratories of Canada)

Preparation: Tablets disintegrate rapidly when placed in 10 mL of water to give a fine dispersion that settles quickly.(1) Treat
as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.
asp) for additional information on the safe handling of this and other hazardous medications.

melatonin Use an Enteral Closed System: No



Monitor for loss of efficacy.(1)

meloxicam Use an Enteral Closed System: No
Intragastric: Mobicox tablet (Boehringer Ingelheim Canada Ltd)

Administration: Consider therapy alternative.(1)
Intrajejunal: Mobicox tablet (Boehringer Ingelheim Canada Ltd)

Administration: Consider therapy alternative.(1)
Rectal: Mobicox tablet (Boehringer Ingelheim Canada Ltd)

Preparation: Suppositories are commercially available in other countries. No compounding recipe available.

memantine HCL Use an Enteral Closed System: No
Oral: Ebixa tablet (Lundbeck Canada Inc)

Preparation: No specific data on enteral tube administration are available for this formulation.(1)

meperidine Use an Enteral Closed System: No
Parenteral:

mercaptopurine Use an Enteral Closed System: Yes
Oral: tablet
Administration: Administer using the intragastric administration method.(1)

mesna Use an Enteral Closed System: No
Oral: Uromitexan injectable prepared for oral use (Baxter Corporation)

Intragastric: Uromitexan injectable prepared for oral use (Baxter Corporation)

3.Draw up the appropriate dose of injection into the appropriate size and type of enteral syringe.
Intrajejunal: Uromitexan injectable prepared for oral use (Baxter Corporation)

Administration: No data available. Use parenteral therapy.(1)

metformin Use an Enteral Closed System: No
Oral: Glucophage tablet (Merck Frosst Canada Ltd)

Preparation: Tablets are film coated but can be crushed if required. Tablets do not disperse well in water owing to the size of
the tablet, but do crush easily and disperse well in water.(1)
Oral: Glumetza extended-release tablet (Valeat)

Preparation: Do NOT crush/chew. Immediate release tablets available.(2)
Intragastric: Glucophage tablet (Merck Frosst Canada Ltd)

the tablet, but do crush easily and disperse well in water to form a fine suspension that flushes easily via an 8Fr NG tube.(1)
4.Add a few millilitres of water and mix to form a paste.
6.Draw this into an appropriate size and type of syringe.
water into the syringe and also flush this via the feeding tube (this will rinse the mortar and syringe and ensure the total dose is
administered).
9.Finally, flush the enteral feeding tube with the recommended volume of water.
10.Re-start the feed immediately.(1)
Intrajejunal: Glucophage tablet (Merck Frosst Canada Ltd)

the tablet, but do crush easily and disperse well in water to form a fine suspension.(1)
Administration: Same as intragastric administration. Metformin is absorbed throughout the small intestine, with most
absorption occuring in the duodenum. Therefore, jejunal administration may result in decreased bioavailability. Monitor for loss
of efficacy.(1)

methadone Use an Enteral Closed System: No
Oral: Metadol tablet, oral solution (Paladin Laboratories Inc)

Preparation: Do NOT crush/chew/dissolve Metadol tablets as it can result in rapid release and absorption of a potentially fatal
dose.(2)
Use commercially available oral solution.(2)
Intragastric: Methadose oral solution concentrate (Mallinckrodt Canada Inc)

Preparation: Use commercially available oral concentrate.(2)
3.Draw medication solution into the appropriate size and type of enteral syringe.
Intrajejunal: Methadose oral solution concentrate (Mallinckrodt Canada Inc)

Preparation: Use commercially available oral concentrate.(2)
Monitor for increased side effects or loss of efficacy. Theoretically there should not be an effect on absorption.(1)

Preparation: Conversion of oral methadone to rectal methadone is 1:1.(78) Rectal administration results in rapid absorption,
higher bioavailability, and a longer duration of action.(79,19) Rectal suppositories are available through the Central Production
Pharmacy within the Calgary Zone.(80)
Buccal: Methadose oral solution (Mallinckrodt Canada Inc)

Preparation: Use commercially available oral solution.(2) An alternative to sublingual administration in palliative patients
previously stabilized on methadone.(153)
Administration: Patients may be administered up to 1.5 mL of a 10 mg/mL methadone solution in each buccal space three
times daily. After administration, the buccal space was gently massaged to enhance absorption in one Canadian case series.
The goal was to have a dwell time of 2 minutes. A 1:1 dosing ratio for converting oral:buccal was used, thus when a patient
required more than 9 mL of methadone a day, the dosing frequency was increased to four times a day.(153)
Parenteral:
Sublingual: sublingual solution

Preparation: Use AHS compounded liquid.(6) **AHS compounded liquid is for SL use and is reserved for use in Adult Palliative
Care Service ONLY**

methimazole Use an Enteral Closed System: No
Oral: tablet

Preparation: Compounding recipe available from Nabil et al.(81) Treat as a hazardous drug. Refer to the Hazardous
Administration: In a 1982 study, patients were given methimazole compounded rectal suppositories, not manufactured by
pharmacy. It might be feasible for patients to be given the tablet rectally and be monitored for clinical outcome.(81)

methotrexate Use an Enteral Closed System: Yes




methotrimeprazine Use an Enteral Closed System: No
Oral: Nozinan tablet, injection prepared for oral use (Link)

Preparation: 1.Tablets disperse within 2 minutes when placed in 10 mL of water to give a coarse dispersion; some of the larger
particles break up when drawn into the syringe.(1)
2.Injection can be administered orally if necessary.(1)
Intragastric: Nozinan tablet, injection prepared for oral use (Link)

particles break up when drawn into the syringe. The dispersion flushes via an 8Fr NG tube without blockage, although it is likely
to block finer tubes.(1)
Administration: Tablets:
4.Draw 10 mL of water into the syringe and allow the tablet to dissolve, shaking if necessary.
Intrajejunal: Nozinan tablet, injection prepared for oral use (Link)

particles break up when drawn into the syringe. The dispersion flushes via an 8Fr NG tube without blockage, although it is likely
to block finer tubes.(1)
Administration: Same as intragastic administration. No specific data exists, therefore monitor for increased side-effects or loss
of efficacy.(1)

methyldopa Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) OR crush & mix with water, followed by adequate rinsing with water.(1) Tablet
crushing in an open device such as a tablet crusher or pestle and mortar can result in a 10-30% reduction in the dose delivered.
(1)
(1)
6.Draw this into an appropriate syringe.
(1)
Administration: Jejunal administration is unlikely to affect bioavailability.(1)

methylene blue Use an Enteral Closed System: No
Oral: powder
Parenteral:

methylphenidate extended release Use an Enteral Closed System: No
Oral: Concerta extended release tablet (Janssen-Ortho Inc)

Oral: Ritalin tablet (Novartis Pharmaceuticals Canada Inc)

Rectal: Ritalin (Novartis Pharmaceuticals Canada Inc)

Administration: Well absorbed orally & intramuscularly. Cannot recommend rectal administration.(8)

methylprednisolone Use an Enteral Closed System: No
Oral: Medrone tablet (Pharmacia)

Preparation: Tablets disperse in water.(1)
Intragastric: Medrone tablet (Pharmacia)

4.Draw 10 mL of water into the syringe and allow the tablet to dissolve, shaking if necessary.
Intrajejunal: Medrone tablet (Pharmacia)

of efficacy.(1)
Parenteral:

metoclopramide Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) or tablets can be crushed if liquid formulation is not available.(1)
Stability: Use immediately if crushing tablet.(1)
Preparation: Use AHS compounded liquid (6) or tablets can be crushed if liquid formulation is not available.(1)
3.Draw the medication suspension into the appropriate size and type of syringe
Stability: Use immediately if crushing tablet.(1)
Administration: No data available.(1)

Administration: Both the tablets and the liquid can be administered rectally. For the compounded suppository, a
pharmacokinetic study showed 70-100% IV levels achieved.(8)
Parenteral:

metolazone Use an Enteral Closed System: No
Oral: tablet
4. Draw 10 mL of water into the syringe & allow the tablet to disperse, shaking if necessary.

metoprolol Use an Enteral Closed System: No
Oral: regular release tablet

Preparation: Use AHS compounded liquid (6)OR crush & mix with water, followed by adequate rinsing with water.(1)
Other info: Parenteral product available.(2)
Intragastric: regular release tablet

Other info: Human and animal studies suggest no specific site of absorption in small and large intestine, therefore absorption
unlikely to be affected by intrajejunal vs. intragastric administration.(1)
Intrajejunal: regular release tablet

Preparation: Use AHS compounded liquid (6)OR crush & mix with water, followed by adequate rinsing with water.(1)
10.Re-start the feed.(1)
Other info: Human and animal studies suggest no specific site of absorption in small and large intestine, therefore absorption
unlikely to be affected by intrajejunal vs. intragastric administration.(1)
Rectal: regular release tablet

Administration: A very common rectal inquiry. Drop in heart rate, systolic & diastolic blood pressure seen after first
suppository. In practice, tablets are given rectally with no change in dose; mixed results. Variable based on patient position,
rectal cavity evacuation,etc. Must monitor patient.(8)

metronidazole Use an Enteral Closed System: Yes
Oral: Flagyl tablet (Aventis Pharma Inc)

Preparation: Use AHS compounded liquid (6) or crush tablet, mix with water, flush with water.(1)
Other info: For oral use, consider Metronidazole Benzoate preparation as it is tasteless.(1)
Oral: metronidazole benzoate powder

Other info: For oral use, consider Metronidazole Benzoate preparation as it is tasteless.(1)
Intragastric: Flagyl tablet (Aventis Pharma Inc)

Preparation: Use AHS compounded liquid (6) or crush tablet, mix with water, flush with water.(1)
3.Allow a 1-hour break before dose administration, if possible.
Intrajejunal: Flagyl tablet (Aventis Pharma Inc)

Rectal: Flagyl tablet (Aventis Pharma Inc)

Administration: Used prophylactically & to supplement parenteral metronidazole (see parenteral entry).(8)
Vaginal: Flagyl Cream, Nidagel tablet

Preparation: Vaginal cream and gel are commercially available.(2)
Parenteral:

mexiletine Use an Enteral Closed System: No
Oral: capsule
Preparation: Use AHS compounded liquid (6) OR open & mix contents with water, followed by adequate rinsing with water.(1)

midazolam Use an Enteral Closed System: No


3.Draw up the appropriate dose of oral liquid or injection into the appropriate size and type of enteral syringe. (If using the
injection, the solution should be drawn up using a filter straw).

Administration: No data available.(1)
Rectal:
Administration: Pharmacokinetic & clinical studies. Higher doses (0.3 – 0.5 mg/kg) effective clinically. Absorption significantly
less than diazepam and lorazepam (form unspecified).(8)
Intranasal: nasal atomizer with syringe

Administration: Intranasal midazolam is commonly used for treating breakthrough seizures in infants and children (82,84). It is
also used in procedural sedation (85, 267). Intranasal midazolam is also listed by the American Epilepsy Society as a
reasonable first-line option for the prehospital treatment of convulsive status epilepticus, along with rectal diazepam and buccal
midazolam, due to the difficulties in administering IM or IV benzodiazepines in non-medical environments; the data is
extrapolated to adults from available pediatric studies and intranasal midazolam use may not be suitable for larger patients (see
"Miscellaneous Information" below) (266). Practice guidelines and protocols are available from Insite (82, 84, 85, 266) and EMS
Medical Control Protocols (available from https://www.albertahealthservices.ca/info/Page3165.aspx).
Other info: Intranasal midazolam use is frequently associated with a burning sensation or bitter taste (264).
The absorptive capacity of the nasal mucosa is limited; the volume of medication administered per nostril should be no more
than 1 mL in adults (ideally, no more than 0.5 mL) in order to avoid loss of the drug to the nasopharynx with subsequent
deactivation (264, 269). Based on this information, a maximum possible single dose of 10 mg (1 mL of the 5 mg/mL injection
per nostril) may be delivered in one dose; the intranasal route may therefore not be suitable for larger patients requiring single
weight-based doses close to or in excess of 10 mg (264, 269). Splitting the dose, regardless of total administration volume,
between nostrils is recommended in order to maximize drug absorption (264, 269)
administration (264); refer to the product information for the specific device being used.

minoxidil Use an Enteral Closed System: No
Oral: Loniten tablet (Pharmacia)

Preparation: Tablets can be crushed & mixed with water.(1)
Intragastric: Loniten tablet (Pharmacia)

Intrajejunal: Loniten tablet (Pharmacia)


mirtazapine Use an Enteral Closed System: No
Oral: Remeron, Remeron RD tablet, orally disintegrating tablets (Organon Canada Ltd)
Preparation: Do NOT chew film-coated tablet as coating on tablet masks the bitter taste. Ingredients can cause numbness of
trachea & impede swallowing.(86) Mirtazapine orally disintegrating tablets are unique tablets that are designed to rapidly
disintegrate on the tongue. No water is needed to take these tablets.(2)
Intragastric: Remeron, Remeron RD tablet (Organon Canada Ltd)

Preparation: Crush film-coated tablet & mix with water for feeding tube use. Do NOT chew film-coated tablet as coating on
tablet masks the bitter taste. Ingredients can cause numbness of trachea & impede swallowing.(86)
Intrajejunal: Remeron, Remeron RD tablet (Organon Canada Ltd)

Preparation: Crush film-coated tablet & mix with water for feeding tube use. Do NOT chew film-coated tablet as coating on
tablet masks the bitter taste. Ingredients can cause numbness of trachea & impede swallowing.(86)

misoprostol Use an Enteral Closed System: Yes
Oral: Cytotec tablet (Pharmcia)

Preparation: Hazardous and unstable if crushed. Use an alternative route or therapeutic alternative, if available.(1) Treat as a
Intragastric: Cytotec tablet (Pharmcia)

Preparation: No data currently available. Hazardous and unstable if crushed. (1) Use an alternative route or therapeutic
alternative, if available.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Intrajejunal: Cytotec tablet (Pharmcia)

Preparation: No data currently available. Hazardous and unstable if crushed. (1) Use an alternative route or therapeutic
alternative, if available.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Rectal: Cytotec tablet (Pharmcia)

Preparation: Hazardous and unstable if crushed. (1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling
Administration: Misoprostol commonly studied, but oxytocin favoured due to more favorable side effects and lower costs.
Authors suggest rectal misoprostol not as effective as vaginal.(8)
Vaginal: Cytotec tablet (Pharmcia)

Preparation: Hazardous and unstable if crushed.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling
Administration: Vaginal use of misoprostol include: labour induction(87,88) and medical termination.(89,90)

mobendazole Use an Enteral Closed System: No
Oral: Vermox tablet (Janssen-Ortho Inc)

Preparation: Tablets may be crushed as per product monograph.(2)

moclobemide Use an Enteral Closed System: No
Oral: Manerix tablet (Roche)

Preparation: Tablets disperse in water if shaken for 5 minutes.(1)
Intragastric: Manerix tablet (Roche)

8.Re-start the feed, unless a prolonged break is required.(1(
Stability: Disperse the tablets in water immediately prior to administration..(1)
Intrajejunal: Manerix tablet (Roche)


modafinil Use an Enteral Closed System: No
Oral: Alertec tablet (Shire Biochem Inc)

Intragastric: Alertec tablet (Shire Biochem Inc)

Intrajejunal: Alertec tablet (Shire Biochem Inc)

Rectal: Alertec tablet (Shire Biochem Inc)

Administration: Manufacturer has no contraindications to rectal use of the tablets, but there is no supporting literature or
research. Patients must be followed clinically.(91)

montelukast Use an Enteral Closed System: No
Oral: Singulair tablet, chewable tablets (Merck Canada)

Preparation: Tablets should disperse if shaken in 10 mL of water for 3 minutes.(1)
Chewable tablets are commercially available.(2)
Oral: Singulair oral granules (Merck Frosst Canada Ltd)

