A nasogastric tube and four tablets that cannot be crushed
A 78-year-old man is transferred to a rehabilitation ward 2 weeks after a stroke, with a fine-bore nasogastric tube in situ and dysphagia expected to last months. His regular medicines are aspirin 75 mg enteric-coated tablets, omeprazole 20 mg gastro-resistant capsules, nifedipine gastrointestinal therapeutic system (GITS) 30 mg once daily, sodium valproate 500 mg modified-release tablets twice daily and ferrous sulfate 200 mg once daily. The ward nurse plans to crush all of them, mix with water and give them together as a single syringe bolus, followed immediately by a 200 mL enteral feed. The pharmacist is asked to approve the plan.
1. For each of the five medicines, state whether it can be given through the tube, and what you would recommend instead if it cannot.
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Aspirin 75 mg enteric-coated - do not crush. Crushing destroys the coat and delivers an irritant dose to the stomach with no benefit. Change to dispersible aspirin 75 mg, dispersed in water and given through the tube.
Omeprazole 20 mg gastro-resistant capsules - open, do not crush. The enteric-coated granules must not be crushed or chewed; they can be dispersed in about 10 to 15 mL of slightly acidic liquid (water or apple juice) and given through the tube within 30 minutes, then flushed. If the tube is too fine for the granules, ask for a soluble or intravenous alternative (for example esomeprazole or pantoprazole injection) until swallowing returns.
Nifedipine GITS 30 mg - never crush or open. The tablet is an osmotic pump; crushing gives an uncontrolled dose with profound hypotension and loses the 24-hour profile. Switch to amlodipine 5 mg once daily, which can be dispersed in water and given through a tube with the same clinical intent.
Sodium valproate 500 mg modified-release - do not crush. Crushing turns it into an immediate-release dose with peak-related toxicity and troughs that may allow seizures. Change to sodium valproate oral solution (for example 200 mg/5 mL), giving 12.5 mL twice daily, and counsel that liquid and modified-release products are not interchangeable without checking the level; recheck the plasma concentration 1 to 2 weeks after the switch and watch for gastrointestinal upset.
Ferrous sulfate 200 mg - can be crushed and dispersed. Flush well afterwards; expect dark stools and constipation, and separate from other medicines by flushing, since iron can bind some drugs in the tube.
Overall: four of the five need a formulation change, so this is a prescribing conversation, not a nursing instruction.
2. Critique the administration plan itself (single bolus, immediately before feed) and describe how these medicines should be given through the tube.
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What is wrong with the plan:
- All together in one bolus removes any chance of identifying which drug caused a blockage or a reaction, and mixing medicines risks physical and chemical incompatibility (for example iron with omeprazole).
- No flushing between doses promotes tube blockage, especially with crushed modified-release matrices.
- Immediate feed matters for some drugs: enteral feed can bind medicines and reduce absorption and is a particular issue for drugs like phenytoin; as a standard, give each medicine separately, flush with 15 to 30 mL of water before and after, and pause the feed for at least 30 minutes either side where absorption is critical.
- Aspirin and nifedipine should not be crushed at all, so the plan has to change before technique is discussed.
Correct sequence:
- Stop the feed; flush the tube with water.
- Give each medicine one at a time, each dispersed in its own syringe with its own 15 to 30 mL water flush.
- Give the dispersible aspirin and amlodipine first, then valproate liquid, then omeprazole granules, then iron last with a generous flush (iron is the most likely to stain or block).
- Restart the feed 30 minutes later.
- Use a 50 mL enteral syringe, never a small syringe that generates high pressure, and never force a blocked tube.
Monitoring: blood pressure after the amlodipine switch, valproate level and seizure control, and a stool history for iron. Document the whole plan in the medicine chart so it survives shift changes.