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Article

The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients

1
Department of Pharmacy, University of Genoa, Viale Cembrano, 16148 Genoa, Italy
2
Hospital Pharmacy, Department Technical Health, San Paolo Hospital, Via Genova, 17100 Savona, Italy
3
Department of Sciences for the Quality of Life, University of Bologna, Corso D’Augusto 237, 47921 Rimini, Italy
*
Authors to whom correspondence should be addressed.
J. Pers. Med. 2022, 12(8), 1307; https://doi.org/10.3390/jpm12081307
Submission received: 22 July 2022 / Revised: 3 August 2022 / Accepted: 8 August 2022 / Published: 12 August 2022
(This article belongs to the Section Evidence Based Medicine)

Abstract

:
Usually, the administration of drugs by feeding tube in dysphagic patients involves handling of marketing licenses outside their term, due to the lack of suitable formulations. This circumstance has put health professionals in the dilemma of choosing the formulation whose manipulation possibly does not alter the effectiveness of the drug. In this regard, a practical guide providing indications on the prescription, handling, and administration of drugs through enteral feeding tube could be of paramount utility. For this purpose, we have considered the 1047 solid oral pharmaceutical forms included in the formulary of San Paolo Hospital (Savona, Italy). From our analysis, it emerges that 95% of medicinal products are worryingly used off-label and 40% have to be managed by the hospital pharmacists without having suitable indications by either the manufacturers or by literature studies. To fill this gap, we have compiled a detailed table containing missing indications derived from pharmacist expertise and evidence-based practices, with the aim that the sharing of our procedures will contribute to make uniform pharmacological therapies from one hospital to another. This study will allow doctors to have easy access to information on drugs that can be prescribed and nurses to become familiar only with the pharmaceutical forms that can be administered.

Graphical Abstract

1. Introduction

In the past, interest in enteral nutrition (EN) was rather low, due to the introduction of new and safer parenteral administration techniques. However, in the last two decades, EN through percutaneous endoscopic gastrostomy (PEG) has been reevaluated as a valid metabolic rebalancing therapy, both by virtue of an improvement in the quality of the tubes and nutritional mixtures used. Additionally, thanks to the recent dietary and physiological acquisitions of the digestive system, a more correct overview of the limitations of total parenteral nutrition (TPN) has been achieved [1,2,3]. According to the guidelines of the European Society for Clinical Nutrition and Metabolism (ESPEN) on EN in adults [4], in all the conditions in which an indication for artificial nutrition (AN) is present and where there is normal functioning of the gastrointestinal tract with the possibility of covering needs by the enteral route, EN should be considered the first choice nutritional technique. In fact, it has been demonstrated that EN is simpler, more physiological less expensive, and safer than TPN, since it avoids the risks of venous catheter infections [5]. Furthermore, it is therapeutically superior to TPN, as the nutrients perform a direct trophic action on the intestinal lumen by inducing the release of trophic hormones and supporting the structural and functional integrity of the intestinal mucosa, which seems essential for maintaining immune function [6]. In our territory, managed by the local health authority ASL 2 Savonese (Liguria, Italy), the data are confirming this trend, as from 2019 to 2021, the hospitalized patients, both adults and pediatrics, requiring EN were 706, and 142 were EN patients in affiliated nursing homes (RSA) and 202 those at home from 2021 to April 2022.
In clinical practice, the feeding tube is also necessarily used as a route of administration for pharmacological therapies, because this route is less risky for systemic infections (septicemia) and more economical with respect to parenteral drug administrations [5]. Even considering that injectable formulations have the great advantage of ensuring the total absorption of the drug and do not require any formulation manipulations, they are not suitable for long-term use [2]. On the contrary, the administration of drugs by the feeding tube usually involves handling of marketing licenses outside their term (off-label use), due to the inadequacy of medicines on the market for this route of administration [6]. Consequently, to avoid undesired therapeutic failures, health care professionals must face daily the dilemma of choosing formulations whose manipulation does not alter drug efficacy. Although the use of enteral feeding tubes has become widely employed for the administration of both nutrients and pharmacological therapies, the lack of standardized guidelines and protocols at both national and international level is a limit to the homogeneity and appropriateness of administrations and prescriptions. Therefore, for patients subjected to EN, there are particular situations where the administration of oral medicines can be a pharmaceutical challenge.
Consequently, this study arose from the necessity to accomplish a proper therapy for dysphagic adult and pediatric patients, whose needs are usually unmet by the pharmaceutical companies. In this context, the role of the hospital pharmacist is essential in selecting and compounding the medicinal product able to ensure the best outcomes of the pharmacological therapy. In the case of patients subjected to EN, it becomes impossible to keep the medicinal product intact, since it is often necessarily crushed or diluted. Meanwhile, it would be mandatory to guarantee that such manipulations do not affect the pharmacokinetics of the drug, and that no interaction between the drug and the nutritional mixture could occur. The essential need to ensure a therapy for dysphagic patients too often pushes health-care professionals to seek impromptu solutions, in which it may happen that not all the necessary pharmaceutical items have been evaluated. In fact, the guidelines still refer to general behavior and general principles, without directing towards specific protocols. In this scenario, off-label drug administrations—sometimes adequate, others often incorrect—have been justified.
From these considerations, it is clear there is a need for shared procedures deriving from the fusion between clinical practice and what exists in the field of academic research. The aim of our study was to provide a practical guide on the correct use of solid oral formulations for patients subjected to EN through PEG. With this purpose, practical suggestions for the prescription, methods of handling, and administration of drugs through enteral feeding tube not only in hospitals but also at home have been provided in form of a reader-friendly and easily consultable table. We report advice received from manufacturers, collected from the literature, or deriving from the experience born within the pharmacy of the hospital. Particularly, we firstly asked pharmaceutical companies to share information regarding active pharmaceutical ingredient (API) stability following manipulation of the formulation and change of route of administration. Secondly, we analyzed the medicines managed by the local health authority ASL 2 Savonese, providing information about their suitability for administration by tube. In addition, extemporaneous liquid formulations of some drugs to be administered through the enteral tube are proposed, which can be of valuable help in order to make therapies uniform and to improve the quality of medical practice. Finally, we have also outlined the procedure for hospital staff to administer pharmacotherapy by tube.

2. Materials and Methods

The medicinal products considered were those available in the district area of Liguria (Italy), according to the local formulary PTRO (Prontuario Terapeutico Ospedaliero Regionale), and according to the minor formulary ASL 2 Savonese. The list of medicines analyzed comprises 1047 solid oral pharmaceutical forms, equal formulations but with a different dosage from the same company, have been grouped together in the same line, thus obtaining a list of 701 formulations. The information regarding the splittability/crushability of the considered medicinal products was obtained by evaluating the summary of product characteristics (SmPC) of the drug (source: Italian Medicines Agency AIFA, Agenzia Italiana del Farmaco database) [7] and in particular by analyzing qualitative and quantitative composition, pharmaceutical form, posology, and method of administration.
Meantime, 124 pharmaceutical companies were contacted with a specific letter, requesting detailed information on the API’s stability upon crushing of the tablets or opening of the capsules (1), on suitability of mortar for crushing (2), and on possible recommendations for API administration via tube or alternative routes (3) (Figure 1).
Other eminent sources considered were the practical guidelines from the Società Italiana di Nutrizione Artificiale e Metabolismo (SINPE) and European Society for Clinical Nutrition and Metabolism (ESPEN). In particular, the SINPE guideline on Nutrizione Artificiale Ospedaliera [8] and the ESPEN guideline on home enteral nutrition [9]. In addition, since administration via tube is a route that in most cases is not provided for in the SmPC, some information has been extrapolated by consulting the Handbook of Drug Administration via Enteral Feeding Tubes on behalf of the British Pharmaceutical Nutrition Group [10] and reading published studies present in the literature (PubMed database). Finally, indications of use were established also by analyzing the list of excipients employed by the producer. In these instances, the directions provided are based on the pharmacist’s practical experience and knowledge. The sources chosen to evaluate the suitability of drug administration via tube are summarized in Table 1 in hierarchical order.
For each solid oral drug formulation listed in the hospital formulary, the Anatomical Therapeutic Chemical (ATC) Classification System, the name of the API, the trade name, the manufacturer, the pharmaceutical form, if the product can be administered via tube or not, instructions for handling, and finally the sources of the information are highlighted in different colors according to their level of reliability. An attempt was made to provide as much information as possible: the events that the administration by tube can be carried out, when to administer the drug, compatibility between the drug and EN, and the presence of some particular excipients (e.g., alcohol).
Since the use of oral liquid pharmaceutical forms creates a minimal risk of tube obstruction and ensures adequate absorption of the drug, a switch from a solid oral formulation to a corresponding one in liquid form was considered advisable whenever possible. However, the liquid formulations may be hyperosmolar and require appropriate dilution. The volume of water (V) to be added has been calculated with the following formula:
V f = V i × m O s m i n i t i a l   k g m O s m d e s i r e d   k g
V = V f V i
where mOsmdesired is 300–500 mOsm/kg, mOsminitial is the osmolality of the pharmaceutical product, Vi is the volume of the liquid pharmaceutical product before handling, and Vf is the volume of the final product with the desired osmolality.
To complete our study, we reported the most numerous extemporaneous liquid preparations intended to be administered by PEG to patients in the Neurology, Internal Medicine, and Otorhinolaryngology departments of the San Paolo Hospital in Savona.