Preparation: SINGULAIR oral granules can be administered either directly in the mouth, or mixed with a
spoonful of cold or room temperature soft food (e.g., applesauce). The packet should not be
opened until ready to use. SINGULAIR oral granules are NOT intended to be
dissolved in liquid for administration. However, liquids may be taken subsequent to
administration.(2)
Stability: Must be administered within 15 minutes after opening packet.(2)
Intragastric: Singulair tablet (Merck Frosst Canada Ltd)

Preparation: Tablets should disperse if shaken in 10 mL of water for 3 minutes to give a fine cloudy dispersion that flushes via
8.Restart the feed, unless a prolonged break is required.
Note: Alternatively, at step 3 place the tablet into a medicine pot, add 10 mL of water and allow the tablet to dissolve. Draw this
into an appropriate syringe. Ensure that the measure is rinsed and that this rinsing water Is administered also to ensure that the
total dose is given.(1)
Intrajejunal: Singulair tablet (Merck Canada)

Preparation: Tablets should disperse if shaken in 10 mL of water for 3 minutes to give a fine cloudy dispersion.(1)
Administration: Same as intragastic administration. No specific data exists, therefore monitor for increased side-effects or loss
of efficacy.(1)

morphine sulfate Use an Enteral Closed System: No
Oral: M-Eslon extended release capsule (Aventis Pharma Inc)

Preparation: The capsules may be opened, and the microgranules (beads) given mixed with soft food or liquid. (2) Do NOT
crush the microgranules (beads). (2)
Updated: 2018-May-4
Oral: MS Contin sustained release tablet (Purdue Pharma)

Preparation: Do NOT crush, break, chew, or dissolve tablets. (1,2)
Updated: 2018-May-4
Oral: Statex Syrup oral liquid (Paladin Labs)

Preparation: Use commercially available product. (1) Note: the commercially available, alcohol-free morphine 1 mg/mL and 5
mg/mL syrup products (Statex brand) are on long-term backorder with an indeterminate release date. (209) The alternative
product, Doloral, contains 4.8% ethanol and may not be appropriate for certain patient populations, including neonates, patients
experiencing or at risk of CNS depression, and patients also receiving medications that interact with alcohol. (209) Available
supplies of Statex morphine syrup should be conserved for neonates. (209). If the alcohol-free suspension is unavailable,
consideration could be given to crushing the immediate-release morphine tablets immediately prior to administration. (209).
Updated: 2018-May-4
Intragastric: oral liquid

consideration could be given to crushing the immediate-release morphine tablets and suspending the crushed tablet(s) in sterile
water immediately prior to administration, or to diluting the alcohol-containing product with sterile water for morphine doses less
than 1.25 mg. (209, 210).
Administration: Immediate-release morphine:
Updated: 2018-May-8
Intragastric: M-Eslon Extended Release Capsules (Ethypharm Inc)

Preparation: M-Eslon capsules may be opened to allow administration of the microgranules via gastric tube or gastrostomy
tube (2). Note that difficult administration and/or tube clogging may occur if administration is attempted via a tube with a
diameter of <4.66 mm (170).
Administration: One small study describes the following administration procedure (170); this procedure is NOT appropriate for
tubes with an external diameter of <4.66 mm (or at least 12 Charriere French gauge):
1) Flush tubes with a dead volume and a lateral outlet with 5 mL of water prior to proceeding.
2) Place contents of capsule into the tube cup while the tube clamp is closed.
3) Attach tube-friendly syringe to tube cup, open tube clamp, and flush tube at least twice with an appropriate volume of water
(2 x 20 mL in this study; follow recommendations for the type of tube in situ).
4) If quantity of granules to be administered is large, this procedure may need to be repeated multiple times.
Notes:
- Do NOT mix the granules with water prior to administration.
- The tube must be flushed well, within the confines of the patient's daily fluid volume tolerance, as any granules left in the tube
may degrade (1). Subsequent flushes may cause these semi-decayed granules to be delivered to the patient, resulting in
delivery of an unintended bolus dose of morphine (1).
Updated: 2018-May-1
Intrajejunal: oral liquid

consideration could be given to diluting the alcohol-containing product with sterile water. (209, 210).
Administration: Dilute the oral liquid with an equal volume of water immediately prior to administration, following the
intragastric method.(1)
Updated: 2018-May-4
Rectal: Statex suppository (Paladin Labs)

Preparation: Commercial suppositories are available at strengths of 5, 10, 20, or 30 mg.(2)
Buccal: oral rinse

Preparation: AHS compounding recipe available for morphine oral rinse.(6)
Parenteral:

moxifloxacin Use an Enteral Closed System: No
Oral: Avelox tablet (Bayer Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6,92)

mycophenolate mofetil Use an Enteral Closed System: Yes
Oral: CellCept tablet, capsule, oral suspension (Roche)

Preparation: Use AHS compounded liquid (100 mg/mL sugar-free) (6) OR commercially available 200 mg/mL oral suspension.
Do NOT open capsules or crush tablets.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on
Intragastric: CellCept oral suspension (Roche)

Intrajejunal: CellCept tablet, capsule, oral suspension (Roche)

(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.
Administration: Administer using the intragastric administration method. Although not quantified, it is expected that a
substantial proportion of the dose would be absorbed following jejunal administation.(1)
Parenteral:
Drug on NIOSH List:

nabilone Use an Enteral Closed System:
Oral: Cesamet capsule (Valeant Canada)

Preparation: Use AHS compounded liquid. (6)
Stability: Use within 30 days. (6)

nadolol Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) OR disperse tablet by shaking for 5 minutes in 10 mL of water, followed by
adequate rinsing with water.(1)
Rectal:
Administration: Low oral bioavailability. Cannot recommend rectal administration.(8)
Drug on NIOSH List:

naloxegol Use an Enteral Closed System:
Oral: Movantik Tablet (Knight Therapeutics Inc.)

Preparation: For patients who are unable to swallow the tablet whole, the MOVANTIK tablet can be crushed to a powder and
mixed in half of a glass of room temperature, non-carbonated water (120 mL) and drunk immediately (2). The glass should then
be rinsed with a further half glass of room temperature, non-carbonated water (120 mL) and the contents drunk (2).
Intragastric: Movantik Tablet (Knight Therapeutics Inc.)

Preparation: Movantik tablets can be crushed to a powder and administered via nasogastric tube at least 8 French in diameter
(2, 262).
Administration: When administered via nasogastric tube, a total water volume of 240 mL should be used (2). The following
steps are recommended by the drug manufacturer (2, 262):
1. Flush the nasogastric tube with 30 mL of water using a 60 mL enteral syringe.
2. Crush the tablet to a fine powder in an appropriate container and mix with approximately 60 mL of water.
3. Draw up the mixture using the 60 mL enteral syringe and administer the syringe contents through the nasogastric tube.
4. Add approximately 60 mL of water to the same container used to prepare the dose of Movantik. Draw up the water using the
same syringe and use all the water to flush the nasogastric tube and any remaining medicine from the nasogastric tube into the
stomach.
5. Flush the nasogastric tube with an additional 120 mL of water to ensure complete delivery of the ordered dose.
Other info: Naloxegol oxalate should be taken on an empty stomach at least 1 hour before feeds or two hours after feeds; in
clinical trials, administration of naloxegol with meals resulted in a substantial increase in oral bioavailability and is therefore not
recommended (2).
A prospective, open-label, randomized, 4-way crossover study conducted in 43 healthy adult volunteers found that Cmax and
AUC values were within the 80 - 125% bioequivalence limit when the oral tablet was crushed, mixed with water, and
administered via nasogastric tube (comparator was oral administration of the intact oral tablet) (261).
Drug on NIOSH List:

naloxone Use an Enteral Closed System:
Oral: Solution for Injection

Preparation: The injectable formulation of naloxone may be administered by mouth for the treatment of constipation and fecal
impaction associated with opioids. DO NOT ADMINISTER NALOXONE INJECTION ORALLY FOR THE MANAGEMENT OF
OPIOID OVERDOSE due to extensive inactivation via first-pass metabolism (239).
Administration: Care Beyond Cure, 4th Edition, provides the following practice tips (186):
- Monitor patients for sensitivity to the drug's effects; if the effects appear proportional to the dose and duration of treatment,
establish a drug regimen using the lowest possible dose; moderately high doses (2 - 4 mg tid) may give rise to antagonism of
the underlying analgesia.
- Begin with a low dose, e.g.1 mg PO bid (dosage variation: 2 to 18 mg/day)
- Increase dosage gradually and monitor closely.
- Adjust other laxatives accordingly.
- Monitor for symptoms of opioid withdrawal: regional withdrawal may occur, with significant diarrhea being the main sign of
withdrawal, and systemic withdrawal may occur with increased doses (because of absorption and crossing of the central
nervous system barrier).
- Address any opioid withdrawal symptoms: administer an opioid rescue dose (such that the rescue dose competes for
receptors), and re-evaluate the dose of naloxone or the therapeutic choice.
Intranasal: Narcan Nasal Spray Nasal spray (Adapt Pharma Canada Ltd.)
Preparation: Use the commercially-available product. If the commercially-available nasal spray is unavailable, naloxone can
be administered intranasally using the injectable solution via syringe with attached nasal mucosal atomizer device (154,155).
However, due to concerns highlighted in the "Miscellaneous Information" section below, the appropriateness of intranasal
administration of the 1 mg/mL injectable solution via nasal musocal atomizer device should be considered carefully given the
availability of other routes of administration; consultation with PADIS is recommended.
Administration: Note: Narcan Nasal Spray contains a SINGLE DOSE per device (2). Do NOT prime or test the device. For
complete dosing instructions for the commercially-available product, refer to the product monograph.
For patient-specific advice on the use of this product, please contact the Poison & Drug Information Service (PADIS) at 1-800
-332-1414.
Other info: Intranasal administration of naloxone results in a slower onset of effect and lower bioavailability compared to IV or
IM (154, 239, 264).
The effectiveness of the commercially-available product has not been assessed in patients with abnormal nasal anatomy, nasal
symptoms (i.e. blocked and/or runny nose, nasal polyps, epistaxis etc.) or in people who have sprayed something into the nose
prior to naloxone administration (e.g. topical vasocontrictors such as decongestants, cocaine) (2). Prior use of systemic
phenylephrine may also alter blood flow to the nasal mucosa, and, therefore, intranasal drug absorption (264). An evaluation of
the patient's nasal passages should be undertaken before administering intranasal naloxone; if conditions that may alter
naloxone absorption across the nasal mucosa are identified, it may be prudent to administer naloxone by the IM or IV routes
instead (2, 239).
The absorptive capacity of the nasal mucosa is limited; the volume of medication administered per nostril should be no more
than 1 mL in adults (ideally, no more than 0.5 mL) in order to avoid loss of the drug to the nasopharynx with subsequent
deactivation (264). The 0.4 mg/mL injectable naloxone solution should not be used for intranasal administration via syringe with
nasal mucosal atomizer device (268); note that the total dose that can be administered is limited by volume to 2 mg (i.e. 1 mg of
the 1 mg/mL solution per nostril). The commercially-available nasal spray delivers doses of 2 mg or 4 mg in a total volume of
0.1 mL, minimizing loss of the dose to the nasopharynx and allowing for administration of larger single doses of naloxone (2).
Due to the limitations associated with available naloxone injection formulations in Canada, administration of naloxone injection
solution via syringe with attached nasal atomizer device should be undertaken only if the commercially-available product is
unavailable and other routes of administration are not available; involvement of PADIS is recommended.
administration (264); refer to the product information for the specific device being used. Proper assembly of the nasal mucosal
atomizer device is also required for effective administration of the injectable naloxone solution; use of the commercially-
available naloxone nasal spray avoids medication errors related to errors assembling the nasal mucosal atomizer device (268).
Parenteral:

naltrexone Use an Enteral Closed System: No
Oral: tablet

naproxen Use an Enteral Closed System: No
Oral: Naprosyn oral suspension, tablet (Hoffmann-La Roche Limited)

Preparation: Use commercially available liquid, if not available then use AHS compounded liquid.(6)
Do NOT crush enteric-coated tablets.(2)
Intragastric: Naprosyn oral suspension, tablet (Hoffmann-La Roche Limited)

Intrajejunal: Naprosyn oral suspension, tablet (Hoffmann-La Roche Limited)

Administration: Jejunal administration is not expected to affect bioavailability as enteric coated tablets are available.
Administer using the intragastric method.(1)
Rectal: PMS-Naproxen suppositoy (Pharmascience Inc)

Preparation: Use commercially available product.(2) Efficacy has not been established although bioavailability ~80%.(8)

naproxen/esomeprazole Use an Enteral Closed System: No
Oral: Vimovo modified-release tablet (AstraZeneca Canada Inc)

Preparation: Don NOT crush/chew/split.(2)

naratriptan Use an Enteral Closed System: No
Oral: tablet
Preparation: Contact Drug Information to obtain published compounding recipe (93) OR use alternative product.

nelfinavir Use an Enteral Closed System: No
Oral: Viracept tablet, oral powder (Roche)

Preparation: Use commercially available oral powder or tablets can be crushed & mixed with water.(1)
Administration: The oral powder may be mixed with a small amount of water, milk, formula, soy formula, soy milk or nutritional
preparations; once mixed, the entire contents must be consumed in order to obtain the full dose. The recommended use period
for storage of the product in these media is 6 hours under refrigeration (2-8°C). Dosing media not recommended include any
acidic food or juice (e.g. orange juice, apple juice or apple sauce) because the combination may result in a bitter taste. The oral
powder should not be reconstituted with water in its original container.(2)
Intragastric: Viracept tablet, oral powder (Roche)

Intrajejunal: Viracept tablet, oral powder (Roche)


neostigmine Use an Enteral Closed System: No
Oral: tablet
Preparation: Neostigmine is very soluble in water. Tablets will disperse within 1 minute in 10mL of water if shaken in the barrel
of a syringe.(1)
of a syringe. The fine dispersion flushes easily via a feeding tube without risk of blockage.(1)
of a syringe. The fine dispersion flushes easily via a feeding tube without risk of blockage.(1)
Administration: There are no specific data available on jejunal administration. If clinically indicated, administer using the
intragastric method and monitor closely for clinical effect and signs of toxicity.(1)

nevirapine Use an Enteral Closed System: No
Oral: Viramune tablet (Boehringer Ingelheim Canada Ltd)

Preparation: Use 10 mg/mL commercial liquid (available through Health Canada's Special Access Programme) OR crush 200
mg (immediate-release) tablet & mix with water, followed by adequate rinsing with water.(94) Treat as a hazardous drug. Refer
to the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information
on the safe handling of this and other hazardous medications.
Intragastric: Viramune tablet (Boehringer Ingelheim Canada Ltd)

Intrajejunal: Viramune tablet (Boehringer Ingelheim Canada Ltd)

Administration: There are no specific data available on jejunal administration. Contact the appropriate HIV Clinic prior to
administration via this route. Administer using the intragastric method. Plasma concentration monitoring may be available.

niacin (nicotinic acid) Use an Enteral Closed System: No
Oral: Niaspan extended release tablet (Sunovion Pharmaceuticals)


nicotine Use an Enteral Closed System: No
Oral: Nicorette lozenge

Preparation: Integrity of lozenge compromised by chewing or crushing. Consider alternatives: patches, gum, and inhalers.(2)

NIFEdipine Use an Enteral Closed System: No
Oral: Adalat XL extended release tablet (Bayer Inc)

Oral: capsule
Preparation: Use the instructions in the AHS Compounding Manual for removal of the liquid from the capsule.(6) Note the
significant differences in AUC and Cmax.
Stability: Use immediately as the medication is very light sensitive.(2)
Intragastric: Adalat XL extended release tablet (Bayer Inc)

Administration: NOT suitable for enteral tube administration.(1)
Intrajejunal: Adalat XL extended release tablet (Bayer Inc)

Administration: NOT suitable for enteral tube administration.(1)
Administration: The exact site of absorption in the small intestine is unknown. Complete absorption following administration via
a jejunostomy tube cannot be guaranteed & clinical response, such as control of blood pressure, must be carefully monitored.
(1)
Rectal: Adalat XL extended release tablet (Bayer Inc)

