Pharmacy & Therapeutics - March 2009 - (Page 148) PPIs in Enteral Nutrition Table 3 Alternative Methods of Enteral Tube Administration of Proton Pump Inhibitors (PPIs): Recipes and Efficacy continued Study Sharma et al.24 Tube Gastrostomy PPI Omeprazole Recipe 1. Flush tube with 15 mL of orange juice. 2. Empty contents of capsule into syringe. 3. Administer contents of syringe using small amounts of orange juice until all granules are administered. 4. Flush tube with 15 mL of orange juice. 1. Place contents of 20-mg capsule into 15-mL syringe. 2. Draw 10 mL of 8.4% sodium bicarbonate solution into syringe. 3. Gently shake for 10–15 minutes until white suspension forms. 4. Administer; flush tube with 10–15 mL of tap water. Efficacy Effective in raising baseline pH and in maintaining therapeutic pH for most of a 24-hour period. Effective in raising baseline pH. Sharma et al.25 Gastrostomy Omeprazole Sharma et al.26 Gastrostomy Lansoprazole 1. Empty contents of 30-mg capsule into a 30-mL Effective in raising baseline catheter-tipped syringe. pH. 2. Add 1.5 fluid ounces of orange juice to administer granules. 3. Flush tube with an additional 1.5 fluid ounces of orange juice. 1. Empty contents of 30-mg capsule into 15-mL syringe. 2. Draw 10 mL of 8.4% sodium bicarbonate into syringe. 3. Gently shake for 10–15 minutes until granules dissolve and a white suspension forms. 4. Administer immediately; flush tube with 10–15 mL of tap water. Effective in raising baseline pH. Sharma et al.27 Gastrostomy Lansoprazole White et al.30 Gastrostomy Esomeprazole 1. Empty contents of capsule into 60-mL catheter-tipped syringe. 2. Add 50 mL of water. 3. Replace plunger, leaving 5 mL of air between liquid and plunger. 4. Shake syringe until all pellets move throughout syringe. 5. Shake syringe vigorously from front to back for 15 seconds. 6. Attach to tube; administer contents over 30 seconds; use gentle side-to-side shaking. Omeprazole 1. Dissolve contents of two 20-mg capsules in 20 mL of 8.4% sodium bicarbonate solution. 2. Gently shake to ensure mixing. 3. Administer contents; flush tube with 10 mL of water. In vitro administration resulted in delivery rate of approx. 99%. Phillips et al.31 Jejunal Higher Cmax.; faster Tmax compared with nasogastric administration; effective at raising and maintaining pH of less than 4. AUC = area under the curve; Cmax = maximum concentration; Tmax = time of maximum concentration. pH remained above 4 and was maintained at this level for 97.8% ± 5.4% of the time after multiple dosage intervals. Mean maximum concentration (Cmax ) and area-under-the-curve (AUC) values were significantly greater after multiple dosing intervals compared with the first dosing interval, as follows: Cmax initial = 812 ± 409.1 vs. Cmax multiple = 1,258.7 ± 286.2 (P < 0.05) AUC initial = 4,956.3 ± 3,305.4 vs. AUC multiple = 7,622.9 ± 2,738 (P < 0.05) Kaufman et al.16 In another study of 22 liver and/or intestinal transplant pediatric patients, omeprazole was effective in suppressing gastric pH. Patients received omeprazole 0.5 mg/kg twice daily. Measured outcomes were gastric pH and the percentage of time spent with the pH above 4. Baseline pH, after the initiation of therapy, did not differ between patients undergoing liver transplantation (6.2 ± 0.5) or intestinal transplantation (6.1 ± 0.4). In addition, the time spent with the pH above 4 did not differ between liver transplant patients (86% ± 7%) and intestinal transplant patients (81% ± 8%). Finally, the time spent with the 148 P&T® • March 2009 • Vol. 34 No. 3
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