3. Results and Discussion

3.1. Drug Formulations for Administration by Tube: The Pivotal Role of the Pharmacist

The therapeutic process is defined as the sum of several phases, including drug procurement, storage, preservation, stock management, prescription, preparation, administration, and the evaluation of side effects and/or benefits (Italian Ministry of Health, recommendation n. 7 for the prevention of death, coma, or severe damage arising from errors in drug therapy) [11]. Such definition evidences that there may be numerous factors that can lead to an unreliable therapy, and meanwhile health-care professionals must be able to ensure that the hospitalized patients receive the appropriate drug in the correct pharmaceutical form and route of administration. Specifically, the skills of the hospital pharmacist, in the context of preventing errors in therapy, could play a key role in evaluating the correct and safe use of drugs, both in the prescription and in the administration phase. In fact, it has been already demonstrated that pharmacy intervention can significantly reduce the number of errors related to administering medication through the enteral feeding tube with minimal additional workload [12].
Nowadays, the need to carry out a correct manipulation of oral drugs to be administered to patients subjected to EN is an increasingly emerging problem. Before deciding whether to modify the original pharmaceutical form in any way, the compounding pharmacist refers to SmPC, but, unfortunately, the clinical studies on the bioavailability of oral pharmaceutical forms performed by the companies rarely consider administration via artificial tubes. In most cases, manufacturers lack data to support the chemical stability of tablets when crushed and dispersed in water prior to use, and there are no studies comparing the efficacy or bioavailability of split and crushed solid pharmaceutical forms, which means that no company feels able to provide recommendations on the use of drugs by means of a tube. In this study, we contacted 124 pharmaceutical companies to obtain more detailed information on drug stability after crushing or switching routes of administration. Unfortunately, only one company (0.8%) gave us further information. In most cases, companies only suggested referring to the SmPC. Indeed, drug stability assessment performed by pharmaceutical companies generally involves the testing of the drug substance or drug product using a stability-indicating method in order to establish the retest period (for premarket stability) and shelf life (for commercial stability). Since the companies had not carried out any evaluation of the stability of the drug after handling and/or change of administration route, they avoided taking any kind of responsibility in giving us advice. However, before resorting to off-label use, the general indications stress first of all evaluation of the existence of formulations suitable for alternative routes to oral administration. Table 2 shows APIs for which there are multiple options of routes of administration.
When such alternatives are not suitable, as indicated in the column of limitations, or only oral formulations are available, the PEG also becomes a unique access route for drug administration. In these cases, the SINPE guideline for Hospital Artificial Nutrition states that the administration of drugs by enteral tube preferably requires the use of liquid pharmaceutical forms, when available, or as a last resort the trituration of the solid forms and their dispersion in a suitable solvent [8]. It must be considered that switching from one formulation to another may involve dose adjustment and careful monitoring of the plasma levels of the drug for imperfect equivalence between the different formulations (e.g., liquid phenytoin vs. tablets) [13]. This raises a number of issues regarding the responsibility of such administrations and of any adverse effects that the patients may experience.
Many members of health-care teams, especially pharmacists, are in a position to raise the awareness of potential drug–nutrient interactions and incompatibilities that may derive from the off-label use of a drug. Pharmaceutical incompatibility arises in dosage forms where the release of API is controlled by enteric or delayed coatings. In these cases, the manipulation (i.e., trituration) of the medicinal product leads to an immediate release and absorption of the API with overdose at the start of treatment and subtherapeutic dosages thereafter. As shown in Figure 2, modified-release tablets are the fourth most numbered formulation and all the modified-release solid oral formulations, including gastroresistant ones, represent the 12% of the total medications included in the Savona hospital formulary.
Pharmacological incompatibility manifests itself with an alteration in pH, motility, or gastrointestinal secretions resulting from a pharmacological effect of the drug and generally alters the tolerance or absorption of enteral nutrition and/or the absorption of other drugs administered in polypharmacy. It is the case of drugs with anticholinergic effect that relax smooth muscle and inhibit gastric motility, such as antihistamines (promethazine, diphenhydramine, etc.), tricyclic antidepressants (amitriptyline, imipramine, maprotiline, trimipramine, etc.), phenothiazines (chlorpridomazine, etc.), and antiparkinsonians (biperidene, trihexyphenidyl, bornaprine, orphenadrine, etc.).
Pharmacokinetic interactions can occur following the simultaneous administration of drugs and EN blends since the nutritional mixtures can alter the processes of release, absorption, distribution, metabolism, and excretion of drugs, which, in turn, can alter the kinetics of nutrients. Clinically, the most significant drug–enteral feeding interactions concern phenytoin and carbamazepine. The greatest number of compatibility studies with EN preparations have been performed for phenytoin [14]. The plasma levels of the drug were lower (70–80%) when administration was associated with EN, while they increased when EN was interrupted 2 h earlier and restored 2 h later. The mechanisms proposed were different, from the joining of the drug to the proteins or electrolytes of the nutrition mixture to the alteration of the solubility. It was observed that the interaction was more evident when phenytoin was introduced directly at the jejunal level, perhaps due to a decrease the time of intestinal transit. It is well known that the absorption of theophylline varies according to the composition of the diet; therefore, to avoid a 60–70% decrease in drug absorption, due to the increased metabolism that some diets (rich in proteins and low in carbohydrates) cause, it is necessary to suspend enteral feed at least 1 h before administration and restore it 2 h after. For the sake of completeness, we point out that some drugs are optimally absorbed only on an empty stomach (e.g., tetracyclines, penicillins, rifampicin, verapamil, atenolol, captopril).
Pharmacodynamic interactions occur when alterations in the action of the drug are related to pharmacological antagonism at the receptor site. The vitamin K content of nutritional preparations can determine an antagonism towards the therapeutic action of oral anticoagulants, such as warfarin. Initially, it was thought that this antagonism was only to be attributed to the quantity of vitamin K contained in the nutritional mixtures and therefore preparations with low doses of the same (less than 75–78 mg/1000 kcal) were recommended. Recently, this antagonism has also been observed for preparations with minimal contents of vitamin K and therefore the decrease in the therapeutic effect of the drug has been related to an alteration of its absorption probably attributable to its union with soy proteins and caseinates. This makes monitoring the prothrombin time necessary to guarantee the anticoagulant effect, as well as the indication to prefer heparin in critical clinical conditions [15].

3.2. The Feasibility of Drug Administration by Enteral Feeding Tube

3.2.1. Liquid Formulations

The best choice of a formulation to be administered via tube could be represented by a liquid one. Indeed, the liquid formulations can be easily administered with sufficient tranquility by means of a tube and generally they are immediately diluted in gastric juices and promptly absorbed. However, the assumption that liquid formulations are the first choice may be questionable. Cosolvents, such as ethanol, glycerol, and propylene glycol, may be present in all drug formulations being used and the acceptable daily intake (ADI) may be easily exceeded. Therefore, before shifting from a solid dosage form to a liquid, it is recommended to consider this worrying issue, i.e., ranitidine syrup (Ranidil 150 mg/10 mL) [16].
Another noteworthy aspect relates to the osmolality of liquid formulations, which is one of the physical characteristics that most affect individual tolerance to a preparation. Osmolality values close to those of intestinal secretions are better tolerated (100–400 mOsm/kg H2O) [13]. Formulations having osmolality values higher than 6000 mOsm/kg H2O) if administered without dilution could cause intolerance phenomena, especially if introduced at high speed or with tubes located in the duodenum or jejunum. This type of interaction is sometimes misinterpreted as the symptoms tend to be attributed to an intolerance to nutritional support or to gastrointestinal infections resulting in an incongruous interruption of the enteral feeding. Sorbitol is a case in point. Sorbitol is a common excipient of liquid formulations, often used as a stabilizer and sweetener. High amounts (>10 g/day) can cause intraluminal production of gas and abdominal tension, and, at higher doses (>15 g/day), important secondary effects, such as abdominal spasms and diarrhea. Pharmaceutical forms with a high sorbitol content include iron protein succinylate oral solution (Rekord Ferro 40 mg/15 mL) [17] and acyclovir oral suspension (Aciclovir Dorom 400 mg/5 mL) [18]. In cases where antiviral therapy at 400 mg five times a day is required, it is easy to exceed sorbitol ADI. Mannitol may provide the same undesirable reactions. This often happens when using the oral route for medicinal products with exclusive parenteral indication. In routine practice, when the osmolality of the preparations is not known, it is advisable to dilute the medicine with at least 30 mL of water to make the administration in the stomach compatible, thus preventing diarrheic phenomena by osmotic effect. Moreover, some suspensions and syrups may be too viscous and lead to the obstruction of the tube, such as clotrimoxazole, amoxicillin–clavulanic acid, which should always be diluted with at least 100–150 mL of water and introduced through tubes of appropriate diameter. These drugs, in fact, in addition to the risk of obstruction, have a high tube-crossing time that leads to a delay in the administration time, resulting in a possible decrease in the dose effectively administered.
Also, formulations in drops are frequently hyperosmolar (e.g., clonazepam, digoxin), and the amount of water used for drug dilution must then be obviously counted in the water–electrolyte balance. In some cases, their administration is not recommended for the adhesion of the drug to the plastic walls of the tube, resulting in therapeutic ineffectiveness (e.g., diazepam [19], carbamazepine suspension [20]). Some other liquid medical solutions cause gastric motility to slow down, and the formation of insoluble gelatins in the presence of acids predispose to the formation of bezoars (indigestible deposits that can form in the stomach). In patients in coma, sedated or with altered state of consciousness and with gastroesophageal reflux, such aggregates can cause obstruction of the esophagus with sometimes impossibility of removal of the enteral probe itself (e.g., liquid sucralfate) [21].