Administration: Insert intact XL tablet rectally.(95) Nifedipine kinetics & dynamics during rectal infusion to steady state with an
osmotic system resulted in blood pressure lowering effect without concurrent reflex tachycardia.(8)
Rectal: capsule
Administration: Contents of a 10 mg pierced capsule administered rectally, showed good absorption in comparison to oral
administration in 10 healthy subjects or patients. The peak concentration (52.4 nanograms/mL at 1 hour) is lower, but the
concentration at 8 hours is higher than that following oral administration.(96)
Stability: Use immediately as the medication is very light sensitive.(2)

nimodipine Use an Enteral Closed System: No
Oral: Nimotop tablet (Bayer HealthCare)

Preparation: It is not recommended by Bayer to crush the tablets as the coprecipitate structure of the tablets, which guarantees
the proven bioavailibility, is reduced. The absolute bioavailability due to the first pass effect is 10-15%. If the tablets are crushed
& added to water, nimodipine will recrystallize and the bioavailability is reduced further.(97)

nitrazepam Use an Enteral Closed System: No
Oral: tablet

nitrofurantoin Use an Enteral Closed System: No
Oral: MacroBID capsule (Procter Gamble Pharmaceuticals Canada, Inc)

Preparation: Do NOT open/crush capsule, NOT for NG.(1,98)
Oral: tablet

nizatidine Use an Enteral Closed System: No
Oral: Axid capsule (Pendopharm)

Preparation: Use alternative product (AHS Provincial Formulary level 1 therapeutic interchange to raniditine).

norfloxacin Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) OR crush & mix with water, followed by adequate rinsing with water.(1) (Hold
feed for 2 hours prior and post administration of dose, due to interaction with cations in the feeds.)

nystatin sugar-free Use an Enteral Closed System: No
Oral: powder

ofloxacin Use an Enteral Closed System: No
Oral: tablet
Preparation: Contact Drug Information to obtain published compounding recipe (99) OR use alternative product, as tablets do
not disperse well in water. If oral therapy with ofloxacin is indicated and compounded liquid is not available, crush & mix with
water, followed by adequate rinsing with water. Wait 2 hours before and after dose due to interaction with cations in the feeds.
(1)
(1)
3.Wait at least 2 hours
4.Place the tablet in a mortar & crush to a fine powder using the pestle.
5.Add a few mL of water & mix to form a paste.
6.Add up to 15 mL of water & mix thoroughly, ensuring that there are no large particles of tablet.
11.Wait at least 2 hours before re-starting the feed.(1)
(1)
Administration: There are no specific data available on jejunal administration. Consider alternative therapy. Administer using
the intragastric method; use the higher end of the dose range. Monitor for increased side effects of loss of efficacy.(1)
Otic: ophthalmic drops

Administration: Ofloxacin 0.3% ophthalmic drops have been administered in the ear for otitis externa and otitis media: 2-3
drops TID.(100)

olanzapine Use an Enteral Closed System: No
Oral: Zyprexa Zydis disintegrating tablet (Lilly)

Preparation: Stir into 125 mL (4 ounces) of water, milk, coffee, orange juice or apple juice & promptly consume or flush down
tube, then flush with water.(101)
Oral: Zyprexa tablet (Lilly)

Intragastric: Zyprexa Zydis disintegrating tablet (Lilly)

ensure that the total dose is administered.
Intrajejunal: Zyprexa Zydis disintegrating tablet (Lilly)

Preparation: Stir into 125 mL (4 ounces) of water, milk, coffee, orange juice or apple juice & promptly consume or flush down
tube, then flush with water.(101)
Intrajejunal: Zyprexa tablet (Lilly)

Rectal:
Administration: Well absorbed orally. Extensive first pass metabolism. Cannot recommend rectal administration.(8)

olmesartan Use an Enteral Closed System: No
Oral: Olmetec tablet (Merck Frosst Canada Ltd)

Preparation: Film coated tablets should NOT be chewed.(1)
Intragastric: Olmetec tablet (Merck Frosst Canada Ltd)

Administration: No specific data on enteral tube administration are available. Consider changing to an alternative angiotensin
II receptor antagonists.(1)
Intrajejunal: Olmetec tablet (Merck Frosst Canada Ltd)

Administration: No specific data on enteral tube administration are available. Consider changing to an alternative angiotensin
II receptor antagonists.(1)

olsalazine sodium Use an Enteral Closed System: Yes
Oral: Dipentum tablet (Celltech)

Preparation: Tablets will disperse in 10 mL of water if shaken for at least 8 minutes. The dispersion is bright orange and will
stain.(1) Tablet dispersed in water may stain porous surfaces.(1)
Intragastric: Dipentum tablet (Celltech)

stain, but flushes down 8Fr NG tube without blockage.(1)
Intrajejunal: Dipentum tablet (Celltech)

stain.(1)

omeprazole Use an Enteral Closed System: No
Oral: capsule, tablet

Administration: Capsule: Oral Administration (when a fraction of a formulation is required):
1.Open one capsule and weigh the contents.
2.Determine how many pellets are required for the recommended dose.
3.Repack the pellets into gelatin capsules. Protect capsules from moisture. Suggest relabeling the original bottle or using glass
or high-density polyethylene container a tight closure and a desiccant.
4.Immediately prior to administration, mix the intact pellets with an acidic beverage(pH>5.3) such as orange juice, cranberry
juice or yogurt. An acidic beverage will help preserve the integrity of the pellet coat.
5.Instruct the patient not to chew the granules in the vehicle.
6.Recommended shelf-life of the repacked omeprazole is 7 days, since there is no data on its stability.(1)
Intragastric: compounded liquid

Preparation: Use AHS compounded liquid, or change to esomeprazole MUPS tablets (which are licensed for enteral tube
administration), depending on patient and enteral tube characteristics.(1, 177)
Intrajejunal: compounded liquid

Administration: Administer using the intragastric method. Omeprazole is absorbed when administered into the jejunum with no
reduction in bioavailability.(1)

Administration: Using compounded suppository in a pharmacokinetic study, absorption was immediate & substantial in 10
male subjects. Rate & extent of absorption comparable to oral capsule. First-pass metabolism is presumably avoided through
rectal administration.(8)

ondansetron Use an Enteral Closed System: No
Oral: tablet
Other info: Due to its lipophilic nature and high permeability coefficient, ondansetron is likely absorbed throughout the intestine.
(1)
Preparation: Use AHS compounded liquid (6) OR crush & mix with water, followed by adequate rinsing with water. A
commercial oral solution is available.
Other info: Due to its lipophilic nature and high permeability coefficient, ondansetron is likely absorbed throughout the intestine.
(1)

Preparation: Ondansetron suppository recipe is available from IJPC.(102)
Administration: Absorption of compounded suppository takes up to 3 hours, so it must be retained for at least 3-4 hours.(19)
Parenteral:

orlistat Use an Enteral Closed System: No
Oral: Xenical capsule (Roche)

Preparation: Not appropriate for use in patients on enteral feed.(1)

orphenadrine Use an Enteral Closed System: No
Oral: Norflex extended release tablet (3M Pharmaceuticals)

Other info: Note that an injection is available.(2)
Commercial oral solution has been used for enteral feeding tube administration. However, the product is NOT marketed in
Canada.

oseltamivir Use an Enteral Closed System: No
Oral: Tamiflu oral suspension, capsule (Roche)

Preparation: Commercially available suspension (2) OR, if not available, use AHS compounded liquid.(6)
Intragastric: Tamiflu capsule (Roche)

3.Empty the contents of the capsule into a medicine pot.
4.Add 5 mL of water and stir to mix thoroughly.
5.Draw the dispersion into an appropriate enteral syringe taking care to draw up all particles.
6.Add another 5 mL of water to the medicine pot, stir and draw into the syringe. This will ensure no residual dose remains in the
pot.
8.Flush this via the feeding tube.
Intrajejunal: Tamiflu capsule (Roche)

Administration: There are no specific data available on jejunal administration. Seek specialist advice and consider therapeutic
alternative.(1)

oxazepam Use an Enteral Closed System: No
Oral: tablet
Preparation: Tablet can be crushed & dispersed in water.(1)

oxcarbazepine Use an Enteral Closed System: No
Oral: Trileptal oral suspension, tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Use commercially available oral suspension.(2) Treat as a hazardous drug. Refer to the Hazardous Medication
Intragastric: Trileptal oral suspension (Novartis Pharmaceuticals Canada Inc)

Preparation: Can be mixed with water immediately before administration.(1) Treat as a hazardous drug. Refer to the
4.Draw the required dose into an appropriate size and type of syringe.
5.Dilute with recommended amount of water.
6.Flush the medication down the feeding tube.
7.Draw another 10 mL of water into the syringe and also flush this via feeding tube (this will rinse the syrine and ensure total
dose is administered).
9.Restart the feed immediately.(1)
Intrajejunal: Trileptal oral suspension (Novartis Pharmaceuticals Canada Inc)

Preparation: Can be mixed with water immediately before administration.(1) Treat as a hazardous drug. Refer to the
of efficacy.(1)

oxybutynin Use an Enteral Closed System: No
Oral: Ditropan XL extended release tablet (Janssen-Ortho Inc)

Intragastric: oral syrup

Intrajejunal: tablet, oral syrup


Administration: A 5mg fatty base suppository has been used to relieve detrusor muscle instability. Benefits are likely from local
effects rather than systemic absorption.(22)
Topical: gel, patch

Preparation: Topical route of administration available: (1) Gelnique-topical gel, (2) Oxytrol- transdermal patch available.(2)

oxycodone Use an Enteral Closed System: No
Oral: Oxy-IR tablet (Purdue Pharma)

Oral: Oxycontin controlled release tablet (Purdue Pharma)

Preparation: Do NOT crush, not for NG tube.(1)
Intrajejunal: Oxy-IR tablet (Purdue Pharma)

Administration: There are no specific data available on jejunal administration. Monitor for increased side-effects or loss of
efficacy.(1)
Other info: Human studies have suggested that oxycodone is likely absorbed from the small intestine.(1)
Rectal: Supeudol suppository (Sandoz Canada)

Preparation: Commercially available suppository.(2)
Administration: Not a controlled release formulation therefore has to be given several times a day.(8)

paliperidone Use an Enteral Closed System: No
Oral: Invega extended release tablet (Janssen-Ortho Inc)

Preparation: Do NOT divide/crush/chew tablet; swallow whole.(2) Treat as a hazardous drug. Refer to the Hazardous
Other info: Injection also available.(2)

pancrelipase Use an Enteral Closed System:
Oral: Cotazym capsule (Organon Canada Ltd)

Preparation: Do NOT crush. Open capsule, mix with water, flush with water.(1) For Creon, do not mix capsule contents with
alkaline products, such as milk.(1)
Intragastric: Cotazym capsule (Organon Canada Ltd)

Preparation: Do NOT crush. Open capsule, mix with water, flush with water.(1)
3.Open the capsule & pour the contents into a medicine pot.
Intrajejunal: Cotazym capsule (Organon Canada Ltd)

Preparation: Do NOT crush. Open capsule, mix with water, flush with water.(1)

pantoprazole Use an Enteral Closed System: No
Oral: Pantoloc tablet (Solvay Pharma Inc)

Intragastric:
Preparation: Not appropriate for enteral administration. Alternatives include esomeprazole MUPS, AHS omeprazole
compounded suspension, or AHS lansoprazole compounded suspension, depending on patient characteristics and enteral tube
size. (177) Parenteral pantoprazole may also be an option.
Parenteral:

paromomycin Use an Enteral Closed System: No
Oral: capsule
Preparation: No data currently available. Oral liquid may be available from compounding pharmacies.

paroxetine Use an Enteral Closed System: No
Oral: Paxil tablet (Glaxosmithkline Inc)

Preparation: Crush tablet, mix with water, flush with water.(103) As per manufacturer, the tablet has a very bitter taste.(103)
Oral: Paxil CR controlled release tablet (Glaxosmithkline Inc)

Preparation: Do NOT crush.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.
Intrajejunal: Paxil tablet (Glaxosmithkline Inc)

Rectal:
Administration: Well absorbed orally. Cannot recommend rectal administration.(8)

penicillamine Use an Enteral Closed System: No
Oral: Cuprimine capsule (Acton)

Preparation: Use AHS compounded liquid (6) OR open capsule & mix contents with water, followed by adequate rinsing with
water.
Drug on NIOSH List:

penicillin V potassium Use an Enteral Closed System:
Oral: Pen-VK tablet (AA Pharma)

Preparation: Commercially-available suspension has been on backorder since 2010; see AHS Backorder Database for
availability updates (webappsint.albertahealthservices.ca/pharmacy/BACKORDERS/default.aspx). Consideration could be
given to providing therapy with parenteral penicillin G sodium, or to using an oral alternative, such as amoxicillin oral
suspension, if therapeutically appropriate.
Intragastric: Pen-VK tablet (AA Pharma)

Preparation: Penicillin V is not well-suited to intragastric administration as the bioavailability has been reported to drop 30 -
80% when exposted to enteral nutrition solutions. (195) As a result, enteral nutrition should be held one to two hours prior to
drug administration, and one to two hours post administration, resulting in unacceptable interruptions in continuous enteral
feeds with likely nutritional compromise when the drug is administered on a q6h schedule. (1, 195) In addition, the
commercially-available suspension has been on backorder since 2010; see AHS Backorder Database for availability updates
(webappsint.albertahealthservices.ca/pharmacy/BACKORDERS/default.aspx). Consideration could be given to providing
therapy with parenteral penicillin G sodium, or to using an oral alternative, such as amoxicillin oral suspension, if therapeutically
appropriate.

pentoxifylline Use an Enteral Closed System: No
Oral: Trental sustained release tablet (Aventis Pharma Inc)

Intragastric: Trental sustained release tablet (Aventis Pharma Inc)

Administration: Avoid administration of pentoxifylline via feeding tube due to a significant increase in side effects.(1)
Intrajejunal: Trental sustained release tablet (Aventis Pharma Inc)

Administration: Avoid administration of pentoxifylline via feeding tube due to a significant increase in side effects.(1)

perindopril erbumine Use an Enteral Closed System: No
Oral: Coversyl tablet (Servier Canada Inc)

Preparation: Tablets can be crushed or dispersed in 10 mL water within 2-5 minutes.(1)
Administration: Food decreases bioavailability of the active drug. Space dosing at least 30 minutes before, and 1-2 hours after
food. If patient is on continuous feeding, consider switching to alternative ACEI that is unaffected by food.(1)
Intragastric: Coversyl tablet (Servier Canada Inc)

3.Wait for 1-2 hours before administering the dose.
9.Allow at least 1 hour before restarting feed.(1)
Intrajejunal: Coversyl tablet (Servier Canada Inc)


perphenazine Use an Enteral Closed System: No
Oral: powder

phenelzine Use an Enteral Closed System: No
Oral: Nardil tablet (Erfa Canada Inc)

Preparation: No specific data available.(1)
Intragastric: Nardil tablet (Erfa Canada Inc)

Intrajejunal: Nardil tablet (Erfa Canada Inc)


pHENobarbital Use an Enteral Closed System: No
Oral: PMS-Phenobarbital elixir oral elixir (Pharmascience Inc)

Preparation: Use the commercially available product,(2) followed by adequate rinsing with water OR use AHS compounded
suspension, which is alcohol-free.(6) **Note the different strengths for commercial (5mg/mL) vs compounded (10mg/mL).
Intragastric: PMS-Phenobarbital elixir oral elixir (Pharmascience Inc)

3.Draw the medication elixir into an appropriate size and type of syringe.
Intrajejunal: PMS-Phenobarbital elixir oral elixir (Pharmascience Inc)

Preparation: Use the commercially available product, followed by adequate rinsing with water OR use AHS compounded
Rectal: PMS-Phenobarbital elixir (Pharmascience Inc)

Administration: Anecdoctal evidence exists; use a syringe & administer about 15 cm into the rectum.(8)
Intramuscular:
Administration: One author reports that the total daily dose of phenobarbital may be administered as a single daily IM injection
(168). For palliative patients previously stabilized on a different anticonvulsant now switching to phenobarbital due to loss of the
oral route, a double dose may be given on the first day of therapy to serve as a loading dose (168). However, phenobarbital
injection causes tissue irritation (169).
Other info: Bioavailability with intramuscular administration is 100% (19). Sedating (168).
Parenteral:

phenoxybenzamine Use an Enteral Closed System: No
Oral: capsule
Preparation: Use AHS compounded liquid (6) OR open & mix contents with water, followed by adequate rinsing with water.
Administration: Capsules are NOT suitable for enteral tube administration.(1)
Administration: Capsules are NOT suitable for enteral tube administration.(1)

phenylalanine Use an Enteral Closed System: No
Oral: powder

phenylbutyrate Use an Enteral Closed System: Yes
Oral: powder

phenyTOIN Use an Enteral Closed System: No
Oral: Dilantin extended capsule (Pfizer Canada Inc)

Preparation: Open capsules, prepare as 'slurry'.(1) Commercially available oral suspension.(2) AHS compounded liquid is also
available.(6) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http://insite.
Intragastric: Dilantin extended capsule (Pfizer Canada Inc)

Preparation: Open capsules, prepare as 'slurry'. Monitor levels. Hold feeds at least 2 hours before & 2 hours after
administration.(1) Commercially available oral suspension.(2) AHS compounded liquid and parenteral forms are also available.
NOTE: The suspension could be used as an alternative to the capsules but must be given in 2 or 3 divided doses per day which
results in significant disruptions to patient feeding schedules due to the requirement to hold feeds for 2 hours pre and post dose.
Monitor levels and monitor for therapeutic efficacy and toxicity.

