TAM (Treatments and Medicines) NHS Highland
First flush enteral feeding tube with 15 to 30mL water, crush and/or disperse tablet in 10 to 15mL water (or more if required), immediately administer dose using an oral syringe. Rinse crusher, medicine pot and syringe with 10mL water and administer rinsing fluid. Reflush enteral feeding tube with 15 to 30mL water. Flush tube between each medication and at the end. Use tap water to flush enteral feeding tubes. For administration beyond the stomach sterile water is advised. In fluid restricted patients revise the recommended flush volume to meet prescribed fluid restriction.
Parkinson's disease - alternative ways to administer medication (Guidelines)
Warning
Important notes - please read before using the information in these pages.
- This is general information and may not apply to all patients. If necessary, seek advice from the prescriber, specialists (see contact details in Parkinson’s disease guideline) or Medicines Information.
- Always clearly prescribe the route of administration, eg ‘crush tablet and give by nasogastric (NG) tube’.
- Crushing or dispersing non-dispersible tablets means that the medicine will be administered outwith the terms of its product license with liability being assumed by all those involved in the medicines administration process, including prescriber, dispensing pharmacist and nurses administering the medicine.
- Use tablet crushers designed specifically for this purpose, these can be obtained through PECOS system.
- Where tablets are dispersed ensure that the whole tablet content is rinsed from tablet crushers, medicine pots and oral syringes and administered to the patient.
- Poorly soluble crushed tablets may pose an aspiration risk for patients with swallowing difficulties. Aim for a liquid with a uniform consistency.
- Crush or disperse tablets immediately prior to administration.
- It may be necessary to consider switching to a rotigotine patch if there is no route to administer Parkinson’s medicines using the guide below. See guidance in Inpatient management of Parkinson’s including nil by mouth guidance.
- Covert medicating is the administration of medication in a disguised form without the individual’s knowledge. It is not necessarily covert if given by NG, PEG or patch but it may be considered to be if the individual is not told that medication is being given. To avoid this please advise the individual that they are receiving their medication in this way. If they do not have capacity or are unconscious this may need to be discussed with their welfare attorney or guardian. See Policy for the Administration of Medicines by Nurses and Midwives in NHS Highland.
Drug | Alternative methods of administration | Notes |
Ropinirole tablets (Requip®) | Tablets may be crushed and mixed with water | Tablets can be crushed and mixed with water or soft food for patients with swallowing difficulties. The tablets can be crushed and mixed with water for administration via enteral feeding tubes. Tablets rapidly disintegrate when placed in 20mL water to give a fine dispersion. Administer immediately after preparation. |
Ropinirole modified-release tablets (Requip® XL) | Change to immediate-release ropinirole tablet | For conversion to immediate-release tablets, seek advice. |
Pramipexole tablets (Mirapexin®) | Tablets can be cut into equal halves or Tablets may be crushed and mixed with water | Tablets can be divided into equal halves using a tablet cutter. The tablets are light sensitive and should be administered shortly after crushing. |
Pramipexole modified-release tablets (Mirapexin Prolonged-Release®) | Change to immediate-release pramipexole tablets | For conversion to immediate-release tablets, seek advice. |
Domperidone tablets | Use oral suspension or tablets will disperse in water or can be crushed and mixed with water | Suspensions should be used for enteral feeding tubes to avoid blockage. Suspension should be diluted with an equal volume of water for administration via enteral tubes. Suspension contains sorbitol. |
Co-beneldopa dispersible tablets (Madopar®) | Dispersible tablets can be given via enteral feeding tubes | Tablets disperse in 10ml of water within 2 minutes to give a cloudy white dispersion. Administration after food may delay/reduce absorption of levodopa. See notes below regarding enteral administration of preparations containing levodopa. |
Co-beneldopa immediate release capsules (Madopar®) | Use dispersible Madopar® tablets | Madopar® capsules and dispersible tablets are dose equivalent. Onset of action may be quicker for dispersible tablets; monitor the patient for any change in effect due to altered bioavailability. See notes below regarding enteral administration of preparations containing levodopa. |
Co-beneldopa modified-release capsules (Madopar® CR) | Change to dispersible Madopar® tablets | Patients taking Madopar® CR need to have their dosage and administration times tailored when converting to dispersible tablets. Seek advice. See notes below regarding enteral administration of preparations containing levodopa. |
Co-careldopa tablets(Sinemet®) | Tablets can be dispersed in water or change to dispersible Madopar® | Lower strengths disperse within one minute. 25/250 strength disperses within one to 5 minutes. Give immediately when dispersed as the drug will degrade. The dispersed tablets may settle at the bottom of the container/syringe; ensure that the whole dose is administered. Direct dose conversion between Sinemet® and Madopar® may not be appropriate in all patients. For conversion to Madopar®, withdrawal of therapy and retitration of dose may be necessary. Seek advice. See notes below regarding enteral administration of preparations containing levodopa. |
Co-careldopa modified-release tablets | Change to immediate-release Sinemet® tablets and increase dosing frequency or change to dispersible Madopar® | For conversion to immediate-release tablets seek advice. Direct dose conversion between Sinemet® and Madopar® may not be appropriate in all patients. For conversion to Madopar®, withdrawal of therapy and re-titration of dose may be necessary. Seek advice. See notes below regarding enteral administration of preparations containing levodopa. |
Co-careldopa plus entacapone tablets (Stanek®) | Use the separate components (co-careldopa and entacapone) or change to dispersible Madopar® | See entries in table for administration of entacapone and co-careldopa If changing to Madopar®, dose adjustments may be necessary, seek advice. See notes below regarding enteral administration of preparations containing levodopa. |
Selegiline tablets | disperse tablets in water | Selegiline tablets can be dispersed in water and should disperse within one minute. This method is suitable for use with enteral feeding tubes or for patients with swallowing difficulties. |
Rasagiline | Tablets may be crushed and mixed with water | |
Entacapone tablets (Comtess®) | Disperse tablets in water | Either place the tablet in a syringe with 10mL water and shake for 5 minutes or place in medicine pot with 10mL water and allow to disperse (takes 1 to 5 minutes). The dispersion is a bright orange colour and will stain enteral tubes, skin and clothing. Entacapone does not fully dissolve in water, so if giving via enteral feeding tube, the tube should be well flushed after administration. Avoid crushing tablets as this produces red dust which will stain. Crushed tablets may be administered orally with jam, honey or orange juice to cover bitter taste. |
Amantadine capsules | Capsules may be opened and the contents mixed with water or change to syrup | Amantadine is highly soluble in water. For long-term use consider transferring to syrup. If the syrup is used, monitor total daily intake of sorbitol. |
Notes: Problems with enteral administration of preparations containing levodopa (Madopar®, Sinemet®)
- Levodopa is absorbed mainly in the jejunum. Administering directly to the site of absorption (J or NJ) may result in unexpected drug levels and side-effects.
- High protein in the gut from enteral feed may alter absorption of levodopa and cause fluctuations in response to the drug. Drug administration should be consistent in relation to feed administration times.