3.2.2. Solid Formulations

Recommendation n.19 by the Italian Ministry of Health deals with the risks related with the crushing and splitting of oral solid formulations [22]. Capsules and tablets require necessarily manipulation for their administration via PEG tube. In addition, particular attention should be paid to the choice of enteral mixtures, because those characterized by a high protein concentration, especially containing caseinates, interact with numerous drugs, and, due to the high viscosity, cause clots obstructing the tube. Once again, to avoid tube obstruction, it is the responsibility of the pharmacist to carefully evaluate the components of the formulation (Figure 3).
Regarding the methods of administration via PEG, it should be noted that the infusion technique is very influential. In fact, the continuous-release mode (even if conducted with pumps) more frequently predisposes to clogging of the tubes because it does not allow washing between meals, as well as not leaving free margins for drug absorption in the fasting state. Therefore, bolus and intermittent techniques are preferable. For flushing the tube, no solution has been shown to be superior to water in preventing occlusion. Obstruction may arise also from inadequately crushed tablets, precipitate formation caused by interaction between feed and drug formulation, or between drugs, and consequently it is always suggested to give each API separately, avoiding the fixed formulations [23,24]. In addition, many known interactions between drugs and conventional foods are also applicable to EN. For example, amoxicillin and digoxin are adsorbed to the fiber contained in nutritional mixtures, aluminum salts induce the precipitation of dietary proteins, tetracyclines and ciprofloxacin form complexes with calcium, paracetamol is adsorbed by pectins, and phenytoin and warfarin bind to proteins [25].

3.3. Analysis of the Solid Oral Formulations Present in the Hospital Formulary

From the analysis of the solid oral formulations of the 701 drugs included in the hospital formulary, 339 (48%) cannot be crushed or administered via tube; however, for 211 of these (30%) alternative dosage forms or other routes of administration are possible (Figure 4). For the remaining 52% of active ingredients, however, their suitability for administration via PEG was found, but only for 5% of these, the possibility of crushing the tablet into a fine powder or opening the capsule in patients unable to swallow is indicated in the SmPC. This means that 95% of the drugs are given outside the terms of their product license.
Medication management is not so obvious. It often represents an area in which there can be many differences from one hospital to another due to the lack of standardized protocols. At San Paolo Hospital in Savona, the key role played by the hospital pharmacist is particularly evident from Figure 5, where the pharmacist’s expertise in administering a feeding tube therapy is necessary for the management of 40% of the formulations present in the hospital formulary. These data arose from the analysis of Table 3, which contains embedded all the collected information. Particularly, the different colors, both in Figure 5 and in Table 3, are indicative of the sources behind the decisions on the feasibility of using a solid pharmaceutical form administered by tube, and each color refers to a level of reliability, as reported in Table 1.
The practical suggestions embedded in Table 3 are partly available in the SmPC or were supplied by the companies at our request (green lines), partly present in the literature (pink lines), partly suggested by guidelines (light blue lines), and partly developed in the hospital pharmacy according to pharmacists’ knowledge (yellow lines). When the SmPC does not include information about the change in administration route, the suitability of a formulation to be administered via tube was taken, firstly considering the SINPE and ESPEN guidelines, where it is clearly stated that it is dangerous to break up prolonged-release drugs (retard formulations) or gastroresistant preparations, whose manipulation can cause overdoses or reduction of the therapeutic effect. Moreover, if the drug is in form of soft capsules, it is not possible to crush them nor is it advisable to pierce them to suck the content. The guidelines also suggest switching from the oral solid dosage form to the corresponding liquid form where possible and to administer one drug at a time. If any of these conditions are present, the pharmacist has to act accordingly (light blue lines). Instead, pink lines are representative of drugs, whose administration via tube was already experienced and reported in the literature, while the yellow colored lines report all cases where the pharmacist’s experience is essential to the preparation of the medicinal product. The importance of the pharmacist’s expertise in the administration of a therapy by the feeder tube is evident. Indeed, 40% of medicinal products have to be managed by the pharmacist without any data provided by the manufacturer, research studies, or evidence-based practices present in the literature.

3.4. Magistral Liquid Preparations

The analysis of the prescriptions within the hospital shows that liquid pharmaceutical forms are administered only to a small extent, despite being the most suitable for this route of administration. This low percentage of liquid forms can be partly explained by the lack of a wide availability of liquid medicinal products in the hospital formulary. As for the pharmaceutical form in most cases, tablets were prescribed, followed by liquid formulations (solutions, suspensions, and drops), powders for oral solutions, and capsules. To increase the administrations of liquid forms and meanwhile reduce the use of off-label prescriptions, the pharmacists are used to compounding some magistral preparations (Table 4).

3.5. Instructions for the Nursing Staff Concerning Administration of Drugs via Tube

The administration of drug therapy should be a unitary act, performed by the same person. It is necessary to avoid, as far as possible, interruptions during the preparation and administration of drugs. The main steps of the procedure can be listed as follows:
  • if the patient is undergoing EN, temporarily stop the infusion;
  • before administration, wash the probe with 30 mL of water;
  • take, where necessary, a tablet crusher, wash it with water and dry it, then grind the tablet to a fine powder;
  • put the powder or other pharmaceutical forms directly in a plastic cup, add 30 mL of water at room temperature, shake and dissolve (possibly with the help of a disposable plastic spoon);
  • once a solution or a suspension is obtained, draw it with a 60 mL catheter cone syringe (dedicated syringe for EN). Make sure there are no drug residues left in the glass;
  • check the correct positioning of the tube; insert the syringe cone into the tube connector and flush the medication dose down the feeding tube. If the medical prescription provides for the administration of several drugs at the same time, do not simultaneously grind several drugs and do not mix them in the same syringe, but it is necessary to rinse the tube between one drug and another with at least 5–10 mL of water to ensure that the tube is clean during the transition to the next drug;
  • rinse the tube with at least 40 mL of water after the administration;
  • restart the feed, unless a break is required.
A thorough description of the recommendations for each pharmaceutical form is summarized in Table 5.

4. Conclusions

The present paper has highlighted the need to oversee and investigate the problem of administering drugs by feeding tube in dysphagic patients. The management of therapeutic pathways, due to the complexity and high clinical risk that it entails, requires advanced, updated, and integrated skills. The alteration of oral pharmaceutical forms, if not properly managed, can lead to errors in therapy, side effects, occupational exposure by inhalation or contact with the drug, and cost increase. The advice of the clinical pharmacist, especially for the verification of alternative pharmaceutical forms, can prove effective in reducing therapeutic errors. This study provides health-care teams a practical guide for the correct administration of oral drugs in patients undergoing EN through PEG. The hope that has accompanied the drafting of this document is that it can be a tool that allows the prescriber to receive the correct information on the drug and consequently to adapt the pharmacological prescription for the new type of administration. Secondly, we want to provide nurses with practical suggestions regarding the correct methods of handling and adequate administration of drugs via tube, in order to ensure continuity of care and adherence to the therapeutic program.

Author Contributions

Conceptualization, methodology, writing—original draft preparation, G.Z.; investigation, G.Z., S.M.; resources, G.Z., S.M.; data curation, G.Z.; writing—review and editing, S.A., E.R., L.M.; supervision, E.R., S.A. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

Data are contained within the article.

Acknowledgments

We thank Brunella Parodi for her support in this research before retirement.

Conflicts of Interest

The authors declare no conflict of interest.