3.Allow a 2-hour break without feed.
5.Measure the required volume of suspension and mix with an equal volume of water (this may be a large volume) in a suitable
container.
6.Draw the medication suspension into an appropriate size and type of syringe (may need to dose in portions owing to the large
volume)
7. Add another 10-15mL of water to the container to rinse, ensuring any remaining suspension is rinsed from the container.
8.Draw this into the syringe an flush this via the feeding tube (ensuring the total dose is administered).
10.Do NOT restart feed for at least 2 hours.(1)
Intrajejunal: Dilantin Oral suspension (Pfizer Canada Inc)

Administration: Administration of this medication via alternative routes (such as parenteral administration), or the use of
therapeutic alternatives, is strongly recommended as phenytoin appears to be absorbed exceptionally poorly, if at all, via the
jejunal route. (1, 194, 205, 206) Potential explanations for poor bioavailability of phenytoin when administered via the jejunal
route include (1, 192, 195, 205 - 208):
1) Reduced availability of drug in solution at the site of absorption. Phenytoin appears to be best absorbed in the proximal small
bowel, is poorly soluble in aqueous solution, appears to have concentration-dependent absorption, and requires an extended
period of time for peak absorption to occur. Drug delivery beyond the site of maximal drug absorption, reduced time for
disaggregation and dissolution of the drug, and decreases in gastrointestinal transit times would all be expected to have a
significant effect of bioavailability.
2) Adsorption to the enteral feeding tubes (jejunal tubes are longer than gastric tubes), resulting in increased drug binding to the
enteral tube and reduced drug delivery to the small intestine.
3) Drug binding to components of enteral feeding solutions, particularly protein and calcium salts
Note: the contents of the phenytoin capsules are likely to clog jejunal enteral tubes.
Rectal:
Administration: Rectal administration is unreliable & is NOT recommended. Consider alternative antiepileptic.(8,156)
Parenteral:

phosphates Use an Enteral Closed System: No
Oral: effervescent tablet

Preparation: Use AHS compounded liquid (6) OR tablets will dissolve in 20 mL of water.(1) Phosphate is primarily absorbed in
the duodenum and jejunum. Avoid administration with calcium or aluminum as may result in decreased absorption of
phosphate.(1)
Intragastric: effervescent tablet

Preparation: Use AHS compounded liquid (6) OR tablets will dissolve in 20 mL of water and flush via a 6Fr NG tube with little
resistance.(1) Phosphate is primarily absorbed in the duodenum and jejunum. Avoid administration with calcium or aluminum as
may result in decreased absorption of phosphate.(1)
3.Measure an appropriate volume of water (20-50 mL) into a measuring pot. .
4.Add the effervescent tablet(s) and allow to dissolve.
7.Rinse the measure and administer this also to ensure that the total dose is given.
Intrajejunal: effervescent tablet

Preparation: Use AHS compounded liquid (6) OR tablets will dissolve in 20 mL of water and flush.(1) Phosphate is primarily
absorbed in the duodenum and jejunum. Avoid administration with calcium or aluminum as may result in decreased absorption
of phosphate.(1)
Administration: Administer effervescent tablets using the above method. Monitor for increased gastrointestinal side-effects.(1)

phytonadione (Vitamin K1) Use an Enteral Closed System: No

Parenteral:

pilocarpine Use an Enteral Closed System: No
Oral: Salagen tablet (Pfizer Canada Inc)

Preparation: Crush & mix with water, flush with water.(56)
Sublingual: ophthalmic drops

Administration: Pilocarpine 4% ophthalmic drops are used sublingually (1-4 drops QID) to manage xerostomia.(14,104)

pimozide Use an Enteral Closed System: No
Oral: Pimozide tablet (AA Pharma)

Preparation: No stability data about crushing/splitting tablets. As per the manufacturer, the tablets do not possess a special
coating nor do they have a special release formulation.(105) Foreign centres have dispersed tablets in greater than 2 minutes.
(106)

pinaverium Use an Enteral Closed System: No
Oral: Dicetel tablet (BGP Pharma)

Preparation: Do NOT crush/chew as tablet is film-coated.(2)

piroxicam Use an Enteral Closed System: No
Oral:
Preparation: No data available.
Rectal: PMS-Piroxicam suppository (Pharmascience Inc)

Preparation: Suppositories are commercially available at strengths of 10 mg and 20 mg.(2)

pizotifen Use an Enteral Closed System: No
Oral: Sandomigran tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: No data available.
Intragastric: Sandomigran tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Commercial liquid preparation has been used for enteral feeding tube, but product is NOT marketed in Canada.(2)
Administration: No specific data on enteral tube administration are available for this preparation.(1)
Intrajejunal: Sandomigran tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Commercial liquid preparation has been used for enteral feeding tube, but product is NOT marketed in Canada.(2)

polyethylene glycol (PEG) Use an Enteral Closed System: No
Oral: oral powder

Preparation: The usual dose is 17 g (about 1 heaping tablespoon or one single-dose sachet) of PEG powder per day (or as
directed by physician) to be stirred in a cup (250 mL) of water, juice, soda, coffee, or tea until completely dissolved.(2)
NOT suitable for fluid-restricted patients due to the large volume necessary to administer the dose.(1)
Intragastric: oral powder

Preparation: NOT suitable for fluid-restricted patients due to the large volume necessary to administer the dose.(1)
3.Measure the appropriate quantity of water into a suitable size container.
4.Add the contents of the sachet and allow to dissolve.
5.Draw into an appropriate size and type of syringe; owing to the large volume this will be several syringe volumes.
6.Flush medication dose down the feeding tube.
Intrajejunal: oral powder

Preparation: NOT suitable for fluid-restricted patients due to the large volume necessary to administer the dose.(1)
Administration: Mechanism of action is local within the bowel thus jejunal administration should not affect efficacy. Administer
using the intragastric method.(1)

polysaccharide-iron complex (PIC) Use an Enteral Closed System: No
Oral: FeraMAX capsule (BioSyent Inc)

Preparation: Manufacturer states that the capsule shell may be removed carefully over the sink and mixed with water or food.
(107)
Intragastric: FeraMAX capsule (BioSyent Inc)

Administration: Manufacturer states that the capsule shell may be removed carefully over the sink and mixed with water or
food to be used via G-tube.(107)

posaconazole Use an Enteral Closed System: No
Oral: Noxafil oral suspension (Schering Canada Inc)

Preparation: Commercially available oral suspension.(2)
Intragastric: Noxafil oral suspension (Schering Canada Inc)

Preparation: Tablets are NOT suitable for enteral tube administration.(2) Use commercially available oral suspension.(1)
4.Draw the required dose into an appropriate size and type of syringe.
5.Flush the medication down the feeding tube.
7.Restart the feed immediately.(1)
Intrajejunal: Noxafil oral suspension (Schering Canada Inc)

Preparation: Tablets are NOT suitable for enteral tube administration.(1) Use commercially available oral suspension.(2)
Administration: No specific data exists. As acid-suppresive therapy may reduce absorption, it is possible that jeujunal
administration of posaconazole may be ineffective.(1)

potassium chloride Use an Enteral Closed System: No
Oral: Euro Brand sustained release tablet (Euro Brand)

Preparation: Do NOT crush. Use liquid. Tablet does not disperse like K-Dur which is no longer manufactured.(2)
Oral: K-10 liquid (Glaxosmithkline Inc)

Oral: Apo-K sustained release tablet (Apotex)

Oral: Slow-K slow release tablet (Novartis Pharmaceuticals Canada Inc)

Intragastric: K-10 liquid (Glaxosmithkline Inc)

3.Measure the required volume of potassium liquid & mix with 50-100 mL of water. 4. Draw into an appropriate size & type of
syringe.
Intrajejunal: K-10 liquid (Glaxosmithkline Inc)

Administration: Administer using the intragastric administration method. Monitor for increased gastrointestinal side effects.(1)

potassium citrate Use an Enteral Closed System: No
Oral: powder

potassium iodide Use an Enteral Closed System: No
Oral: powder

potassium perchlorate Use an Enteral Closed System: No
Oral: powder

prasugrel Use an Enteral Closed System: No
Oral: Effient tablet (Eli Lilly Canada Inc)

Preparation: The tablet is not scored and should not be broken or divided for dosing purposes. Exposure of the split tablet to
moisture may affect stability.(108)
May crush tablet and mix in food or liquid such as applesauce, juice, or water; ADMINISTER IMMEDIATELY.(151)
Intragastric: Effient tablet (Eli Lilly Canada Inc)

Preparation: If necessary the tablet may be crushed and mixed with liquids, so that it can be administered using a feeding tube.
(151)

pravastatin Use an Enteral Closed System: No
Oral: Pravachol tablet (Squibb Canada)

Preparation: Use AHS compounded liquid (6) OR tablet will disperse in water if shaken in 10 mL of water for 5 minutes.(1)
Intragastric: Pravachol tablet (Squibb Canada)

Intrajejunal: Pravachol tablet (Squibb Canada)


praziquantel Use an Enteral Closed System: No
Oral: Biltricide tablet (Bayer Inc)

Preparation: Do NOT crush. When broken, each of the four tablet segments contains 150 mg of the active ingredient so that
the dosage can be easily adjusted to the patient's body weight. Segments are broken off by pressing the score (notch) with
thumbnails. If one quarter of a tablet is required, this is best achieved by breaking the segment from the outer end.(2)

prazosin Use an Enteral Closed System: No
Oral: tablet
Administration: There are no specific data available on jejunal administration. Administer using the intragastric method and
monitor blood pressure closely.(1)

prednisoLONE Use an Enteral Closed System: No
Oral: Pediapred oral solution (Sanofi-Synthelabo Canada Inc)

Preparation: Commercially available product.(2)
Rectal: Pediapred (Sanofi-Synthelabo Canada Inc)

Administration: Suppositories and enemas are available for treatment of local disease only. There may be some systemic
effect, but it is NOT predictable enough for use as an alternative route.(1)

predniSONE Use an Enteral Closed System: No
Oral: tablet
Intrajejunal:
Administration: Studies have suggested that the site of prednisone absorption is in the upper jejunum where the pH is close to
6.(109)

pregabalin Use an Enteral Closed System: No
Oral: Lyrica capsule (Pfizer Canada Inc)

Preparation: Open capsule, mix with water, flush with water. The capsule contents pour easily from the capsule and disperse in
water to give a fine dispersion.(1)
Intragastric: Lyrica capsule (Pfizer Canada Inc)

water to give a fine dispersion which flushes via an 8Fr NG tube without blockage.(1)
Intrajejunal: Lyrica capsule (Pfizer Canada Inc)

water to give a fine dispersion.(1)
Rectal: Lyrica capsule (Pfizer Canada Inc)

Administration: Rectal use not recommended by manufacturer.(110)

primaquine phosphate Use an Enteral Closed System: No
Oral: tablet

primidone Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) OR disperse tablet in 10 mL of water.(1)

procainamide Use an Enteral Closed System: No
Oral: Procan SR tablet (Erfa Canada Inc)

Preparation: Do NOT crush or chew tablets as it is a sustained- release formulation.(2)
Parenteral:

prochlorperazine Use an Enteral Closed System: No
Oral: Prochlorperazine tablet (AA Pharma)

Preparation: Crush tablet, mix with water, flush with water. Manufacturer indicated that the film-coat is simply a coat for the
tablet.(111)
Intragastric: Apo-Prochlorazine tablet (Apotex)

tablet.(111)
Administration: Same as intrajejunal.(1)
Intrajejunal: Apo-Prochlorazine tablet (Apotex)

tablet.(111)
Rectal: suppository
Preparation: Suppositories are commercially available.(2)

progesterone Use an Enteral Closed System: No
Rectal: Prometrium capsule, compounded suppository (Merck Frosst Canada Ltd)

Administration: Both male and female subjects used in study. Despite rise in drug levels, no clinical effect noted.(8)
Vaginal: Prometrium capsule (Merck Frosst Canada Ltd)

Preparation: Vaginal products that are commercially available: (1) vaginal gel-Crinone Gel, (2) effervescent vaginal tablets-
Endometrin.(2)
Administration: Prometrium capsules have been used vaginally for luteal phase support and as an alternative treatment option
for early postmenopausal patients.(112, 113,114,115) Advise patients to wear pantiliners since a discharge that looks like a
yeast infection or coffee grounds may occur after a few days of use.(68)

promethazine Use an Enteral Closed System: No
Oral: tablet, oral syrup

Other info: If the commercially available oral syrup is unsuitable, consideration could be given to parenteral administration of
the medication, as an injectable form is also available.(2)
Intragastric: oral syrup

Intrajejunal: oral syrup

Rectal: rectal solution

Preparation: Promethazine rectal solution recipe available from IJPC.(116)
Administration: Rectal bioavailability varies among individuals: 4%-343%. It is effective in postoperative nausea and vomiting.
(22)

propafenone Use an Enteral Closed System: No


propranolol Use an Enteral Closed System: No
Oral: Inderal-LA extended release capsule (Wyeth Canada)

Preparation: Do NOT crush/chew. Capsules may be opened and contents spread over soft food and swallowed whole.(2)
Oral: tablet
Stability: Use immediately after crushing tablet
Other info: Animal data suggests propranolol may be absorbed throughout the intestine, but primarily in the colon. Therefore,
jejunal administration is unlikely to adversely affect absorption compared to intragastric administration.(1)
Other info: Animal data suggests propranolol may be absorbed throughout the intestine, but primarily in the colon. Therefore,
jejunal administration is unlikely to adversely affect absorption compared to intragastric administration.(1)
Rectal:
Preparation: No compounding recipe.
Administration: Rectal administration (form unknown) may partially avoid first-pass effects.(8)
Parenteral:

propylthiouracil Use an Enteral Closed System: No
Oral: Propylthyracil tablet (Paladin Laboratories Inc)

Preparation: Use AHS compounded liquid OR disperse tablet in water within the barrel of an enteral syringe. (6, 235)
Stability: Use immediately (crushed tablets)
Rectal: enema (using crushed tablets)

