Pharmacy & Therapeutics - March 2009 - (Page 151) PPIs in Enteral Nutrition White et al.30 One additional in vitro study sought to determine whether the method of delivery or bore size affected the delivery rate of esomeprazole pellets. White et al. evaluated two sizes of nasogastric tubes and a size 20 French gastrostomy tube. They used current manufacturer guidelines for nasogastric administration; therefore, results for only the gastrostomy tube are reviewed here. The authors tested delivery methods tested by administering medication in one or two steps. However, they tested the gastrostomy tube by only the one-step method, noting that almost 99% of pellets were delivered via gastrostomy tubing. No significant differences were observed between gastrostomy tubes and size 14 French nasogastric tubing. Jejunostomy Phillips et al.31 or their potential to be retained in the tubing. For jejunostomy tubes, only omeprazole has been studied. All administration methods cited in this article are listed in Table 3 along with a summary of their efficacy or bioavailability. When giving PPIs via a nasogastric tube, health care professionals should follow all manufacturer recommendations regarding preparation and administration (see Table 2). Care should be taken with children and adolescents, because nasogastric administration has not been consistently found to be highly effective except for liver and intestinal transplant patients. Omeprazole and lansoprazole have been effective when they are administered via gastrostomy tube. In vitro data suggest that esomeprazole may be a suitable option as well. For patients with a jejunostomy tube, only omeprazole has been effective. Published studies describing the administration of PPIs via a jejunostomy tube are exceedingly limited. Only one study was available. Phillips et al. evaluated pharmacokinetic parameters and gastric pH using omeprazole suspension in nine critically ill surgical patients in the intensive-care unit. The authors found that the Tmax was significantly lower with the jejunal route (12.1 minutes) than with nasogastric administration (108.3 minutes) (P < 0.001). The Cmax was also significantly higher with jejunal tubing (1.833 mcg/mL) than with nasogastric administration (0.970 mcg/mL) (P = 0.0006). Although these two pharmacokinetic parameters did differ, the bioavailability of each administration route did not, indicating only limited to no clinical significance for the kinetic differences seen. Baseline pH rose from 1.63 to greater than 4 throughout the study period for patients who received omeprazole via the jejunal route. However, over a 24-hour period, jejunal administration resulted in a significantly lower mean pH when compared with nasogastric administration (5.57 vs. 6.32, respectively; P = 0.015). REFERENCES 1. Lexi-Drugs. Hudson, OH: Lexi-Comp, Inc. Available at: http:// online.lexi.com/crlonline. Accessed September 30, 2008. 2. DiPiro JT, Talbert RL, Yee GC (eds). Pharmacotherapy: A Pathophysiologic Approach, 6th ed. New York: McGraw-Hill; 2005. 3. Hoogerwerf WA, Pasricha PJ. Pharmacotherapy of gastric acidity, peptic ulcers, and gastroesophageal reflux disease. In: Hardman JG, Limbird LE (eds). Goodman and Gilman’s The Pharmacological Basis of Therapeutics, 11th ed. New York: McGraw-Hill; 2001. 4. Bistrian Br, Driscoll DF. Enteral and parenteral nutrition therapy. In: Fauci A, Braunwald E, Kasper DL, et al. (eds). Harrison’s Principles of Internal Medicine, 17th ed. McGraw-Hill; 2008. Stat!Ref Online Electronic Medical Library. Jackson, WY. Available at: http://online.statref.com. Accessed June 2, 2008. 5. Nexium (esomeprazole), package insert. Wilmington, DE: AstraZeneca; February 2008. 6. Prevacid (lansoprazole), package insert. Lake Forest, IL: Tap Pharmaceuticals; July 2007. 7. Prilosec (omeprazole), package insert. Wilmington, DE: AstraZeneca; March 2008. 8. Zegerid (omeprazole/sodium bicarbonate), package insert. San Diego, CA: Santarus, Inc.; January 2008. 9. Protonix (pantoprazole), package insert. Philadelphia, PA: Wyeth Pharmaceuticals; May 2008. 10. Aciphex (rabeprazole), package insert. Woodcliff Lake, NJ: Eisai, Inc.; February 2007. 11. Larson C, Cavuto NJ, Flockhart DA, Weinberg RB. Bioavailability and efficacy of omeprazole given orally and by nasogastric tube. Dig Dis Sci 1996;41(3):475–479. 12. Phillips JO, Metzler MH, Palmieri MT, et al. A prospective study of simplified omeprazole suspension for the prophylaxis of stressrelated mucosal damage. Crit Care Med 1996;24(11):1793–1800. 13. Tuleu C, Arenas-Lopez S, Robinson C, et al. ‘Poppy seeds’ in stomach aspirates: Is oral omeprazole extemporaneous dispersion bioavailable? Eur J Pediatr 2008;167:823–825. 14. Haizlip JA, Lugo RA, Cash JL, Vernon DD. Failure of nasogastric omeprazole suspension in pediatric intensive care patients. Pediatr Crit Care Med 2005;6(2):182–187. 15. Olsen KM, Bergman KL, Kaufman SS, et al. Omeprazole pharmacodynamics and gastric acid suppression in critically ill pediatric transplant patients. Pediatr Crit Care Med 2001;2:232–237. 16. Kaufman SS, Lyden ER, Brown CR, et al. Omeprazole therapy in pediatric patients after liver and intestinal transplant. J Pediatr Gastroenterol Nutr 2002;34(2):194–198. 17. Dunn A, White CM, Reddy P, et al. Delivery of omeprazole and lansoprazole granules through a nasogastric tube in vitro. Am J Health Syst Pharm 1999;56:2327–2330. 18. Chun AHC, Shi HH, Achari R, et al. Lansoprazole: Administration of the contents of a capsule dosage formulation through a nasogastric tube. Clin Ther 1996;18(5):833–842. continued on page 160 Vol. 34 No. 3 • March 2009 • CONCLUSION Selecting agents to be included on an institutional formulary can be a daunting task for P&T committee members, particularly when several agents in a class exist with multiple formulations. PPI administration to hospitalized patients is a daily occurrence; therefore, the selection of one agent to include on the formulary is likely to be the most cost effective. When choosing an appropriate agent to interchange for the class, one would hope to ensure similar efficacy with the lowest cost possible and the flexibility to administer the medication in special populations. Almost all PPIs may be given in some form via a nasogastric tube. Care must be taken to ensure that medications do not adhere to or clog the tubing. Health care professionals must consider many factors when administering a PPI via nasogastric tubing. Most frequently, the size of the tubing’s diameter, the pellets, or the granules can affect the procedure; however, in populations such as the critically ill or pediatric patients, factors such as volume and sodium status must be considered as well. Only three PPIs for delivery by gastrostomy tubes have been reported in the literature to support either their efficacy P&T® 151 http://online.lexi.com/crlonline http://online.lexi.com/crlonline http://online.statref.com
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