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  18. Available online: https://farmaci.agenziafarmaco.gov.it/aifa/servlet/PdfDownloadServlet?pdfFileName=footer_000813_028467_RCP.pdf&sys=m0b1l3 (accessed on 8 July 2022).
  19. Treleano, A.; Wolz, G.; Brandsch, R.; Welle, F. Investigation into the Sorption of Nitroglycerin and Diazepam into PVC Tubes and Alternative Tube Materials during Application. Int. J. Pharm. 2009, 369, 30–37. [Google Scholar] [CrossRef] [PubMed]
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  25. Koziolek, M.; Alcaro, S.; Augustijns, P.; Basit, A.W.; Grimm, M.; Hens, B.; Hoad, C.L.; Jedamzik, P.; Madla, C.M.; Maliepaard, M.; et al. The Mechanisms of Pharmacokinetic Food-Drug Interactions–A Perspective from the UNGAP Group. Eur. J. Pharm. Sci. 2019, 134, 31–59. [Google Scholar] [CrossRef] [PubMed]
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Figure 1. Letter addressed to the pharmaceutical companies whose products appear on the hospital formulary.
Figure 1. Letter addressed to the pharmaceutical companies whose products appear on the hospital formulary.
Jpm 12 01307 g001
Figure 2. Solid oral dosage forms included in the Savona hospital formulary.
Figure 2. Solid oral dosage forms included in the Savona hospital formulary.
Jpm 12 01307 g002
Figure 3. (a) Obstruction of a tube. (b) Obstruction of a PEG with breakage of the terminal bumper.
Figure 3. (a) Obstruction of a tube. (b) Obstruction of a PEG with breakage of the terminal bumper.
Jpm 12 01307 g003
Figure 4. Feasibility of drug administration via enteral feeding tube of the solid oral dosage forms included in the Savona hospital formulary.
Figure 4. Feasibility of drug administration via enteral feeding tube of the solid oral dosage forms included in the Savona hospital formulary.
Jpm 12 01307 g004
Figure 5. The weight of pharmacist skill in the administration of a therapy by feeder tube. The different colors are indicative of the sources behind the decisions on the feasibility of using a solid pharmaceutical form administered by tube.
Figure 5. The weight of pharmacist skill in the administration of a therapy by feeder tube. The different colors are indicative of the sources behind the decisions on the feasibility of using a solid pharmaceutical form administered by tube.
Jpm 12 01307 g005
Table 1. Sources chosen to evaluate the suitability of drug administration via tube and their level of reliability in decreasing order. The sources of the information are highlighted in different colors according to their level of reliability. Green, level A (SmPC); light blue, level B (Guidelines); pink, level C (literature); yellow, level D (pharmacist know-how).
Table 1. Sources chosen to evaluate the suitability of drug administration via tube and their level of reliability in decreasing order. The sources of the information are highlighted in different colors according to their level of reliability. Green, level A (SmPC); light blue, level B (Guidelines); pink, level C (literature); yellow, level D (pharmacist know-how).
SourceLevel of Reliability
Summary of product characteristicsA
European and Italian guidelines on artificial nutritionB
Research studies available in the literatureC
Hospital pharmacist know-howD
Table 2. APIs endowed with formulations alternative to oral administration.
Table 2. APIs endowed with formulations alternative to oral administration.
Administration RouteAPILimitations
Intramuscular (i.m.)Ampicillin/sulbactam
Lorazepam
Prednisolone
Expensive
Invasive procedure
Inappropriate in immunocompromised or bleeding-prone patients
Only feasible with expert help
Intravenous (i.v.)Dexamethasone
Digoxin
Phenytoin
Hydromorphone
Methotrexate
Morphine
Prometazin
Expensive
Invasive procedure
Only feasible with expert help
InhalationSalbutamolo
Nicotina
Zanamivir
Unavailable, not to be used if there is trauma to the upper airway
RectalAspirin
Bisacodil
Caffeine/ergotamin
Lactulose
Morphine
Prochloroperazine
Prometazin
Sodium polystyrene sulfonate
Low compliance
Inappropriate in patients with heart disease, immunocompromised, rectal surgery or bleeding
SubcutaneousFentanyl
Hydromorphone
Morphine
Expensive
Invasive procedure
May cause local tissue damage
Absorption of the drug may be slower than via i.v or i.m.
Inappropriate in immunocompromised patients
Only feasible with expert help
TransdermalEstradiol
Fentanyl
Nicotine
Nitroglycerin
Inappropriate in patients with cutaneous rush, dermatitis or open lesions
Risk of skin irritation, itching, contact dermatitis
Table 3. General suggestions for the oral solid medications listed in the Savona hospital formulary given by tube. The sources of the information are highlighted in different colors according to their level of reliability. Green, level A (SmPC); light blue, level B (Guidelines); pink, level C (literature); yellow, level D (pharmacist know-how).
Table 3. General suggestions for the oral solid medications listed in the Savona hospital formulary given by tube. The sources of the information are highlighted in different colors according to their level of reliability. Green, level A (SmPC); light blue, level B (Guidelines); pink, level C (literature); yellow, level D (pharmacist know-how).
ATCAPI
(Strength)
Brand Name
(Manufacturer)
Dosage FormVia TubeOperative InformationRef.
A02AD01Aluminum hydroxide
Magnesium hydroxide
(800 mg)
MAALOX
(SANOFI)
Chewable
tablets
NoInteraction with dietary proteins
Tube obstruction
Use alternative medications
A02AHSodium bicarbonate
(500 mg)
SOD BIC NAR
(NOVA ARGENTIA)
TabletsNoUse other routes of administration
A02BA02Ranitidine hydrochloride
(150 mg)
RANIDIL
(A.MENARINI)
Effervescent
tablets
YesThe tablet should be diluted with at least 75 mL of water (to be avoided in patients on a low sodium diet or with phenylketonuria)
Alternatives: liquid formulation to be diluted with 60 mL of water (contains ethyl alcohol), or sugar-free galenic preparation
A02BA02Ranitidine hydrochloride
(150 mg)
ZANTAC
(GLAXOSMITHKLINE)
Coated tabletsNoThe effervescent tablets are the first choice (to be avoided in patients on a low sodium diet or with phenylketonuria)
Alternatives: liquid formulation to be diluted with 60 mL of water (contains ethyl alcohol), or Ranitidine 15 mg/mL galenic preparation
[8,9]
ZANTAC SOLUB
(GLAXOSMITHKLINE)
Effervescent
tablets
RANITIDINA MYL
(MYLAN)
Coated tablets
RANITIDINA RATIO
(RATIOPHARM)
Coated tablets
RANITIDINA TEV
(TEVA)
Coated tablets
A02BB01Misoprostol
(200 µg)
CYTOTEC 200
(PFIZER)
TabletsYesCrush the tablet in a mortar, add 15 mL water, draw the suspension into the syringe and administer immediately
Rinse the mortar with 15 mL water, draw this water into the syringe and administer
Due to the poor stability of the API better an alternative therapy (Ranitidine or Lansoprazole)
[10]
A02BC01Omeprazole
(20 mg)
ANTRA
(ASTRAZENECA)
Gastro-resistant capsulesYesOpen the capsule, suspend the granules contained therein with 20 mL water and then administer after 15–20 min in a tube >8 Fr
The granules must not be crushed
For children the galenic preparation of omeprazole suspension 2 mg/mL is required
[26]
Omeprazole
(10 mg)
OMEPRAZOLO TEV
(TEVA)
A02BC02Pantoprazole sodium
sesquihydrate
(20, 40 mg)
PANTORC
(TAKEDA)
Gastro-resistant
tablets
NoChange route of administration or substitute API with Omeprazole or Lansoprazole[8,9]
A02BC03Lansoprazole
(15, 30 mg)
LANSOX
(TAKEDA)
Orodispersible
tablets
YesDisperse in a small amount of water and administer through a nasogastric tube or oral syringeSmPC
A02BC03Lansoprazole
(15, 30 mg)
LANSOX
(TAKEDA)
CapsulesYesOpen the capsule, suspend the granules with water and administer after 20 min
Prefer orodispersible tablets
[26]
A02BC04Rabrepazole sodium
(10, 20 mg)
PARIET
(JANSSEN CILAG)
Gastro-resistant
tablets
NoDo not grind gastro-resistant tablets
Alternatives: esomeprazole, lansoprazole or omeprazole
[8,9]