Preparation: A rectal suspension has been prepared by grinding up the tablets in a mortar and pestle and suspending the
powder in 90 mL of sterile water (up to 8 of the 50 mg tablets have been used); the suspension is then administered via a
disposable urinary catheter into the rectum. (117) However, due to the hazardous nature of this medication, it may be
preferable from an occupational exposure perspective to disperse the tablets within the barrel of an enteral syringe immediately
prior to rectal administration (tablets should disperse within a few minutes). (235) Use appropriate personal protective
equipment when handling the tablets. (235) Due to the lack of stability information for propylthiouracil tablets when dispersed
in water, preparation of the rectal suspension immediately prior to administration is recommended.
Case reports involving the use of rectal suspensions prepared by suspending crushed propylthiouracil tablets in Fleet mineral oil
or Fleet phosphosoda enemas also exist; preparation of propylthiouracil suppositories has also been reported. (117, 277-279)
However, preparation of enemas using Fleet mineral oil or phosphosoda enema solutions as the base would likely involve
increased healthcare worker exposure to crushed tablets compared to administering tablets dispersed in water. A literature
search failed to identify compounding recipes for propylthiouracil suppositories, and one small study in 15 patients
demonstrated a significantly higher AUC and Cmax with crushed tablets administered as a rectal suspension in water compared
to propylthiouracil enemas. (117)
Stability: Use immediately.

pyrazinamide Use an Enteral Closed System: No
Oral: Rifater tablet (Aventis Pharma Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, & flush with water.(6) Do not use with rifampin or
vitamin C.
Intragastric: Rifater tablet (Aventis Pharma Inc)

vitamin C.
3.Draw the medication suspension into the appropriate size and type of syringe.
Intrajejunal: Rifater tablet (Aventis Pharma Inc)

vitamin C.
Administration: Tablet administration (crushing tablets should be considered a last resort):
4.Add a few millilitres of water and mix thoroughly, ensuring that there are no large particles of tablet.
5.Draw into the syringe and administer via the feeding tube.
7.Add another 15mL of water to the mortar and stir to ensure that any remaining drug is rinsed from the container. Draw this
water into the syringe and also flush this via the feeding tube (this will rinse the mortar and syringe and ensure that the total

pyridostigmine bromide Use an Enteral Closed System: No
Oral: Mestinon Immediate-release tablet (Bausch Health )

Preparation: Use AHS compounded liquid (6) OR crush & mix with water, followed with adequate rinsing with water.(118, 235)
If the patient cannot safely swallow thin liquids, the crushed tablet could be mixed with a spoonful of yogurt or apple sauce.
(235) Alternatively, tablets may be cut in half.(2) The use of gloves and glasses has been recommended if crushing the tablet
to avoid development of serious eye irritation or contact dermatitis. (235)
Other info: Patients developing new difficulty swallowing intact tablets should be carefully evaluated before the decision is
made to crush Mestinon tablets, as inability to swallow may indicate lack of product efficacy or be an early sign of
pyridostigmine toxicity. (2, 235)
Oral: Mestinon SR Sustained-release tablet (Bausch Health )

Preparation: Do NOT crush tablets. Tablets may be cut in half, but cannot be quartered or crushed without excessive disruption
of the sustained-release matrix.(2) Use the immediate-release tablets or the AHS compounded liquid for patients unable to
swallow intact or halved Mestinon SR tablets.(2,6,235)
Intragastric: Mestinon Immediate-release tablet (Bausch Health )

Preparation: Use AHS compounded liquid (6) OR crush & mix with 10 - 20 mL of water (intact tablets will not disperse well in
water), followed with adequate rinsing with water.(118, 235) The use of gloves and glasses has been recommended if crushing
the tablet to avoid development of serious eye irritation or contact dermatitis. (235)
3.Place the tablet in a crushing syringe and grind to a fine powder, or grind the tablet to a fine powder using a mortar and pestle.
4.Draw at least 10mL of water into the crushing syringe and shake to form a suspension, or add 10 mL of water to the powder in
the mortar and mix well before drawing suspension into an enteral syringe. If using a mortar to crush the tablet, rinse the mortar
twice with 10 to 20 mL of water and include this rinse water in the dose administered to the patient.
6. Draw another 10-20 mL of water into the syringe and also flush this via the feeding tube to rinse the syringe.
8.Re-start the feed, unless a prolonged break is required.(1, 235)
Intrajejunal: Mestinon Immediate-release tablet (Bausch Health )

Preparation: Use AHS compounded liquid (6) OR crush & mix with 10 - 20 mL of water (intact tablets will not disperse well in
water), followed with adequate rinsing with water.(118, 235) The use of gloves and glasses has been recommended if crushing
the tablet to avoid development of serious eye irritation or contact dermatitis. (235)
Administration: There appears to be no clinical data available on jejunal administration (1). The Australian product information
for Mestinon immediate-release tablets indicates that the major site of pyridostigmine absorption is the duodenum. (235, 274)
As a result, this product may not be suitable for jejunal administration. If not alternatives are available, administer using the
intragastric method, monitor patient closely for signs of clinical efficacy and/or emergence of adverse effects, and adjust the
dose and frequency as necessary.(1)

pyridoxine Use an Enteral Closed System: No
Oral: injectable prepared for oral use, tablet

Preparation: Use AHS compounded liquid (6) OR crush immediate-release tablet & mix with water, apple sauce or yogurt, OR
disperse immediate-release tablet in water immediately prior to administration. (235)
Stability: If crushing immediate-release tablet, use immediately.
Intragastric: injectable prepared for oral use, immediate-release tablet

Preparation: Review need for supplementation with the clinical dietician, as nutritionally complete enteral feeds will contain
some pyridoxine. (1) If supplementation is required, use AHS compounded liquid (due to osmolality, this option may not be
suitable for large doses) (6), or crush immediate-release tablet & mix with water (1), OR disperse the immediate-release tablet
in 10 - 20 mL of water within the barrel of an enteral syringe (235). For some indications (e.g. isoniazid toxicity), intragastric
administration should be considered ONLY IF parenteral pyridoxine is not available; seek guidance from PADIS (1-800-332
-1414).
Administration:
Option 1: crush immediate-release tablet and mix with water (1):

3. Place the tablet in a mortar and crush to a fine powder using the pestle.
4. Add a few millilitres of water and mix to form a paste.
5. Add up to 15 mL of water to the mortar and mix thoroughly ensuring that there are no large particles of tablet.
6. Draw this into an appropriate enteral syringe.
water into the syringe and also flush this via the feeding tube (this will rinse the mortar and syringe and ensure that the total
Option 2: disperse immediate-release tablet in the barrel of an enteral syringe (235):

3. Remove the plunger and place the immediate-release tablet into an enteral syringe. Replace the plunger.
gently if required. ***If the dispersion generated yields large drug particles despite shaking, consider reverting to administration
option 1, especially if the enteral tube is 12 French gauge or smaller, in order to generate smaller drug particles and minimize
the risk of blocking the enteral tube.*** (196, 207)
5. Give the dispersed tablet immediately into the enteral feeding tube.
6. Rinse the enteral syringe with a further 10 mL of water to ensure the entire dose is given.
7. If other medicines are given, flush the tube with an appropriate amount of water between each one.
8. After the final medicine is given, flush the tube with 30 mL of water.
Other info:
A prolonged break in enteral feeding is not required. (1, 235)
Extended-release pyridoxine tablets are not suitable for administration via enteral feeding tubes; ensure that immediate-release
tablets are used for this purpose. (235)
Several clinical reports involving the administration of crushed pyridoxine tablets for the management of pyridoxine-dependent
seizure disorders or management of isoniazid toxicity may be located in the medical literature. (236 - 238) Regarding the
management of isoniazid toxicity specifically, several standard toxicology references suggest that pyridoxine tablets may be
crushed and administered via the intragastric route in the event that injectable pyridoxine cannot be located in a timely manner.
(239, 240). However, due to the slower onset of action of enterally-administered pyridoxine compared to injectable pyridoxine,
urgent consultation with PADIS (1-800-332-1414) is recommended prior to substituting crushed tablets for injectable pyridoxine
in the management of isoniazid toxicity as additional therapeutic measures may be necessary to ensure patient safety. (241)

Intrajejunal: injectable prepared for oral use, immediate-release tablet

Preparation: Review need for supplementation with the clinical dietician, as nutritionally complete enteral feeds will contain
some pyridoxine. (1) If supplementation is required, use AHS compounded liquid (Note: due to osmolality, this option may not
be suitable if large doses of pyridoxine are required) (6). No data on the impact of crushing the immediate-release tablet &
mixing with water (1), OR dipersing the immediate-release tablet in 10 - 20 mL of water within the barrel of an enteral syringe for
administration (235) on drug absorption from the jejunum appears to be available; pyridoxine is absorbed mainly in the jejunum.
(235) Consultation with a specialist (i.e. PADIS, Neurology, etc.) regarding the most appropriate method of administration may
be required depending on the severity of the underlying condition and the availability of alternative therapies.
Administration: Administer using the intragastric administration methods. (1)
Parenteral:

pyrimethamine Use an Enteral Closed System: No
Oral: Daraprim tablet (Glaxosmithkline Inc)


quetiapine Use an Enteral Closed System: No
Oral: Seroquel tablet (AstraZeneca Canada Inc)

Preparation: Use AHS compounded liquid (6) OR crush & mix with water. Crushed tablets may be mixed with yogurt,
applesauce or mashed potato.(119)
Rectal: Seroquel (AstraZeneca Canada Inc)

Administration: In a study by Leung et al., quetiapine was administered as a moistened suppository with detectable serum
levels. However, the onset of action may be delayed depending on the base used to formulate the suppository.(157) Cannot
recommend rectal administration at this time.(8)

quinapril Use an Enteral Closed System: No
Oral: Accupril tablet (Pfizer Canada Inc)

Preparation: Accupril tablets contain magnesium carbonate. (197) When Accupril tablets are crushed and mixed with sterile
water, the carbonate raises the pH of the solution, causing the active drug to degrade rapidly into a poorly absorbed metabolite.
(193, 198) Consideration should be given to the administration of an alternative ACE inhibitor, if therapeutically appropriate.
Intragastric: Accupril Tablet (Pfizer Canada Inc)

Preparation: Intragastric administration of this product is not recommended. (1) Accupril tablets contain magnesium carbonate.
(197) When Accupril tablets are crushed and mixed with sterile water, the carbonate raises the pH of the solution, causing the
active drug to degrade rapidly into a poorly absorbed metabolite. (193, 198) Consideration should be given to the
administration of an alternative ACE inhibitor, if therapeutically appropriate.
Intrajejunal: Accupril Tablet (Pfizer Canada Inc)

Preparation: Intrajejunal administration of this product is not recommended. (1) Accupril tablets contain magnesium carbonate.
(197) When Accupril tablets are crushed and mixed with sterile water, the carbonate raises the pH of the solution, causing the
active drug to degrade rapidly into a poorly absorbed metabolite. (193, 198) Consideration should be given to the
administration of an alternative ACE inhibitor, if therapeutically appropriate.

rabeprazole Use an Enteral Closed System: No
Oral: Pariet enteric coated tablet (Janssen-Ortho Inc)

Other info: Due to lack of data, consider switching to another PPI.(1)

raloxifene Use an Enteral Closed System: No
Oral: Evista tablet (Eli Lilly Canada Inc)

Preparation: Unacceptable taste and teratogenic potential. Skin contact may enhance tumour production; avoid direct contact.

raltegravir Use an Enteral Closed System: No
Oral: Isentress tablet, chewable tablet (Merck Frosst Canada Ltd)

Preparation: Crushing the tablet is not recommended as the tablets have a bitter taste, which is masked by the film coating.
(120) There is some emerging evidence to suggest that crushing Isentress tablets for short periods of time might not adversely
impact a patient's response to HIV treatment.(149)
Film-coated tablets and chewable tablets are NOT bioequivalent.(2)

Intragastric: Isentress tablet, chewable tablet (Merck Frosst Canada Ltd)

Preparation: Crushing the tablet is not recommended as the tablets have a bitter taste, which is masked by the film coating.
(120) There is some emerging evidence to suggest that crushing Isentress tablets for short periods of time might not adversely
impact a patient's response to HIV treatment.(149)
Film-coated tablets and chewable tablets are NOT bioequivalent.(2)

Administration: There are published case reports, each with one patient, on administering raltegravir through a PEG tube and
a nasograstroduodenal tube.(25,38) Sandkovsky et al. concluded that the absorption of raltegravir is not compromised by this
route.(38)

ramipril Use an Enteral Closed System: No
Oral: Altace capsule (Aventis Pharma Inc)

Preparation: Use AHS compounded liquid (6) OR open capsule, mix with water, flush with water.
Intragastric: Altace capsule (Aventis Pharma Inc)

3.Draw medication suspension into the appropriate size and type of enteral syringe.
the total dose is administered).
Intrajejunal: Altace capsule (Aventis Pharma Inc)

Administration: Ramipril is well absorbed from the human intestine. No specific data exists. Monitor for increased side-effects
or loss of efficacy.(1)

ranitidine Use an Enteral Closed System: No
Oral: Zantac oral solution (Glaxosmithkline Inc)

Preparation: Use commercially available product,(2) if not available then use AHS compounded liquid.(6)
Intragastric: Zantac oral solution (Glaxosmithkline Inc)

5.Flush with the recommended volume of water.
Intrajejunal: Zantac oral solution (Glaxosmithkline Inc)

Administration: Ranitidine is well absorbed following jejunal administration; however, the injection should be used for this route
as the osmolarity of the liquid preparation is likely too high. Administer using the intragastric administration method.(1)
Parenteral:

repaglinide Use an Enteral Closed System: No
Oral: Gluconorm tablet (Novo Nordisk Canada Inc)

Preparation: Crush & mix with water, followed by adequate rinsing with water. Use immediately after crushing tablet.(121)
Other info: According to the manufacturer, no data to support crushing of tablets for administration via enteral tubes. No special
coating to prevent crushing of tablets; however, manufacturer states crushing may result in faster absorption. Close monitoring
of blood glucose levels recommended.(121)

Replavite Use an Enteral Closed System: No
Oral: Replavite tablet (WN Pharmaceuticals Ltd)


riboflavin Use an Enteral Closed System: No
Oral: powder

rifABUTin Use an Enteral Closed System: Yes
Oral: Mycobutin capsule (Pfizer Canada Inc)

water. Note that use of the compounded liquid is preferred to prevent operator exposure to antibiotic powder.
Intragastric: Mycobutin capsule (Pfizer Canada Inc)

Intrajejunal: Mycobutin capsule (Pfizer Canada Inc)


rifAMPin Use an Enteral Closed System: No
Oral: Rofact capsule (Paladin Labs)

water.
Intragastric: Rofact capsule (Paladin Labs)

water.
3.Allow a 2 hour break before dose administration.
Intrajejunal: Rofact capsule (Paladin Labs)

water.
Parenteral:

rifaximin Use an Enteral Closed System: No
Oral: Zaxine tablet (Salix)

Preparation: Use AHS compounded liquid (6)OR crush & mix with water, followed by adequate rinsing with water
Intragastric: Zaxine tablet (Salix)

4. Draw 10 mL of water into the syringe and allow the tablet to disperse, shaking if necessary.
8. Re-start the feed unless a prolonged break is required.(1)
Intrajejunal: Zaxine tablet (Salix)

Administration: There are no specific data. However, since the antibiotic is not absorbed, this route of administration should
not affect the therapeutic effect. Administer using intragastric method.(1)

rilpivirine Use an Enteral Closed System: No
Oral: Edurant film-coated tablet (Janssen-Ortho Inc)

Preparation: No data available for crushing/chewing tablet. Rilpivirine is practically insoluble in water over a wide pH range.(4)

riluzole Use an Enteral Closed System: No
Oral: Rilutek tablet (Aventis Pharma Inc)

Stability: Use the 'suspension' within 15 minutes.(1)
Intragastric: Rilutek tablet (Aventis Pharma Inc)

Intrajejunal: Rilutek tablet (Aventis Pharma Inc)


risedronate Use an Enteral Closed System: No
Oral: Actonel tablet (Procter Gamble Pharmaceuticals Canada, Inc)

Preparation: Disperse tablet in 60 mL of water.(123)
Intragastric: Actonel tablet (Procter Gamble Pharmaceuticals Canada, Inc)