A02BC05Esomeprazole magnesium
trihydrate
(10 mg)
NEXIUM
(ASTRAZENECA)
Gastro-resistant granulesYesTo a dose of 10 mg add 15 mL water, mix and leave to thicken for a few minutes
Do not crush the granules, withdraw the suspension with a syringe and inject through the tube of 6 Fr caliber or greater for 30 min
Rinse the tube with 15 mL water
SmPC
A02BC05Esomeprazole magnesium trihydrate
(10 mg)
LUCEN
(MALESCI)
Gastro-resistant granulesYesMix the granules with 15 mL water, allow to thicken
Pick up the suspension with a syringe and inject it into a tube of 6 Fr caliber or greater
SmPC
A02BX02Sucralfate
(2 g)
SUCRALFIN
(SANOFI)
Granules for oral suspensionNoRisk of tube occlusion, bezoar formations[10,21]
SUCRAMAL
(SCHARPER)
A02BX13Sodium alginate
Sodium bicarbonate
(250 + 133.5 mg)
GAVISCON
(RECKITT BENCKISER)
Chewable
tablets
No [8,9]
A03AA05Trimebutine maleate
(150 mg)
DEBRIDAT
(SIGMA TAU)
Soft gelsNoAlternatives: solution for injection or suppositories[8,9]
A03AA06Rociverin
(10 mg)
RILATEN
(LABORATORI GUIDOTTI)
Coated tabletsYesTablet can be triturated and administered with water
A03AX13Simethicone
(40 mg)
MYLICONGAS
(JOHNSON & JOHNSON)
Chewable tabletsNoAlternative: drops to be diluted with 50 mL water and given immediately[8,9]
A03BB01Scopolamine methyl bromide
(10 mg)
BUSCOPAN
(BOEHRINGER INGELHEIM)
Coated tabletsYesTablet can be triturated
Alternative: solution for injection
A03FA01Metoclopramide hydrochloride monohydrate
(10 mg)
PLASIL
(SANOFI)
TabletsNoAlternative: syrup which must be diluted and given away from EN[8,9]
A03FA03Domperidone maleate
(10 mg)
DOMPERIDONE AGE
(ANGENERICO)
TabletsNoAlternatives: suppositories or oral suspension (to be diluted with water and administered at least 15 min before the start of EN)[8,9]
A03FA03Domperidone
(10 mg)
PERIDON
(ITALCHIMICI)
Coated tabletsNoAlternatives: suppositories or oral suspension (to be diluted with water and administered at least 15 min before the start of EN)[8,9]
A04AA01Ondansetron hydrochloride dihydrate
(4 mg)
ZOFRAN
(GLAXOSMITHKLINE)
Coated tabletsNoPrefer orodispersible tablets, syrup or solution for injection[8,9]
A04AA01Ondansetron
(8 mg)
ZOFRAN
(GLAXOSMITHKLINE)
Orodispersible
tablets
Yes
A04AA01Ondansetron hydrochloride
(4, 8 mg)
ONDANSETRONE TEV (TEVA)Coated tabletsNoAlternative: Zofran syrup[8,9]
A04AA02Granisetron hydrochloride
(2 mg)
KYTRIL
(ROCHE)
Coated tabletsNoAlternative: solution for injection[8,9]
A04AD12Aprepitant
(125, 80 mg)
EMEND
(MSD)
CapsulesNoOpen the capsule and administer the granules with water without crushing
Preferred alternative: Ivemend solution for injection
A05AA02Ursodeoxycholic acid
(450, 150 mg)
DEURSIL
(CHEPLAPHARM ARZNEIMITTEL)
Modified
release capsules
NoAlternatives: granules for oral suspension, capsules[8,9]
A05AA02Ursodeoxycholic acid
(450, 150 mg)
URSILON
(I.B.I.GIOVANNI LORENZINI)
CapsulesYesOpen the capsule and suspend the granules in 20 mL water then administer immediately[10]
A05BA03Sylimarin
(70 mg)
LEGALON
(MEDA PHARMA)
Coated tabletsYes
A06AB06Senna leaves
(12 mg)
PURSENNID (GLAXOSMITHKLINE)Coated tabletsNoPrefer other laxatives in syrups[10]
A06AB58Sodium picosulfate
Magnesium oxide
Anhydrous citric acid
PICOPREP
(FERRING)
Powder for oral
solution
YesDissolve the powder in 150 mL of water
A06AD11Lactulose
(10 g)
LAEVOLAC EPS
(ROCHE)
Granules for oral
solution
YesDilute with at least 60 mL water
Avoid high doses, risk of diarrhea and malabsorption of dietary nutrients
A06AD15Macrogol 4000
(4, 9.7, 10 g)
PAXABEL (IPSEN)Powder for oral
solution
YesDissolve the powder in 125 mL water and administer immediately
Seek dietary advice in case of chronic constipation
REGOLINT
(LABORATORI BALDACCI)
LAXIPEG (ZAMBON)
A06AD65Macrogol 4000
Sodium sulfate
Sodium bicarbonate
Sodium chloride
Potassium chloride
(17.4, 34.8 g)
ISOCOLAN
(GIULIANI)
Powder for oral
solution
YesDissolve the powder in 250 mL water then
shake and administer immediately
SmPC
A06AD65Macrogol 3350 Sodium bicarbonate Sodium chloride Potassium chloride
(13.8 g)
MOVICOL
(NORGINE)
Powder for oral
solution
YesDissolve the powder in 125 mL water, shake and administer immediately
Seek dietary advice in case of chronic constipation
A06AD65Macrogol 3350
Sodium sulfate
Sodium bicarbonate
Sodium chloride
Potassium chloride
Ascorbic Acid
Sodium Ascorbate
(112 g)
MOVIPREP
(NORGINE)
A07AA06Paromomycin sulfate
(250 mg)
HUMATIN
(PFIZER)
CapsulesNoAlternative: syrup to be diluted in at least 60 mL water and then given immediately[8,9]
A07AA09Vancomycin hydrochloride
(250 mg)
MAXIVANIL
(GENETIC)
CapsulesNoAlternatives: powder for oral solution or for infusion[10]
A07AA11Rifaximin
(200 mg)
NORMIX
(ALFA WASSERMANN)
Coated tabletsNoAlternative: oral suspension[8,9]
A07AA12Fidaxomicin
(200 mg)
DIFICLIR
(ASTELLAS)
Coated tabletsYesGrind the tablet, suspend the powder in water and administer immediately[27]
A07BC05Diosmectite
(3 g)
DIOSMECTAL
(MALESCI)
Powder for oral
solution
YesDissolve the powder in half a glass of water and then administer
A07DA03Loperamide hydrochloride
(2 mg)
LOPERAMIDE HEX
(SANDOZ)
CapsulesNoUse other dosage form
A07DA03Loperamide hydrochloride
(2 mg)
DISSENTEN
(SOC.PRO.ANTIBIOTICI)
TabletsYes
A07EA06Budesonide
(3 mg)
ENTOCIR
(ASTRAZENECA)
Modified
release capsules
NoAlternative: suppositories[8,9]
A07EA07Beclomethasone dipropionate
(5 mg)
CLIPPER
(CHIESI FARMACEUTIC)I
Gastro-resistant
tablets
NoAlternative: rectal preparations for distal ulcerative colitis[8,9]
A07EC01Sulfasalazine
(500 mg)
SALAZOPYRIN EN
(PFIZER)
Gastro-resistant
tablets
No [8,9]
A07EC02Mesalazine
(400, 500, 800, 1200 mg)
PENTASA
(FERRING)
Modified
release tablets
YesBreak the tablet and let it disintegrate in water. Alternatives: suppositories or rectal suspensionSmPC
A07EC02Mesalazine
(400, 500, 800, 1200 mg)
MESAVANCOL
(GIULIANI)
Modified
release tablets
NoDo not crush
Alternatives: rectal suspension or suppositories
[8,9]
PENTACOL
(SOFAR)
A07FA02Saccharomyces boulardii
(5 bn)
CODEX
(ZAMBON)
CapsulesNo
CODEX
(ZAMBON)
Powder for oral suspension
A09AA02Pancrelipase
(150, 300 mg)
CREON 25000
(BGP PRODUCTS)
Modified
release capsules
YesOpen the capsule without grinding the granules, suspend them in 20 mL water or in liquids, with a pH <5.5 such as apple, pineapple juice or yogurt, then administer immediately
A10BA02Metformin hydrochloride
(500, 850, 1000 mg)
GLUCOPHAGE
(BRUNO FARMACEUTICI)
Coated tabletsYesGrind the tablet, suspend the powder in 20 mL water, and administer immediately[10]
A10BA02Metformin hydrochloride
(500, 850, 1000 mg)
ZUGLIMET
(ZENTIVA)
Coated tabletsYesGrind the tablet, suspend the powder in 20 mL water, then administer immediately
A10BB01Glibenclamide
(5 mg)
DAONIL
(SANOFI)
TabletsYesGrind the tablet, suspend the powder in 10 mL water, then administer immediately
Stop EN at least 30 min before drug administration
A10BB09Gliclazide
(30, 60 mg)
DIAMICRON
(SERVIER)
Modified
release tablets
No [8,9]
A10BB09Gliclazide
(80 mg)
GLICLAZIDE
(ZENTIVA)
TabletsYesGrind the tablet and suspend the powder in 10 mL water, then administer immediately
Stop EN at least 30 min before drug administration
Divisible tablet.
[10]
A10BB12Glimepiride
(2 mg)
GLIMEPIRIDE ACC
(ACCORD HEALTHCARE)
TabletsYesDisperse the tablet in 10 mL water until a fine dispersion is created
Administer before the main meal
[10]
Glimepiride
(3 mg)
GLIMEPIRIDE SAN
(SANDOZ)
Glimepiride(1, 2, 3, 4 mg)AMARYL(SANOFI)
A10BD02Metformin hydrochloride Glibenclamide
(500 + 5 mg)
GLICONORM
(ABIOGEN PHARMA)
Coated tabletsNoAdminister the two drugs separately
Flush with 10 mL water between each one
[8,9]
Metformin hydrochloride Glibenclamide
(400 + 2.5/500 + 5 mg)
GLIBOMET
(LABORATORI GUIDOTTI)
Metformin hydrochloride Glibenclamide
(400 + 2.5 mg)
SUGUAN
(SANOFI)
A10BD05Pioglitazone
Metformin hydrochloride
(15 + 850 mg)
COMPETACT
(TAKEDA)
Coated tabletsNo [8,9]
A10BD07Sitagliptin phosphate monohydrate
Metformin hydrochloride
(50 + 850 mg)
JANUMET
(MSD)
Coated tabletsYes
A10BD08Vildagliptin
Metformin
(50 + 1000 mg)
EUCREAS
(NOVARTIS)
TabletsNo [8,9]
A10BD10Saxagliptin hydrochloride Metformin hydrochloride
(2.5 + 850 mg)
KOMBOGLYZE
(ASTRAZENECA)
Coated tabletsNo [8,9]
A10BF01Acarbose
(50, 100 mg)
GLUCOBAY
(BAYER)
TabletsYesThe tablets do not disperse easily in water but require gentle stirring for 5 min. A fine suspension is obtained which must be administered immediately, then continue with EN[10]
A10BG03 Pioglitazone hydrochloride
(15, 30 mg)
PIOGLITAZONE ACV
(ACTAVIS)
TabletsYes
ACTOS
(TAKEDA)
A10BH01Sitagliptin phosphate monohydrate
(100 mg)
TESAVEL
(ADDENDA)
Coated tabletsYes
A10BH01Sitagliptin Phosphate Monohydrate
(50, 100 mg)
JANUVIA
(MSD)
Coated tabletsYesCheck the glycemia
A10BH02Vildagliptin
(50 mg)
GALVUS
(NOVARTIS)
TabletsNo
A10BH03Saxagliptin hydrochloride
(5 mg)
ONGLYZA
(ASTRAZENECA)
Coated tabletsNo
A10BX02Repaglinide
(0.5, 1 mg)
REPAGLINIDE EG
(EG)
TabletsYes
Repaglinide
(1, 2 mg)
REPAGLINIDE SAN
(SANDOZ)
A11AA03Vitamins Mineral saltsSUPRADYN
(BAYER)
Effervescent
tablets
YesDissolve in water and administer at the end of the effervescence
A11CC04Calcitriol
(0.25 µg)
DIFIX
(PROMEDICA)
Soft gelsNoDrug adheres to the walls of the tube, risk of loss[8,9]
ROCALTROL
(ROCHE)
CALCITRIOLO TEV
(TEVA)
A11DA01Thiamine hydrochloride
(300 mg)
BENERVA
(TEOFARMA)
Gastro-resistant tabletsNo [8,9]
A11DBThiamine hydrochloride Cyanocobalamin
Pyridoxine hydrochloride
BENEXOL B12
(BAYER)
Coated tabletsNoAlternative: solution for injection[8,9]
A11DB Thiamine hydrochloride Cyanocobalamin
Pyridoxine hydrochloride
TRINEVRINA B6
(LABORATORI GUIDOTTI)
Coated tabletsNoAlternative: solution for injection[8,9]
A11HA02Pyridoxine hydrochloride
(300 mg)
BENADON
(BAYER)
Gastro-resistant tabletsNoAlternative: solution for injection[8,9]
A11HA03Alpha-Tocopherol
(400 IU)
RIGENTEX
(BRACCO)
Soft gelsNo [8,9]
A11JBSodium Citrate
Potassium Citrate
Thiamine diphosphate
Riblofavin-5 monophosphate monosodium
Pyridoxine hydrochloride
Citric acid
BIOCHETASI
(SIGMS TAU)
Effervescent granulesYes
A12AA04Calcium Carbonate
(1000 mg)
CALCIODIE
(SPA)
Effervescent
tablets
YesDissolve in 20 mL water and administer at the end of the effervescence at least 1 h before or 2 h after the NE
A12AXCalcium Carbonate
Cholecalciferol
IDEOS
(MEDA PHARMA)
Chewable
tablets
Yes
METOCAL VIT.D3
(MEDA PHARMA)
A12BA01Potassium Chloride
(600 mg)
KCL-RETARD
(ASTELLAS)
Modified
release tablets
NoChange route of administration[8,9]
A12BA30Potassium Citrate
Potassium Succinate
Potassium Malate
Potassium Tartrate
Potassium Bicarbonate
POTASSION
(ACARPIA)
Effervescent granulesYesDissolve in water, and administer at the end of the effervescence
A16AA02Ademetionine Butanedisulfonate
(400 mg)
SAMYR 400
(BGP PRODUCTS)
Gastro-resistant tabletsNoAlternative: solution for injection[8,9]
B01AA03Warfarin sodium
(5 mg)
COUMADIN
(BRISTOL-MYERS SQUIBB)
TabletsYesGrind the tablet and suspend the powder in 10 mL water, then administer immediately
Stop feeding at least 1 h before and 2 h after drug administration
Avoid supplementation with vitamin K
Warning: drug-EN interaction, continuous monitoring and dosage adjustment.
If possible administer low molecular weight heparins
[10]
B01AA07Acenocumarol
(1, 4 mg)
SINTROM
(MERUS LABS LUXCO II SARL)
TabletsYesGrind the tablet, dissolve in 10 mL water and administer immediately
Trituration can alter bioavailability
Check for clotting and prothrombin time
[10]
B01AB11Sulodexide
(250 LSU)
VESSEL
(ALFA WASSERMANN)
Soft gelsNoOily excipients do not guarantee correct administration
Alternative: solution for injection
[8,9]
B01AC04Clopidogrel besylate
(75 mg)
CLOPIDOGREL AURO
(ACTAVIS)
Coated tabletsNoAlternative: Plavix
B01AC04Clopidogrel besylate
(75, 300 mg)
PLAVIX
(SANOFI)
Coated tabletsYesCrush the tablet and disperse the powder in 10 mL water
Administer by an 8 Fr tube
[10]
B01AC05Ticlopidine hydrochloride
(250 mg)
TIKLID
(SANOFI)
Coated tabletsYesGrind the tablet, dissolve the powder in 20 mL water, and administer immediately
preferably concurrently with EN to avoid gastrointestinal adverse effects
B01AC06Acetylsalicylic Acid
(100 mg)
ACIDO ACETILSALICILICO SAN
(SANDOZ)
Gastro-resistant tabletsNoThe tablet must not be crushed to avoid irritating effects on the intestine
Alternatives: effervescent tablets, chewable tablets, granules for oral solution
[8,9]
B01AC06Acetylsalicylic Acid
Magnesium Hydroxide
Algedrate
ASCRIPTIN
(SANOFI)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water, and administer immediately concurrently with EN
B01AC06Lysine Acetylsalicylate
(75, 100, 160 mg)
CARDIRENE
(SANOFI)
Powder for oral solutionYesDilute with at least 60 mL of water and administer immediately in conjunction with EN
B01AC07Dipyridamole
(75, 200 mg)
PERSANTIN
(BOEHRINGER INGELHEIM)
Coated tabletsYes [10]
B01AC07Dipyridamole
(75 mg)
PERSANTIN R
(BOEHRINGER INGELHEIM)
Modified
release capsules
No [8,9]
B01AC10Indobufen
(200 mg)
IBUSTRIN
(PFIZER)
TabletsYes
B01AC22Prasugrel hydrochloride
(100 mg)
EFIENT
(DAIICHI SANKYO)
Coated tabletsYesGrind the tablet and administer immediately
Highly photosensitive hygroscopic drug
B01AC24Ticagrerol
(90 mg)
BRILIQUE
(ASTRAZENECA)
Coated tabletsYesCrush the tablet to a fine powder, transfer it in half a glass of water and administer
Rinse the tube with water
SmPC
B01AC30Dipyridamole
Acetylsalicylic Acid
(200 + 25 mg)
AGGRENOX (BOEHRINGER INGELHEIM)Modified
release capsules
NoThe granules can block the tube
Alternatives: change dosage form or route of administration
B01AE07Dabigatran etexilate mesylate
(75, 110, 150 mg)
PRADAXA
(BOEHRINGER INGELHEIM)
CapsulesNoThe opening of the capsule increases drug bioavailability by 75%
Bleeding risk
Switch to another anticoagulant
B01AF01Rivaroxaban
(10, 15, 10 mg)
XARELTO
(BAYER)
Coated tabletsYesCrush the tablet, dissolve the powder in water, then administer immediately
Rinse the tube with water
The drug administration should be followed immediately by EN
SmPC
B01AF02Apixaban
(2.5, 5 mg)
ELIQUIS
(BRISTOL-MYERS SQUIBB)
Coated tabletsYesCrush the tablet and suspend the powder in 60 mL water or 5% dextrose water solution, then administer immediately
The crushed tablets are stable up to 4 h when stored at 30 °C
SmPC
B02BX05Eltrombopag olamine
(25, 50 mg)
REVOLADE
(NOVARTIS)
Coated tabletsNo
B03AA01Ferrous (II) glycine sulphate
(100 mg)
NIFEREX
(UCB PHARMA)
CapsulesNoRisk of tube occlusion
B03AA03Ferrous (II) gluconate
(80 mg)
PRONTOFERRO
(IBSA FARMACEUTICI)
Effervescent
tablets
YesDissolve the tablet in water, administer before EN
Alternatives: ampoules or syrup
SmPC
B03AA07Ferrous (II) sulfate
(105 mg)
FERROGRAD
(TEOFARMA)
Modified
release tablets
NoAlternative: ampoules[8,9]
B03BB01Folic Acid
(5 mg)
FOLINA
(TEOFARMA)
CapsulesNoAlternative: liquid formulation [8,9]
B06AAPromelase
(30 mg)
FLAMINASE (GRUNENTHAL)Gastro-resistant tabletsNo [8,9]
C01AA05Digoxin
(0.0625, 0.125 mg)
LANOXIN
(ASPEN PHARMA)
TabletsYesGrind the tablet, dissolve it in 10 mL of water, administer immediately. Stop NE 2 h before and 2 h after the drug administration. Inaccurate dosage, change in bioavailability: monitor the patient
Preferably give liquid formulation
[10]
C01AA05Digoxin
(0.1, 0.2 mg)
EUDIGOX
(TEOFARMA)
Soft gelsNoAlternative: liquid formulation[8,9]
C01AA08Methyl Digoxin
(0.1 mg)
LANITOP
(RIEMSER PHARMA)
TabletsYesGrind the tablet, dissolve it in 10 mL water and administer immediately
Preferably give drops
C01BADihydroquinidine hydrochloride
(250 mg)
IDROCHINIDINA R
(TEOFARMA)
CapsulesYesOpen the capsule, suspend the powder in 10 mL water, then administer immediately
C01BC03Propafenone hydrochloride
(325 mg)
RYTMONORM
(BGP PRODUCTS)
Modified
release capsules
NoAlternatives: Rytmonorm coated tablets or solution for injection[8,9]
C01BC03Propafenone hydrochloride
(150, 300 mg)
RYTMONORM
(BGP PRODUCTS)
Coated tabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Interaction with EN: the effect can be enhanced by the presence of food