Preparation: Disperse tablet in 60 mL of water. After 2 minutes, stir the solution for 30 seconds, pour through the tube. Rinse
with an additional 30 mL of water.(123)
If risedronate is administered via a feeding tube, the once-weekly tablet should be used, owing to the lower incidence of GI-
related side effects.(1)
3.Wait 2 hours.
9.Ensure that the patient is sitting upright or standing for 30 minutes after the dose is given.
10.Re-start the feed after at least 2 hours.(1)
Intrajejunal: Actonel tablet (Procter Gamble Pharmaceuticals Canada, Inc)

Preparation: Disperse tablet in 60 mL of water. After 2 minutes, stir the solution for 30 seconds, pour through the tube. Rinse
with an additional 30 mL of water.(123)
If risedronate is administered via a feeding tube, the once-weekly tablet should be used, owing to the lower incidence of GI-
related side effects.(1)

risperidone Use an Enteral Closed System: No
Oral: oral solution

Preparation: Use commercially available oral solution.(2) Treat as a hazardous drug. Refer to the Hazardous Medication


Rectal:
Administration: Well absorbed orally with substantial oral bioavailability. Cannot recommend rectal administration.(8)

ritonavir Use an Enteral Closed System: No
Oral: Norvir film-coated tablet, oral solution (Abbvie)

Preparation: Do NOT crush/split tablet.(4) Commercially available oral solution.(2)
Intragastric: Norvir film-coated tablet, oral solution (Abbvie)

Administration: There is a case report on administering ritonavir through a PEG tube to 1 patient for over 19 months without
complications (124) and another case report with 1 patient on administering ritonavir through a nasograstroduodenal tube.(26)
There is a case series surrounding the use of a G-tube for the administration of ritonavir to 6 pediatric patients.(66)

rivaroxaban Use an Enteral Closed System: No
Oral: Xarelto tablet (Bayer Inc)

Preparation: Crush tablet, mix with 70 mL applesauce and administer. Rinse mortar used to crush tablet with 65 mL of water
and administer this liquid to patient; repeat rinsing procedure. Finish by administering a liquid meal (medication must be
administered with food).(125)
Intragastric: Xarelto tablet (Bayer Inc)

Administration: Flush NG tube with 20 mL of water. Crush tablet and suspend in 50 mL of water for NG administration. Rinse
mortar with 65 mL of water and flush this water down the NG tube, then repeat this procedure a second time. Finish by
administering a liquid meal via NG tube.(125)

rivastigmine Use an Enteral Closed System: No
Oral: Exelon capsule, oral solution (Novartis Pharmaceuticals Canada Inc)

Other info: Patches are commercially available.(2)
Intragastric: Exelon oral solution (Novartis Pharmaceuticals Canada Inc)

3.Allow 1-hour break.
4.Draw oral solution into an appropriate enteral syringe.
8.Allow 1-hour break before restarting the feed.(1)
Intrajejunal: Exelon oral solution (Novartis Pharmaceuticals Canada Inc)

Administration: There are no specific data available on jejunal administration. Use patch when possible. If liquid is
administered, monitor closely for increased side effects.(1)

ropinirole Use an Enteral Closed System: No
Oral: Requip tablet (Glaxosmithkline Inc)

Preparation: Tablets disintegrate rapidly when placed in 10 mL of water.(1)
Intragastric: Requip tablet (Glaxosmithkline Inc)

Intrajejunal: Requip tablet (Glaxosmithkline Inc)


rosiglitazone Use an Enteral Closed System: No
Oral: Avandia tablet (Glaxosmithkline Inc)

Preparation: Tablets disperse readily in 10 mL of water when shaken for 5 minutes.(1)
Intragastric: Avandia tablet (Glaxosmithkline Inc)

Intrajejunal: Avandia tablet (Glaxosmithkline Inc)


rosuvastatin Use an Enteral Closed System: No
Oral: Crestor tablet (AstraZeneca Canada Inc)

Intragastric: Crestor tablet (AstraZeneca Canada Inc)

Intrajejunal: Crestor tablet (AstraZeneca Canada Inc)

Other info: There is very limited data for the jejunal administration of rosuvastatin. Consider changing to an alternative statin
with more data, such as atorvastatin.(1)

saccharomyces boulardii Use an Enteral Closed System:
Oral: Florastor capsule (Medical Futures)

Preparation: Capsules may be opened and contents may be dissolved in liquid or sprinkled over semisolid food.(127)

sacubitril/valsartan Use an Enteral Closed System: No
Oral: Entresto tablet (Novartis)

Preparation: Manufacturer states that splitting the tablet could yield "halves" containing variable amounts of the drug
substance, resulting in dosing errors. In addition, crushing or cutting tablets is not recommended as crushing tablets that
contain moisture-sensitive active ingredients exposes those ingredients to degradation.(128)

saquinavir Use an Enteral Closed System: No
Oral: Invirase tablet, capsule (Roche)

Preparation: Hard gel capsules may be opened and contents sprinkled onto food, simple syrup, or water.(4)
Administration: The dose should be taken within 2 hours of food.(4)
Intragastric: Invirase tablet, capsule (Roche)

Administration: The dose should be taken within 2 hours of food.(4)
3.Open the capsule & pour the contents into a medicine pot, or place tablet in the barrel of an appropriate size of syringe.
Intrajejunal: Invirase tablet, capsule (Roche)

Administration: The dose should be taken within 2 hours of food.(4) There are no specific data available on jejunal
administration. Administer using the intragastric method. Monitor for increased side effects or loss of efficacy.(1)
Rectal: Invirase tablet, capsule (Roche)

Administration: Very poorly absorbed rectally.(1)

selegiline Use an Enteral Closed System: No
Oral: tablet, oral suspension

Preparation: Contact Drug Information to obtain published compounding recipe.(129)
Intragastric: tablet, oral suspension

Intrajejunal: tablet, oral suspension


senna (standardized sennosides) Use an Enteral Closed System: No
Oral: Senokot oral syrup (Purdue Pharma)

Intragastric: Senokot oral syrup (Purdue Pharma)

5.Flush with the recommended volume of water.
Intrajejunal: Senokot oral syrup (Purdue Pharma)

Administration: Therapeutic effect will be unaffected by jejunal administration. Administer using the intragastric administration
method.(1)

sertraline Use an Enteral Closed System: No
Oral: Zoloft capsule (Pfizer Canada Inc)

Preparation: Open capsule & mix powder with food immediately prior to administration; prefer apple sauce or jam to mask the
bitter taste. No NG tube data.(130)
Other info: Oral suspension (NOT available in Canada) is appropriate for enteral feeding tube administration.(1)

sevelamer Use an Enteral Closed System: No
Oral: Renagel tablet (Sanofi-Aventis)

Preparation: Use AHS compounded liquid.(6) DO NOT crush, break, or disperse the tablets, as sevelamer swells on contact
with water, forming a gelatinous mass. (2,195, 235)
Intragastric: Renagel (Sanofi-Aventis)

Preparation: Some pharmacies may be able to prepare a compounded 80 mg/mL liquid formulation suitable for enteral tube
administration. (235, 248) DO NOT crush, break, or disperse the tablets, as sevelamer swells on contact with water, forming a
gelatinous mass that is likely to block enteral feeding tubes. (195, 235, 248)
Other info: References discussing the administration of sevelamer via gastric tubes cite a single paper published in the
International Journal of Pharmaceutical Compounding that details attempts to develop a formulation of sevelamer suitable for
gastric tube administration to pediatric renal failure patients. (195, 235, 248) The formulation specifically recommended for
gastric tube administration (an 80 mg/mL liquid) is high in sodium (Renagel tablets were found to dissolve in 23.4% sodium
chloride solution). (248) The high sodium content makes this formulation unsuitable for administration via small bowel feeding
tubes. (248) The author notes that the high sodium content was "not a concern" for the ESRD patients at their hospital, although
no clinical patient data to support the use of this preparation is provided in the paper. (248) No clinical reports to support
administration of sevelamer via enteral feeding tubes were located during a search of the medical literature.
Lanthanum has been suggested by some authors as a potential alternative to sevelamer in patients who require enteral
medication administration. (235)

sildenafil Use an Enteral Closed System: No
Oral: Viagara tablet (Pfizer Canada Inc)

Intragastric: Viagara tablet (Pfizer Canada Inc)

Intrajejunal: Viagara tablet (Pfizer Canada Inc)


simvastatin Use an Enteral Closed System: No
Oral: Zocor tablet (Merck Frosst Canada Ltd)

Preparation: Tablets disperse well when crushed & mixed with water. Tablets may take some time to disperse, therefore may
consider switching to atorvastatin.(1)
Intragastric: Zocor tablet (Merck Frosst Canada Ltd)

Other info: Simvastatin is absorbed in the small intestine, but the specific site is unknown.(1)
Intrajejunal: Zocor tablet (Merck Frosst Canada Ltd)

Other info: Simvastatin is absorbed in the small intestine, but the specific site is unknown.(1)

sodium benzoate Use an Enteral Closed System: No
Oral: powder

sodium bicarbonate Use an Enteral Closed System: No
Oral: powder
Parenteral:

sodium citrate Use an Enteral Closed System: No
Oral: powder

sodium phenylbutyrate Use an Enteral Closed System: No
Oral: powder

sodium polystyrene sulphonate Use an Enteral Closed System: No
Oral: Kayexalate powder (Sanofi-Synthelabo Canada Inc)

Preparation: Mix with water, flush with water.(2)
Intragastric: Kayexalate powder (Sanofi-Synthelabo Canada Inc)

Preparation: Mix with water, flush with water.(2)
Administration: The resin may be introduced into the stomach through a plastic tube.(2)
Rectal: Kayexalate powder (Sanofi-Synthelabo Canada Inc)

Administration: Retain for as long as possible, then follow emulsion with cleansing enema. Rectal administration may yield
less effective results. May be used with oral therapy.(2,8)

sofosbuvir Use an Enteral Closed System: No
Oral: Sovaldi tablet (Gilead Sciences)

Preparation: Tablets can disintegrate in water, juice, or milk with sitrring and pressure with a spoon. Disintegrated tablets may
have an unpleasant taste.(2)

solifenacin Use an Enteral Closed System: No
Oral: Vesicare tablet (Astellas Pharma Canada)

Preparation: Manufacturer recommends tablet be swallowed whole; however, this may be due to bitter taste of the ingredients.
The manufacturer is not aware of any formulation properties that would preclude splitting or crushing the tablet.(131)

sotalol Use an Enteral Closed System: No
Oral: tablet
Rectal:
Administration: High oral bioavailability. Cannot recommend rectal administration.(8)

spironolactone Use an Enteral Closed System: No
Oral: Aldactone tablet (Pfizer Canada Inc)

Preparation: Use AHS compounded liquid OR crush & mix with water, followed by adequate rinsing with water.(6) Treat as a
Intragastric: Aldactone tablet (Pfizer Canada Inc)

Intrajejunal: Aldactone tablet (Pfizer Canada Inc)


spironolactone/ hydrochlorothiazide Use an Enteral Closed System: No
Oral: Aldactazide tablet (Pfizer Canada Inc)

Intrajejunal: Aldactazide tablet (Pfizer Canada Inc)

Administration: Both spironolactone & hydrochlorothiazide are absorbed jejunally. Use intrajejunal method as given for
spironolactone.(9)

stavudine Use an Enteral Closed System: No
Oral: Zerit capsule (Bristol-Myers Squibb Canada)

Preparation: For optimal absorption stavudine should be administered on an empty stomach; however, if necessary the
capsules can be opened and mixed with food.(4)The contents of the capsules pour freely, mix with water when stirred.(1)
Commercial oral liquid may be available through the Special Access Program.
Intragastric: Zerit capsule (Bristol-Myers Squibb Canada)

capsules can be opened and mixed with food.(4) The contents of the capsules pour freely, mix with water when stirred, and
flush via an 8Fr NG tube without blockage.(1)
3.Allow a break prior to dosing if possible.
7.Wait at least 30 minutes before re-starting the feed.(1)
Intrajejunal: Zerit capsule (Bristol-Myers Squibb Canada)

capsules can be opened and mixed with food.(4) The contents of the capsules pour freely, mix with water when stirred.(1)

sucralfate Use an Enteral Closed System: No
Oral: Sulcrate Suspension Plus tablet, oral suspension (Axcan Pharma Inc)
Preparation: Use commercially available product OR AHS compounded liquid.(6)
Intragastric: Sulcrate Suspension Plus tablet, oral suspension (Axcan Pharma Inc)
Preparation: Use commercially available product OR AHS compounded liquid.(6)
3.Wait for at least 1 hour.
9.Wait at least an hour before restarting the feed.(1)
Intrajejunal: Sulcrate Suspension Plus tablet, oral suspension (Axcan Pharma Inc)
Administration: Not appropriate for jejunal administration as the site of action is gastric & duodenal.(1)
Rectal: Tablet
Preparation: Crush sucralfate tablets well and suspend 2 g of drug in 20 - 30 mL of water. (214-217)
Administration: Instill suspension rectally twice daily via enema bottle or soft 10 French catheter inserted 5 cm inside the anal
verge. (214 - 217) Rectal leakage of the instillate is possible; advise patients to take appropriate precautions.
Other info: The evidence to support rectal administration of sucralfate enemas is scant and of poor quality. The information
above is pulled from a small number of observational studies and one small, low-quality prospective, randomized, double-blind
trial. (214-217) This information is included due to the relative lack of therapeutic options for the management of radiation-
induced proctosigmoiditis or ulcerative rectosigmoid lesions. Healthcare workers considering the use of sucralfate enemas are
encouraged to review the cited references.

sulfaDIAZINE Use an Enteral Closed System: No
Oral: tablet

sulfamethoxazole - trimethoprim Use an Enteral Closed System: No
Oral: Septra tablet, oral suspension

Preparation: Use commercial liquid,(2) if not available use AHS compounded liquid.(6)
Intragastric: Septra tablet, oral suspension

Preparation: Use commercial liquid, (2) if not available use AHS compounded liquid.(6)
5.Draw 2-3 times the dosage volume of water and a little air into the syringe and shake to mix thoroughly.
Updated: 2018-May-3
Intrajejunal: Septra tablet, oral suspension

Preparation: Use commercial liquid, if not available use AHS compounded liquid.(6)
Administration: There are no specific data available on jejunal administration. Administer as intragastric, but dilute the dose
with at least three times the volume of water to reduce osmolarity.(1)
Parenteral:

sulfaSALazine Use an Enteral Closed System: No
Oral: tablet
Preparation: Use AHS compounded liquid (6) OR crush & mix regular tablets (not enteric-coated tablets) with water, followed
by adequate rinsing with water.(1)
Administration: Same as intragastic administration.(1)
Rectal:
Preparation: Topical therapy using a rectal 5-ASA preparation is considered first line in local rectal disease.(1)

sumatriptan Use an Enteral Closed System: No
Oral: Imitrex tablet (Glaxosmithkline Inc)

Preparation: Use AHS compounded liquid OR crush & mix with water, flush with water.(6)
Intragastric: Imitrex tablet (Glaxosmithkline Inc)

Intrajejunal: Imitrex tablet (Glaxosmithkline Inc)

Rectal: suppository
Preparation: NOT commercially available in Canada.(2) Compounding recipe available from IJPC.(159)
Administration: Studies suggest pharmacokinetic and clinical efficacy with suppository.(8)
Intranasal: Imitrex nasal spray (Glaxosmithkline Inc)

Preparation: Commercially available in Canada as a nasal spray at two strengths: 5 mg/dose and 20 mg/dose.(2)

sunitinib Use an Enteral Closed System: Yes

Other info: CYTOTOXIC - Prepare using cytotoxic handling precautions.

tacrolimus Use an Enteral Closed System: No
Oral: Prograf capsule (Astellas)

Other info: Not compatible with PVC, thus and equipment used to manipulate dose should NOT contain PVC. A prolonged
break in feeding is required to maximize absorption.(1)
Intragastric: Prograf compounded liquid (Astellas)

3.Wait for 2-3hours.
4.Empty the capsule contents into a suitable container and mix with water.
5.Draw up into a suitable size and type of syringe.
6.Flush the medication dose immediately down the enteral feeding tube.
8.If possible, wait for an hour before restarting the feed.(1)
Intrajejunal: Prograf compounded liquid (Astellas)