Alternative: solution for injection
C01BC04Flecanide Acetate
(100 mg)
ALMARYTM
(MEDA PHARMA)
TabletsYesDisperse the tablet in 10 mL water for 2 min
The suspension must be administered immediately
[10]
C01BC04Flecainide Acetate
(100 mg)
FLECAINIDE TEV
(TEVA)
TabletsYesDivisible tablets
C01BD01Amiodarone hydrochloride
(200 mg)
CORDARONE
(SANOFI)
TabletsYesDivisible tablets
C01BD07Dronedarone hydrochloride
(400 mg)
MULTAQ
(SANOFI)
Coated tabletsYes
C01DA08Isosorbide dinitrate
(5 mg)
CARVASIN
(TEOFARMA)
Sublingual
tablets
NoDo not grind
Reduction of the absorption of the drug due to the hepatic first pass effect
Administer sublingually only if the patient is conscious
[8,9]
C01DA14Isosorbide mononitrate
(60 mg)
DURONITRIN (ASTRAZENECA)Modified
release tablets
NoAlternative: Nitroglycerine transdermal formulation[8,9]
Isosorbide mononitrate
(60 mg)
MONOKET MULTITAB (CHIESI FARMACEUTICI)Modified
release tablets
Isosorbide mononitrate
(20 mg)
MONOKET
(CHIESI FARMACEUTICI)
Modified
release tablets
Isosorbide mononitrate
(50 mg)
MONOKET RETARD
(CHIESI FARMACEUTICI)
Modified
release capsules
Isosorbide mononitrate
(20, 40, 50, 80 mg)
MONOCINQUE R
(IST.LUSOFARMACOI)
Modified
release capsules
C01EB17Ivabradine hydrochloridePROCORALAN
(SERVIER)
Coated tabletsYesCrush the tablet, suspend in water and administer immediately
Ivabradine hydrochlorideCORLENTOR
(STRODER)
C01EB18Ranolazine
(375, 500, 750 mg)
RANEXA
(A.MENARINI)
Modified
release tablets
No [8,9]
C02AB01Methyldopa
(250 mg)
ALDOMET
(IROKO PRODUCTS)
Coated tabletsNoChange antihypertensive drug
C02AC01Clonidine hydrochlorideCATAPRESAN
(BOEHRINGER INGELHEIM)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water and administer immediately[10]
C02CA04Doxazosin mesylate
(2, 4 mg)
CARDURA
(PFIZER)
TabletsYesGrind the tablet, dissolve the powder with 10 mL sterile water and administer immediately
Monitor the patient and adjust the therapy
[10]
C02DC01Loniten
(5 mg)
MINOXIDIL
(PFIZER)
TabletsYesThe tablet is dispersed in water to give a fine suspension which must be administered immediately[10]
C02KX01Bosentan monohydrate
(62.5, 125 mg)
TRACLEER
(ACTELION PHARMA)
Coated tabletsYesCrush the tablet and dissolve it in at least 50 mL water, it is not very soluble
Use individual protections for handling
Dispersible tablets (Tracleer 32 mg) for pediatrics
C02KX02Ambriesentan
(5 mg)
VOLIBRIS
(GLAXOSMITHKLINE)
Coated tabletsNo
C02KX04Macitentan
(10 mg)
OPSUMIT
(ACTELION PHARMA)
Coated tabletsYesCrush the tablet into a fine powder and add water, to have a suspension (drug not soluble)
Rinse the tube several times after administration
Use individual protections for handling
Teratogen drug
C02KX05Riociguat
(2.5 mg)
ADEMPAS
(MSD)
Coated tabletsYesThe tablet can be crushed and mixed with waterSmPC
C03AA03Hydrochlorothiazide
(25 mg)
ESIDREX
(NOVARTIS)
TabletsYes
C03BA04Chlorthalidone
(25 mg)
IGROTON
(AMDIPHARM)
TabletsYesThe tablet disperses in water within 2 min[10]
C03BA08Metolazone
(5, 10 mg)
ZAROXOLYN
(TEOFARMA)
TabletsYesGrind the tablet, dissolve it with 10 mL water and administer immediately
Monitor the patient, drug bioavailability variable
[10]
C03CA01Furosemide
(25 mg)
FUROSEMIDE
(LAB.FARMACOLOGICO MILANESE)
TabletsYesGrind the tablet, dissolve it in 10 mL water and administer immediately preferably concomitantly with EN to minimize gastrointestinal effects
It is recommended to use the liquid form
Furosemide
(25, 500 mg)
LASIX
(SANOFI)
Furosemide
(500 mg)
FUROSEMIDE TEV
(TEVA)
C03CA04Torasemide
(10 mg)
TORASEMIDE TEV
(TEVA)
TabletsYesDivisible tablet
C03DA01Spironolactone
(100 mg)
ALDACTONE
(SANOFI)
Coated tabletsYesGrind, dissolve the powder in 10 mL water and administer immediately
Pay attention to concomitant administration with potassium.
[10]
Spironolactone
(25 mg)
ALDACTONE
(SANOFI)
CapsulesYesOpen the capsule, dissolve in 10 mL of water and administer immediately
Pay attention to concomitant administration with potassium.
C03DA01Spironolactone
(25 mg)
URACTONE
SPA (SOC.PRO.ANTIBIOTICI)
TabletsYes
C03DA03Canrenone
(50, 100 mg)
LUVION
(THERABEL GIENNE PHARMA)
TabletsNoAlternative: solution for injection
C03EA01Amiloride hydrochloride Hydrochlorothiazide
(5 + 50 mg)
MODURETIC
(MSD)
TabletsYesGrind, dissolve in 10 mL of water and administer immediately.[10]
C03EA14Potassium Canrenoate
Butizide
(5 + 50 mg)
KADIUR
(THERABEL GIENNE PHARMA)
TabletsNo [8,9]
C03EB01Furosemide
Spironolactone
(25 + 37 mg)
LASITONE
(SANOFI)
CapsulesNoAdminister the two drugs separately
Flush with 10 mL water between each one
[8,9]
C04AD03Pentoxifylline
(400 mg)
TRENTAL
(SANOFI)
Modified
release tablets
No [8,9]
C05CA53Diosmin
Hesperidin
(500 mg)
DAFLON
(SERVIER)
Coated tabletsYesGrind the tablet, dissolve the powder in 10 mL of water and administer it immediately
C05CXEscin
(40 mg)
EDEVEXIN
(I.B.I.GIOVANNI LORENZINI)
Coated tabletsNoAlternatives: solution for injection or cutaneous gel
C07AA05Propranolol hydrochloride
(40 mg)
INDERAL
(ASTRAZENECA)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water and administer immediately
Alternative: galenic preparation (Propranolol 2 or 5 mg/mL oral suspension)
C07AA07Sotalol hydrochloride
(80 mg)
RYTMOBETA
(BGP PRODUCTS)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water by shaking for 5 min, then administer immediately
Stop EN 2 h before and 2 h after drug administration
Follow the same administration schedule
[10]
C07AA12Nadolol
(80 mg)
NADOLOLO SFV
(SANOFI)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water and administer immediately
If possible, use another beta blocker available in liquid form
C07AB02Metoprolol tartrate
(100 mg)
LOPRESOR
(DAIICHI SANKYO)
Coated tabletsYesIt is recommended to use a beta blocker liquid preparation
If Metoprolol is non-replaceable, prepare an extemporaneous suspension of Metoprolol 10 mg/mL with simple syrup, or grind the tablet and dissolve it in 10 mL of water.
[10]
METOPROLOLO HEX (SANDOZ)Tablets
C07AB03Atenolol
(100 mg)
ATENOLOLO RAT (RATIOPHARM)Coated tabletsYesGrind the tablet, dissolve the powder in 10 mL water under shaking for 5 min, then administer immediately Stop EN 30 min before and 30 min after drug administration
Divisible tablets
[10]
ATENOLOLO HEX (SANDOZ)Grind the tablet, dissolve the powder in 10 mL water, then administer immediately
Stop EN 30 min before and 30 min after drug administration
[10]
C07AB07Bisoprolol fumarate
(10 mg)
CONCOR
(BRACCO)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water under shaking for 5 min, then administer immediately preferably in the morning after EN[10]
Bisoprolol hemifumarate
(2.5 mg)
CONGESCOR
(DAIICHI SANKYO)
Coated tabletsYesGrind the tablet, dissolve the powder in 10 mL water under shaking for 5 min, then administer immediately preferably in the morning after EN[10]
Bisoprolol hemifumarate
(1.25, 2.5, 3.75, 5, 10 mg)
CARDICOR
(RECORDATI)
Coated tabletsYesGrind the tablet, dissolve the powder in 10 mL water under shaking for 5 min, then administer immediately preferably in the morning after EN
Divisible tablet
[10]
C07AB12Nebivolol hydrochloride
(5 mg)
NEBIVOLOLO SAN (SANDOZ)TabletsNoAlternative: Atenolol
C07AG01Labetalol hydrochloride
(100 mg)
TRANDATE
(TEOFARMA)
TabletsNo
C07AG02Carvedilol
(6.25 mg)
OMERIA
(MEDIOLANUM FARMACEUTICI)
TabletsYesGrind and dissolve the tablet in 10 mL water
Administer with EN to reduce the risk of orthostatic hypotension
[10]
C07AG02Carvedilol
(25 mg)
Carvedilol ZTV
(ZENTIVA)
TabletsYesGrind and dissolve the tablet in 10 mL water
Administer with EN to reduce the risk of orthostatic hypotension
[10]
C08CA01Amlodipine besylate
(5, 10 mg)
NORVASC
(PFIZER)
TabletsYesDissolve the tablet in 10 mL water and administer immediately concurrently with EN to minimize the gastrointestinal side effects[10]
Amlodipine maleate
(10 mg)
AMLODIPINA WIN
(ZENTIVA)
C08CA02Felodipine
(5 mg)
FELODIPINA WPI