Monitor levels closely.(1)
Parenteral:

tadalafil Use an Enteral Closed System: No


tamoxifen Use an Enteral Closed System: Yes
Oral: Tamofen tablet (Sanofi-Synthelabo Canada Inc)

Preparation: No data available. Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.
Other info: Use a closed system when compounding this preparation. Tamoxifen is a non-steriodal anti-estrogen, avoid
crushing tablets if possible.(1)

Administration: Commercially available oral solution has been used for enteral tube administration.(1) However, the product is
not marketed in Canada.(2)

Administration: Commercially available oral solution has been used for enteral tube administration.(1) However, the product is
not marketed in Canada.(2)
Rectal:
Administration: Poor in vitro release & poor solubility in rectal fluids. Efficacy not established using a suppository compounded
from crushed tablets.(8)

tamsulosin Use an Enteral Closed System: No
Oral: Flomax CR controlled release tablet (Boehringer Ingelheim Canada Ltd)

Preparation: Do NOT crush; not for NG tube.(1,132)
Other info: Use tamsulosin SR capsules or call physician to get order changed to doxazosin or finasteride. See appropriate
section in this document.
Oral: sustained release capsule

Preparation: Although current generic manufacturers do not support opening the capsule, previous manufacturers (Boehringer
Ingelheim Ltd., Novopharm Ltd.) suggested opening the capsule and mixing the contents with an acidic solution such as juice or
cola prior to administration via enteral tubes. DTC supports continuing this practice as they view all tamsulosin SR capsules as
being interchangeable.(133) However, the Drug Information Centre has received numerous clinical reports that tamsulosin
pellets clog enteral tubes. Changing to a therapeutic alternative, where possible, appears prudent (1,255). Avoid use with
small bore feeding tubes.

tapentadol Use an Enteral Closed System: No
Oral: Nucynta CR controlled-release tablet (Janssen-Ortho Inc)

Preparation: Do NOT crush/dissolve divide/chew tablet due to the risk of fatal tapentadol overdose.(2)

telmisartan Use an Enteral Closed System: No
Oral: Micardis tablet (Boehringer Ingelheim Canada Ltd)

Preparation: Tablets can be crushed or dispersed in water when shaken for about 5 minutes.(1)
Intragastric: Micardis tablet (Boehringer Ingelheim Canada Ltd)

Intrajejunal: Micardis tablet (Boehringer Ingelheim Canada Ltd)


temazepam Use an Enteral Closed System: No
Intragastric: Restoril capsule (Aspri Pharma)

Intrajejunal: Restoril capsule (Aspri Pharma)


temozolomide Use an Enteral Closed System: Yes

Other info: CYTOTOXIC - Prepare using cytotoxic handling precautions.

tenofovir disoproxil fumarate Use an Enteral Closed System: No
Oral: Viread tablet (Gilead Sciences)

Preparation: Tablets can be dispersed in 100 mL of water, orange juice or grape juice.(4) Tablets disperse within 5 minutes
when placed in 10mL of water.(1)
Intragastric: Viread tablet (Gilead Sciences)

when placed in 10mL of water and flush via an 8Fr NG tube without blockage.(1)
Intrajejunal: Viread tablet (Gilead Sciences)

when placed in 10mL of water.(1)

tenofovir/emtricitabine Use an Enteral Closed System: No
Oral: Truvada tablet (Gilead Sciences)

Preparation: Tablets may be split/crushed and stirred into water, grape juice, or orange juice.(4)

terbinafine Use an Enteral Closed System: No
Oral: Lamisil tablet (Novartis Pharmaceuticals Canada Inc)

Intragastric: Lamisil tablet (Novartis Pharmaceuticals Canada Inc)

Intrajejunal: Lamisil tablet (Novartis Pharmaceuticals Canada Inc)


testosterone undecanoate Use an Enteral Closed System: No
Oral: Andriol capsule (Merck Frosst Canada Ltd)

Preparation: Do NOT crush/chew capsules.(2) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site

tetracycline Use an Enteral Closed System: No
Oral: capsule
Stability: Use immediately after opening capsule.

theophylline Use an Enteral Closed System: No
Oral: Uniphyl sustained release tablet, compounded suppository (Purdue Pharma)

Preparation: Do NOT crush SR tablet; tablets may be halved.(2)
Oral: Theolair oral liquid (Graceway)

Preparation: Use commercially available liquid.(2) Use AHS compounded liquid if commercial product not available.(6)
Intragastric: Theolair oral liquid (Graceway)

Intrajejunal: Theolair oral liquid (Graceway)


Administration: May be suitable alternative to oral or inhalant solution.(8)

thiamine Use an Enteral Closed System: No
Oral: tablet, oral suspension

Intragastric: tablet, oral suspension

Intrajejunal: tablet, oral suspension

Administration: Administer tablets using the intragastric method.(1)
Parenteral:

thioguanine Use an Enteral Closed System: No
Oral: tablet

ticagrelor Use an Enteral Closed System: No
Oral: Brilinta tablet (AstraZeneca Canada Inc)

Preparation: Crush the tablet(s) in a mortar & pestle, then add a small amount of water (100 mL) & stir for 1 minute. Transfer
the mixture to a drinking glass. Add more water (100 mL) to the mortar & pestle & stir for 30 seconds, then transfer this to the
same drinking glass. Stir the contents & administer to the patient.(2)
Stability: Use immediately after crushing tablets.(2)
Intragastric: Brilinta tablet (AstraZeneca Canada Inc)

Preparation: Crush the tablet(s) in a mortar & pestle, then add a small amount of water (100 mL) & stir for 1 minute. Transfer
the mixture to a drinking glass. Add more water (100 mL) to the mortar & pestle & stir for 30 seconds, then transfer this to the
same drinking glass. Stir the contents & administer to the patient.(2)
3.Prepare the tablet for administration by following the instructions provided in the "Tablet Administration" column. The
medication and water mixture may be administered via a nasogastric tube size of CH8 or greater.
4.Finally, flush the nasogastric tube through with the recommended volume of water.
Stability: Use immediately after crushing tablets.(2)
Intrajejunal: Brilinta tablet (AstraZeneca Canada Inc)

Administration: No data available (as of September 2015)

timolol Use an Enteral Closed System: No
Oral: tablet
Preparation: Tablets can be rapidly dispersed in 10 mL of water.(1)

tipranavir Use an Enteral Closed System: No
Oral: Aptivus capsule (Boehringer Ingelheim Canada Ltd)

Preparation: Do NOT crush/split capsule.(4)

tizanidine Use an Enteral Closed System: No
Oral: Zanaflex tablet (Elan)

Preparation: Tablets can be crushed & dispersed in water.(1)
Intragastric: Zanaflex tablet (Elan)

Intrajejunal: Zanaflex tablet (Elan)


tobramycin Use an Enteral Closed System: No
Otic: eye drops

Preparation: Tobramycin 0.3% ophthalmic solution may be prescribed to treat bacterial otitis externa.(134)
Parenteral:

TOLBUTamide Use an Enteral Closed System: No
Other:
Preparation: Due to limited data consider changing to an alternative sulfonylurea.(1)

tolterodine L-tartrate Use an Enteral Closed System: No
Oral: Detrol tablet (Pfizer Canada Inc)

Preparation: Use AHS compounded liquid OR tablets can be crushed & mixed with water.(6)
Oral: Detrol LA extended release capsule (Pfizer Canada Inc)

Preparation: Do NOT open or crush.(2)
Intragastric: Detrol tablet (Pfizer Canada Inc)

Intrajejunal: Detrol tablet (Pfizer Canada Inc)


tolvaptan Use an Enteral Closed System: No
Preparation: Nasogastric (NG) tube: Administration via NG tube resulted in an ~25% reduction in AUC and a modest reduction
in Cmax in one study; 24-hour urine output was reduced by only 2.8%. Therefore, until further studies are done to determine a
bioequivalent dose when administering via NG tube, NG tube administration of a crushed 15 mg tablet appears to be a viable
alternative method of administration.(135)

topiramate Use an Enteral Closed System: No
Oral: Topamax tablet (Janssen-Ortho Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6) Tablets may be crushed and
mixed into applesauce or oatmeal; must be immediately administered.(145) Treat as a hazardous drug. Refer to the
Oral: Topamax sprinkle capsule (Janssen-Ortho Inc)

Preparation: Open capsule & sprinkle onto a small amount of soft food. Do not chew beads.(2,145) Treat as a hazardous drug.
Intragastric: Topamax tablet (Janssen-Ortho Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6) Treat as a hazardous drug.
Administration: In clinical trials conducted by Jansen, where NG administration was necessary, tablets were crushed and
suspended in water (topiramate solubility is 9.8 mg/mL). The mixture should be administered immediately.(145)
Intragastric: Topamax sprinkle capsule (Janssen-Ortho Inc)

Preparation: Administration of the beads through an enteral feeding tube does not work well as the beads readily stick to the
tubing & block the tube.(2,145) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.
Administration: NOT for NG tube administration as aggregation and clogging has been observed.(145)
Intrajejunal: Topamax tablet (Janssen-Ortho Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6) Treat as a hazardous drug.
Rectal: topiramate rectal suspension

Preparation: Crush 200 mg tablet, add 10 mL tap water, draw into a 35 mL syringe. Similar absorption to oral.(136) Treat as a

tramadol Use an Enteral Closed System: No
Oral: Ralivia, Tridural extended release tablet (Biovail Pharmaceuticals Canada Labopharm)
Oral: Zytram XL controlled release tablets (Purdue Pharma)

Rectal: suppository
Preparation: Suppositories have rapid absorption but side effects, including nausea and vomiting, are more common.(22)
Tramadol suppositories are commercially available in the USA but NOT Canada.(2)

tramadol/acetaminophen Use an Enteral Closed System: No
Oral: Tramacet tablet (Janssen-Ortho Inc)

Preparation: May split or crush tablets.(137)
Intragastric: Tramacet tablet (Janssen-Ortho Inc)

Preparation: May split or crush tablets.(137)
Intrajejunal: Tramacet tablet (Janssen-Ortho Inc)

Administration: There are no specific data relating to jejunal administration.(1)

trandolapril Use an Enteral Closed System: No
Intragastric: Mavik capsule (Abbott Laboratories Limited)

Preparation: No specific data on enteral tube administration are available. Owing to the lack of data, consider changing to an
alternative once daily ACE inhibitor.(1)
Intrajejunal: Mavik capsule (BGP Pharma)

Preparation: No specific data on enteral tube administration are available. Owing to the lack of data, consider changing to an
alternative once daily ACE inhibitor.(1)

tranexamic acid Use an Enteral Closed System: No
Oral: Cyklokapron tablet (Pfizer Canada Inc)

Preparation: Crush tablet, mix with water, flush with water OR use injection.(1)
Intragastric: Cyklokapron tablet (Pfizer Canada Inc)

Intrajejunal: Cyklokapron tablet (Pfizer Canada Inc)

Administration: Administer using intragastric administration method or use the injection.(1)
Buccal: oral rinse, mouthwash

Preparation: Use AHS compounded product. Oral rinse is prepared from tablets, whereas the mouthwash is prepared from the
injectable.(6)
Intranasal: nasal gel

Preparation: Use AHS compounded nasal gel.(6)
Parenteral:

trazodone Use an Enteral Closed System: No
Oral: tablet
Intrajejunal: tablet, compounded suppository


Administration: Clinical efficacy reported - improved mood and better sleep.(8)

tretinoin (all-trans retinoic acid) Use an Enteral Closed System: No
Oral: Vesanoid capsule (Hoffmann-La Roche Limited)

Preparation: Place 3 x 10 mg capsules into a 5 mL oral syringe, and replace the plunger. Draw up 2 - 4 mL of warm water into
the syringe, cap and place in a cup of warm water for 15 - 60 minutes. Shake syringe occasionally until capsules dissolve
completely, then administer dose.(138) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite
medications.
Intragastric: Vesanoid capsule (Hoffmann-La Roche Limited)

Preparation: Place 3 x 10 mg capsules into a 5 mL oral syringe, and replace the plunger. Draw up 2 - 4 mL of warm water into
the syringe, cap and place in a cup of warm water for 15 - 60 minutes. Shake syringe occasionally until capsules dissolve
completely, then administer dose. If by NG/GT flush tube with 5 mL warm water post dose.(138) Treat as a hazardous drug.

triamterene /hydrochlorothiazide Use an Enteral Closed System: No
Oral: Dyazide or equivalent tablet


trifluoperazine Use an Enteral Closed System: No
Oral: Trifluoperazine tablet (AA Pharma)

Preparation: No stability data about crushing/splitting tablets. As per the manufacturer, the tablets do not possess a special
coating nor do they have a special release formulation.(139)

trihexyphenidyl Use an Enteral Closed System: No
Oral: tablet

trimethoprim Use an Enteral Closed System: Yes
Oral: tablet

trimipramine Use an Enteral Closed System: No
Oral: Surmontil tablet (Aventis Pharma Inc)

Preparation: Tablets do not disperse readily in water, but can be crushed and mixed with water.(1)

ursodiol Use an Enteral Closed System: No
Oral: Urso tablet (Axcan Pharma Inc)


valACYclovir Use an Enteral Closed System: No
Oral: Valtrex tablet (Glaxosmithkline Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6)
Intragastric: Valtrex tablet (Glaxosmithkline Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6)
Intrajejunal: Valtrex tablet (Glaxosmithkline Inc)

Administration: No data available. Consider changing to parenteral therapy.(1)

valGANciclovir Use an Enteral Closed System: No
Oral: Valcyte oral solution (Roche)

Preparation: Use commercially available product.(2) If commercially available product is not available or suitable, then use
AHS compounded liquid.(6) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.

valproic acid (valproate) Use an Enteral Closed System: No
Oral: Depakene capsule, oral syrup (Abbott Laboratories Limited)

Preparation: Commercially available oral syrup available.(2) Special access product, Depakote Sprinkle Capsules, can be
administered with applesauce.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.
Intragastric: Depakene oral syrup (Abbott Laboratories Limited)

Preparation: Use the commercially available liquid for enteral tubes; flush before & after.(140) Treat as a hazardous drug.
Other info: Absorption occurs mostly in the small intestine with limited absorption in the stomach, large intestine and colon.(1)
Intrajejunal: Depakene capsule, oral syrup (Abbott Laboratories Limited)

Preparation: Use the commercially available liquid for enteral tubes; flush before & after.(140) Treat as a hazardous drug.
Administration: There are no specific data relating to jejunal administration. Use intragastric administration method, but dilute
the dose with 3-4 times the volume in water to reduce osmolarity.(1)
Other info: Absorption occurs mostly in the small intestine with limited absorption in the stomach, large intestine and colon.(1)
Rectal: Depakene capsule, oral syrup (Abbott Laboratories Limited)

Administration: Use undiluted oral suspension and administer 3 times per day. Bioavailability of rectal administration is at least
equivalent to oral administration.(19)
Absorbed well rectally from the capsules, although the clinical response must be monitored.(8)
Intramuscular: Depacon Injection (Special Access) (Abbvie)

Administration: NEVER ADMINISTER THE IV FORMULATION VIA THE IM ROUTE (166). In an animal study, all of the dogs
administered the IV formulation via the IM route exhibited mild to moderate signs of distress during drug administration (167).
Histopathologic examination of the muscle tissue at the site of injection demonstrated marked discoloration, as well as
extensive inflammatory changes and myonecrosis (166, 167).

valsartan Use an Enteral Closed System: No
Oral: Diovan tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6) The commercially available oral
solution (NOT available in Canada) has been shown to have higher bioavailability compared to the tablet or capsule.(1)
Intragastric: Diovan tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6) The suspension has been
shown to have higher bioavailability compared to the tablet or capsule.(1)
Other info: Valsartan is passively absorbed in a pH-dependent manner, and therefore it is likely absorbed from the small
intestine.(1)
Intrajejunal: Diovan tablet (Novartis Pharmaceuticals Canada Inc)

Preparation: Use AHS compounded liquid OR crush tablet, mix with water, flush with water.(6) The suspension has been
shown to have higher bioavailability compared to the tablet or capsule.(1)
Other info: Valsartan is passively absorbed in a pH-dependent manner, and therefore it is likely absorbed from the small
intestine.(1)

vancomycin Use an Enteral Closed System: Yes
Oral: Vancocin capsule, injection (Lilly)

Intragastric: Vancocin capsule, injection (Lilly)

3.Reconstitute injection as directed (the reconstituted solution can be stored in the fridge for 24 hours for enteral use).
Intrajejunal: Vancocin capsule, injection (Lilly)

Rectal: rectal solution

Preparation: Use AHS compounded rectal solution.(6)
Administration: Rectal vancomycin can be given in combination with IV or oral Vancomycin. Some patients may have difficulty
retaining liquid in rectum.(8)
Parenteral:

vardenafil Use an Enteral Closed System: No
Oral: Staxyn ODT (Bayer Inc)

Preparation: Place on tongue to rapidly dissolve. Tablet should be taken as whole and NOT crushed/split/chewed.(2)

varenicline Use an Enteral Closed System: No
Oral: Champix tablet (Pfizer Canada Inc)

Preparation: Tablets will disperse within 2 minutes to give a dispersion.(1)
Intragastric: Champix tablet (Pfizer Canada Inc)

Preparation: Tablets will disperse within 2 minutes to give a dispersion which flushed via a 8FR NG tube without blockage.(1)
Intrajejunal: Champix tablet (Pfizer Canada Inc)

Preparation: Tablets will disperse within 2 minutes to give a dispersion.(1)

venlafaxine Use an Enteral Closed System: No
Oral: Effexor XR extended release capsule (Pfizer Canada Inc)

Preparation: Use AHS Immediate Release compounded liquid.(6) Alternatively, the extended-release capsules may be
opened and sprinkled on applesauce immediately prior to administration. (175)
Administration: For patients with difficulty swallowing the intact capsule, the capsules may be carefully opened and the
contents sprinkled on a spoonful of applesauce immediately prior to administration. (175) Care should be taken not to crush the
spheroids. Patients should be instructed to swallow the mixture immediately without chewing. (175) The manufacturer
recommends that patients drink a glass of water immediately after swallowing the mixture to ensure complete delivery of the
spheroids. (175)
Intragastric: Effexor XR extended release capsule (Pfizer Canada Inc)

Preparation: Use AHS Immediate Release compounded liquid. (6) Alternatively, the extended-release capsules may be
opened and the intact spheroids administered via feeding tubes that are at least 14 or 16 Fr in diameter (spheroids will block
smaller diameter tubes). (141,235,275,276)
Administration: Immediate-release compounded liquid: If converting patient from the extended-release capsule to the
immediate release liquid, the manufacturer recommends dividing the total daily doses into two doses to be administered on a
twice daily schedule; some centers have chosen to administer the total daily dose in three divided doses, depending on the total
daily dose. (175,276,276) Note that conversion of a patient to immediate-release liquid will result in greater fluctuations in
plasma concentration compared to the extended-release preparation. (175) The manufacturer has indicated that the clinical
effects of such changes are likely to be minimal, but that monitoring for clinical efficacy and tolerability will be required. (175)
Opening the extended-release capsules and administering the intact spheroids: Experiments conducted in Pfizer’s laboratories
used a size 14 or 16 Fr NG tube. DO NOT ADMINISTER the spheroids to patients with smaller enteral tubes, as smaller tubes
will become clogged (275). Open carefully; do NOT crush the spheroids; mix with water and administer via 14 or 16 Fr NG
tube; irrigate the tube with water 2 to 3 times to facilitate complete transfer of the spheroids. Note: a specific recommendation
on the volume of water to use with each flush was not provided by the manufacturer.(141)
Intrajejunal: Effexor XR extended release capsule (Pfizer Canada Inc)

Preparation: Use AHS Immediate Release compounded liquid.(6) Alternatively, for patients with feeding tubes at least 14 or 16
Fr in diameter, the intact spheroids may be administered as per the Intragastric administration instructions. Attempts to
administer the intact spheroids via smaller bore feeding tubes will result in clogging of the enteral tube. (176,275)
Administration: Jejunal administration of venlafaxine is not expected to affect bioavailability as the modified-release
preparation is designed to release drug through the small bowel.(1) However, the size of the feeding tube is crucial. It is
unlikely that intrajejunal feeding tubes would have an internal diameter large enough to permit passage of the spheroids.
Therefore, administration of the immediate-release liquid via intrajejunal feeding tube, rather than the extended-release
spheroids, would be prudent. If converting patient from the extended-release capsule to the immediate release liquid, the
manufacturer recommends dividing the total daily doses into two doses to be administered on a twice daily schedule; some
centers administer the suspension in three divided doses, depending on the patient's total daily dose. (175,275,276) Note that
conversion of a patient to immediate-release liquid will result in greater fluctuations in plasma concentration compared to the
extended-release preparation. (175) The manufacturer has indicated that the clinical effects of such changes are likely to be
minimal, but that monitoring for clinical efficacy and tolerability will be required. (175)
Nasogastric: Effexor XR extended release capsule (Pfizer Canada Inc)

Preparation: Use AHS Immediate Release compounded liquid. (6) Alternatively, the extended-release capsules may be
opened and the intact spheroids administered via feeding tubes that are at least 14 or 16 Fr in diameter. (141; 235, 275)
Administration: Immediate-release compounded liquid: If converting patient from the extended-release capsule to the
immediate release liquid, the manufacturer recommends dividing the total daily doses into two doses to be administered on a
twice daily schedule; some centers have chosen to administer the total daily dose in three divided doses, depending on the total
daily dose. (175, 275, 276) Note that conversion of a patient to immediate-release liquid will result in greater fluctuations in
plasma concentration compared to the extended-release preparation. (175) The manufacturer has indicated that the clinical
effects of such changes are likely to be minimal, but that monitoring for clinical efficacy and tolerability will be required. (175)
Opening the extended-release capsules and administering the intact spheroids: Experiments have conducted in Pfizer’s
laboratories used a size 14 or 16 Fr NG tube. (176) DO NOT ADMINISTER the spheroids to patients with smaller enteral tubes
as smaller tubes will become clogged. Open carefully; do NOT crush the spheroids; mix with water and administer via14 or 16
Fr NG tube; irrigate the tube with water 2-3 times to facilitate complete transfer of the spheroids. (176) Note: a specific
recommendation on the volume of water to use with each flush was not provided by the manufacturer.(141)
Stability: Use immediately after opening capsule. (2)

verapamil Use an Enteral Closed System: No
Oral: Apo-Verap SR, Isoptin SR sustained release tablet (Apotex Inc, BGP Pharma ULC)
Preparation: Do NOT crush. Isoptin SR 240mg tablet may be split in half; other strengths may NOT be split.(2)
Oral: Apo-Verap tablet (Apotex)

Other info: Injection is also available.(2)
Intragastric: Apo-Verap tablet (Apotex)

3.Draw the medication suspention into the appropriate size and type of syringe.
Intrajejunal: Apo-Verap tablet (Apotex)

Parenteral:

vigabatrin Use an Enteral Closed System: No
Oral: Sabril tablet, oral powder (Aventis Pharma Inc)

Preparation: The contents of a sachet should be dissolved in water or a soft drink immediately before taking. Sachet contents
dissolve completely in 10mL of water.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite
medications.
Intragastric: Sabril oral powder (Aventis Pharma Inc)

dissolve completely in 10mL of water and flush down an 8Fr NG tube without blockage.(1) Treat as a hazardous drug. Refer to
the Hazardous Medication Handling site on Insite (http://insite.albertahealthservices.ca/17382.asp) for additional information on
the safe handling of this and other hazardous medications.
3.Measure 10mL of water into a measuring pot.
4.Add the sachet contents and allow to dissolve.
5.Draw into the appropriate size and type of syringe.
9. Re-start the feed.(1)
Intrajejunal: Sabril oral powder (Aventis Pharma Inc)

dissolve completely in 10mL of water.(1) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite
medications.
Administration: There are no specific data. Administer using intragastric method. Monitor for lack of efficacy & increased side
effects.(1)

voriconazole Use an Enteral Closed System: No
Oral: Vfend tablet, oral suspension (Pfizer Canada Inc)

Preparation: Use commercially available product.(2) If not available then use AHS compounded liquid.(6) Treat as a
Other info: If both the commercially available product and the AHS compounded liquid are unsuitable, consideration could be
given to parenteral administration of the medication, as an injectable for is also available. (2)
Intragastric: Vfend oral suspension (Pfizer Canada Inc)

3 .Allow at least 1 hour before giving the dose.
5. Draw the medication suspension into an appropriate size and type of syringe.
8. Allow 1 hour before restarting the feed.(1)
Intrajejunal: Vfend tablet, oral suspension (Pfizer Canada Inc)

Administration: Same as intragastric administration. Absorption does not appear to be affected by intrajejunal administration.
There has been one case report of the tablets being crushed & suspended in 50 mL of water, then administered via a
jejunostomy tube. This gave a similar plasma concentration to oral administration. The dose should be taken 1 hour before
food or 1 hour after.(1)

warfarin sodium Use an Enteral Closed System: No
Oral: Coumadin tablet (Bristol Laboratories of Canada)

Preparation: All brands of tablets can be crushed & suspended in water. Most will disperse in water within 5 minutes if shaken.
Intragastric: Coumadin tablet (Bristol Laboratories of Canada)

3.Where possible, allow a break before dosing.
Other info: Monitor INR for potential drug-enteral feed interactions.(1) Human and animal studies show that warfarin is well
absorbed in the small intestine. However, there is an interaction between warfarin and enteral nutrition which results in reduced
clinical effect. Close monitoring of INR is warranted.(1)
Intrajejunal: Coumadin tablet (Bristol Laboratories of Canada)

Other info: Monitor INR for potential drug-enteral feed interactions.(1) Human and animal studies show that warfarin is well
absorbed in the small intestine. However, there is an interaction between warfarin and enteral nutrition which results in reduced
clinical effect. Close monitoring of INR is warranted.(1)
Rectal:
Administration: Not recommended.(19)

zafirlukast Use an Enteral Closed System: No
Intragastric: Accolate tablet (AstraZeneca Canada Inc)

Administration: NOT suitable for enteral feed. Consider therapeutic alternative.(1)
Intrajejunal: Accolate tablet (AstraZeneca Canada Inc)

Administration: NOT suitable for enteral feed. Consider therapeutic alternative.(1)

zidovudine Use an Enteral Closed System: No
Oral: Retrovir oral syrup (Glaxosmithkline Inc)

Preparation: Use commercially available product;(2) if not available then use AHS compounded liquid.(6) Treat as a
Intragastric: Retrovir oral syrup (Glaxosmithkline Inc)

Intrajejunal: Retrovir oral syrup (Glaxosmithkline Inc)

Parenteral:

zinc acetate Use an Enteral Closed System: No
Oral: powder

zinc gluconate Use an Enteral Closed System: No
Oral: tablet (Jamieson)

Preparation: No data.

zinc sulfate Use an Enteral Closed System: No
Oral: powder
Administration: Intrajejunal administration may lead to reduced bioavailability of zinc preparations. Monitor plasma
concentration & consider using parenteral therapy.(1)

ziprasidone Use an Enteral Closed System: No
Oral: Zeldox capsule (Pfizer Canada Inc)

Preparation: There are case reports of opening capsules and then administering it down feeding tubes. Ziprasidone is very
slightly soluble in water.(142) Treat as a hazardous drug. Refer to the Hazardous Medication Handling site on Insite (http:
medications.

zopiclone Use an Enteral Closed System: No
Oral: Imovane tablet (Sanofi-Aventis)

Preparation: Manufacturer states that tablets are film-coated and crushable. However, they do not have any data regarding
administration via a feeding tube and therefore cannot recommend this route.(144) There are reports of zopiclone tablets
creating a gel when the coating is mixed with water, which may block the tube. Practitioners should use their clinical judgment.
(1)
Oral: Apo-Zopiclone tablet (Apotex)

Preparation: Tablets are not coated and may be crushed.(143) Manufacturer has no information nor conducted studies on
enteral feeding.(143)

zuclopenthixol Use an Enteral Closed System: No
Oral: Clopixol tablet (Lundbeck Canada Inc)

Preparation: Tablets take 8-10 minutes to disperse but form a very fine dispersion.(1)
Other info: Acuphase and Depot injection available.(2)
Intragastric: Clopixol tablet (Lundbeck Canada Inc)

Preparation: Tablets take 8-10 minutes to disperse but form a very fine dispersion which flushes via a 6Fr NG tube without
blockage.(1)
Intrajejunal: Clopixol tablet (Lundbeck Canada Inc)

Page: 1
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Medication Administration

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Alternative Routes of Administration for Medications

Drug on NIOSH List: No

Oral: Pentasa Extended-release tablet (Ferring Inc)

Oral: Asacol Delayed-release tablet (Allergan)

Oral: Salofalk Delayed-release tablet (Aptalis Pharma)

Intragastric: Pentasa (Ferring Inc)

Rectal: Pentasa Suppository; rectal suspension (Ferring Inc)

Rectal: Salofalk Suppositories; rectal suspension (Aptalis Pharma)

Rectal: Mezera Suppository; foam enema (Avir Pharma Inc.)

Drug on NIOSH List: No

Oral: Ziagen Tablet (ViiV Healthcare)

Oral: Ziagen Oral solution (ViiV Healthcare)

Intragastric: Ziagen oral solution (Glaxosmithkline Inc)

Intrajejunal: Ziagen oral solution (Glaxosmithkline Inc)

Drug on NIOSH List: No

Oral: Kivexa film-coated immediate release tablet (ViiV Healthcare)

Drug on NIOSH List: No

Oral: Triumeq film-coated tablet (ViiV Healthcare)

Nasogastric: Triumeq Tablet (ViiV Healthcare)

Drug on NIOSH List: No

Oral: Trizivir film-coated immediate release tablet (ViiV Healthcare)

Drug on NIOSH List: No

Oral: Glucobay tablet (Bayer Inc)

Intragastric: Glucobay tablet (Bayer Inc)

Intrajejunal: Glucobay tablet (Bayer Inc)

Drug on NIOSH List: No

Oral: Sectral capsule (Sanofi-Aventis)

Intragastric: Sectral capsule (Sanofi-Aventis)

Intrajejunal: Sectral capsule (Sanofi-Aventis)

Drug on NIOSH List: No

Oral: Sintrom tablet (Paladin Laboratories Inc)

Intragastric: Sintrom tablet (Paladin Laboratories Inc)

Intrajejunal: Sintrom tablet (Paladin Laboratories Inc)

Drug on NIOSH List: No

Drug on NIOSH List: No

Oral: Diamox tablet (Goldshield)

Intragastric: Diamox tablet (Goldshield)

Intrajejunal: Diamox tablet (Goldshield)

Drug on NIOSH List: No

Oral: Parvolex injectable prepared for oral use (Celltech)

Intragastric: Parvolex injectable prepared for oral use (Celltech)

Intrajejunal: Parvolex injectable prepared for oral use (Celltech)

Drug on NIOSH List: No

Oral: Soriatane capsule (Roche)

Intragastric: Soriatane capsule (Roche)

Intrajejunal: Soriatane capsule (Roche)

Drug on NIOSH List: No

Oral: Zovirax oral suspension (Glaxosmithkline Inc)

Oral: Zovirax tablet (Glaxosmithkline Inc)

Intragastric: Zovirax tablet (Glaxosmithkline Inc)

Intrajejunal: Zovirax tablet (Glaxosmithkline Inc)

Drug on NIOSH List: No

Intragastric: Fosamax Tablet (Merck Frosst Canada Ltd)

Intrajejunal: Fosamax Tablet (Merck Frosst Canada Ltd)

Drug on NIOSH List: No

Intragastric: One-Alpha Oral drops (Leo Pharma Inc)

Intrajejunal: One-Alpha Oral drops (Leo Pharma Inc)

Drug on NIOSH List: No

Oral: Xatral Prolonged-release tablet (Sanofi-Aventis)

Drug on NIOSH List: No