(ZENTIVA)
Modified
release tablets
No [8,9]
C08CA05Nifedipine
(20,30,60 mg)
ADALAT CRONO
(BAYER)
Modified
release tablets
NoDo not grind, use the liquid formulation (Nifedicor 20 mg/mL drops) to be diluted with 60 mL water and administer immediately[8,9]
Nifedipine
(10 mg)
ADALAT
(BAYER)
Soft gelsNoAlternative: Nifedicor 20 mg/mL drop solution to be diluted with 60 mL of water
Nifedipine
(30 mg)
CORAL
(SO.SE.PHARM)
Modified
release tablets
NoAlternative: Nifedicor 20 mg/mL drop solution to be diluted with 60 mL of water
C08CA06Nimodipine
(30 mg)
NIMOTOP
(BAYER)
Coated tabletsYesPhotosensitive drug, use amber syringe
Not compatible with PVC tube
C08CA09Lacipidine
(4 mg)
LACIPIL
(GLAXOSMITHKLINE)
Coated tabletsNoDrug poorly soluble in water and photosensitive
Divisible tablets
Alternative: Amlodipine formulations
C08CA11Manidipine hydrochloride
(20 mg)
IPERTEN
(CHIESI FARMACEUTICI)
TabletsNo
MANIDIPINA MYL
(MYLAN)
Yes
MANIDIPINA TEV
(TEVA)
YesDivisible tablets
C08CA13Lecardipine hydrochloride
(10 mg)
ZANEDIP
(RECORDATI)
Coated tabletsYesAdminister away from EN
Alternative: Amlodipine formulations
C08DA01Verapamil hydrochloride
(40, 80, 180 mg)
ISOPTIN
(BGP PRODUCTS)
Coated tabletsYes [10]
C08DA01Verapamil hydrochloride
(120 mg)
ISOPTIN R
(BGP PRODUCTS)
Modified
release tablets
NoDo not grind
Alternative: solution for injection
[8,9]
VERAPAMIL HEX
(SANDOZ)
C08DB01Diltiazem hydrochloride
(120 mg)
ALTIAZEM (IST.LUSOFARMACO)Modified
release tablets
NoAlternative: 60 mg Diltiazem divisible tablets dosage form[8,9]
Diltiazem hydrochloride
(300 mg)
ALTIAZEM (IST.LUSOFARMACO)Modified
release capsules
Diltiazem hydrochloride
(200, 300 mg)
TILDIEM
(SANOFI)
Modified
release tablets
Diltiazem Hydrochloride
(60, 120 mg)
TILDIEM
(SANOFI)
Modified
release tablets
C09AA01Captopril
(25, 50 mg)
CAPTOPRIL RAT (RATIOPHARM)TabletsYesGrind, dissolve the tablet in 10 mL water and administer immediately
Stop EN at least two h before drug administration. Divisible tablets
[10]
C09AA02Enalapril maleate
(5, 20 mg)
ENAPREN
(MSD)
TabletsYesGrind the tablet, dissolve the powder in 10 mL sterile water and administer immediately[10]
C09AA03Lisinopril dehydrate
(5, 20 mg)
ZESTRIL
(ASTRAZENECA)
TabletsYesDivisible tablets
It is possible to prepare an extemporaneous galenic solution/suspension: stable for 30 days at 2–8 °C
[10]
C09AA03Lisinopril dehydrate
(20 mg)
LISINOPRIL WPI
(ZENTIVA)
TabletsYes
C09AA04Perindopril arginine
(5 mg)
COVERSYL
(SERVIER)
Coated tabletsYes
C09AA04Perindopril tosilate
(5 mg)
PERINDOPRIL TEV
(TEVA)
Coated tabletsNoSwitch to another ACE inhibitor
C09AA05Ramipril
(10 mg)
QUARK
(POLIFARMA)
TabletsYesDissolve the tablet in 20 mL water and administer immediately
Divisible tablets
[10]
Ramipril
(2.5, 5, 10 mg)
TRIATEC
(SANOFI)
C09AA13Moexipril hydrochloride
(15 mg)
FEMIPRES
(UCB PHARMA)
Coated tabletsNo [10]
C09AA15Zofenopril calcium
(30 mg)
BIFRIL
(IST.LUSOFARMACO)
Coated tabletsYes
C09BA04Perindopril arginine
Indapamide
(2.5 + 0.625/5 + 1.25 mg)
PRETERAX
(SERVIER)
Coated tabletsYesGrind, dissolve the tablet in 10 mL water and administer immediately
Perindopril arginine
Indapamide
(5 + 1.25 mg)
PRELECTAL
(STRODER)
C09BA05Ramipril
Piretanide
(5 + 6 mg)
PRILACE
(SANOFI)
Coated tabletsNoDivisible tablets[8,9]
C09BA06Quinapril hydrochloride
hydrochlorothiazide
(20 + 12.5 mg)
ACEQUIDE
(RECORDATI)
Coated tabletsYesCrushable and divisible tablets
C09BA09Fosinopril sodium
Hydrochlorothiazide
(20 + 12.5 mg)
FOSICOMBI
(A.MENARINI)
TabletsNoSwitch to another ACE inhibitor[8,9]
C09CA01Losartan Potassium
(50 mg)
LORTAAN
(MSD)
Coated tabletsYesGrind, dissolve the tablet in 10 mL water and administer immediately[10]
C09CA03Valsatrtan
(40 mg)
TAREG
(NOVARTIS)
Coated tabletsYes
Valsatrtan
(80, 160 mg)
NOVARTISCapsules
C09CA04Ibersartan
(150, 300 mg)
APROVEL
(SANOFI)
TabletsYesThe tablet is dispersed in 10 mL water under stirring for 5–10 min
No blockage risk with an 8 Fr tube
Ibersartan
(150 mg)
KARVEA
(SANOFI)
Stirring to disperse the tablet
C09CA06Candesartan Cilexetil
(8 mg)
RATACAND
(ASTRAZENECA)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water and administer immediately[10]
Candesartan Cilexetil
(16 mg)
BLOPRESS
(TAKEDA)
Grind the tablet, dissolve the powder in 10 mL water and administer immediately. Alternative: Ibersartan
Candesartan Cilexetil
(8, 16 mg)
CANDESARTAN TEV
(TEVA)
Grind the tablet, dissolve the powder in 10 mL water and administer immediately
Divisible tablets.
C09CA07Telmisartan
(20, 80 mg)
PRITOR
(BAYER)
TabletsYesDissolve the tablet in 5 mL water under stirring and administer immediately
Hygroscopic drug
[10]
Telmisartan
(20, 40, 80 mg)
MICARDIS
(BOEHRINGER INGELHEIM)
C09CA08Olmesartan medoxomil
(10, 20 mg)
OLPRESS
(MENARINI)
Coated tabletsNoAlternative: Ibersartan
Olmesartan medoxomil
(10, 20, 40 mg)
PLAUNAC
(MENARINI)
C09DA08Olmesartan medoxomil
Hydrochlorothiazide
(20 + 12.5 mg)
PLAUNAZIDE
(MENARINI)
Coated tabletsNoAdminister the two drugs separately
Flush with 10 mL water between each one
[8,9]
Olmesartan medoxomil
Hydrochlorothiazide
(20 + 25/40 + 25 mg)
OLPREZIDE
(MENARINI)
C09DB02Olmesartan medoxomil
Amlodipine besylate
(40 + 5 mg)
SEVIKAR
(IST.LUSOFARMACO)
Coated tabletsNoAlternative: administer separately another angiotensin II antagonist drug (eg Irbesartan) and the calcium channel blocker[8,9]
C09XA02Aliskiren hemifumarate
(150, 300 mg)
RASILEZ
(NOVARTIS)
Coated tabletsYes
C10AA01Simvastatin
(10, 20 mg)
SINVACOR
(MSD)
Coated tabletsYesGrind the tablet, dissolve the powder in 10 mL water and administer immediately, preferably together with the last course of EN[10]
Simvastatin
(10, 20 mg)
SIMVASTAT.RAT (RATIOPHARM)Grind the tablet, dissolve the powder in 10 mL water and administer immediately, preferably together with the last course of EN
Divisible tablets
Simvastatin
(10 mg)
SIMVASTAT.TEV
(TEVA)
Grind the tablet, dissolve the powder in 10 mL water and administer immediately, preferably together with the last course of EN
Divisible tablets
Simvastatin
(40 mg)
SIMVASTAT.ZTV
(ZENTIVA)
Grind the tablet, dissolve the powder in 10 mL water and administer immediately, preferably together with the last course of EN.
C10AA03Pravastatin sodium
(20 mg)
PRAVASTAT.RAT
(TEVA)
TabletsYesDivisible tablets[10]
C10AA04Fluvastatin sodium
(80 mg)
LESCOL
(NOVARTIS)
Modified
release tablets
NoAlternative: Fluvastatin 20 or 40 mg capsules, or Atorvastatin or Pravastatin[8,9]
C10AA05Atorvastatin calcium trihydrate
(10, 20, 40 mg)
TORVAST
(PFIZER)
Coated tabletsYesThe tablet is dispersed within 2–5 min in 10 mL water
Photosensitive drug
Absorption not affected by the presence of food
C10AA07Rosuvastatin calcium
(5, 10, 20 mg)
CRESTOR
(ASTRAZENECA)
Coated tabletsYesDisperse the tablet in water, after 5 min a milky pink dispersion is obtained, then administer immediately
Better to use Atorvastatin
[10]
C10AB04Gemfibrozil
(600, 900 mg)
LOPID
(PFIZER)
Coated tabletsYesCrushable tablets
C10AB05Fenofibrate
(145 mg)
FULCROSUPRA
(BGP PRODUCTS)
Coated tabletsNo
Fenofibrate
(200 mg)
FENOFIBRATO SAN
(SANDOZ)
CapsulesNo
C10AC01Cholestyramine hydrochloride
(4 g)
QUESTRAN
(BRISTOL-MYERS SQUIBB)
Powder for oral suspensionNoRisk of occlusion of the tube due to the formation of a semi-solid mass
Possible interference with the absorption of other drugs
C10AX06Polyenoic Omega (ethyl esters of polyunsaturated fatty acids)
(1000 mg)
SEACOR
(SOC.PRO.ANTIBIOTICI)
Soft gelsNo [8,9]
C10AX09Ezetimibe
(10 mg)
EZETROL
(MERCK SHARP & DOHME)
TabletsYesDisperse the tablet in 10 mL water under stirring Administer the suspension immediately
C10BA02Ezetimibe
Simvastatin
(10 + 10 mg)
INEGY
(MERCK SHARP & DOHME)
Tablets NoAdminister the two drugs separately
Flush with 10 mL water between each one
[8,9]
Ezetimibe
Simvastatin
(10 + 20 mg)
VYTORIN
(NEOPHARMED GENTILI)
D01BA02Terbinafine hydrochloride
(250 mg)
TERBINAFINA SAN
(SANDOZ)
TabletsYesDisperse the tablet under stirring in 10 mL water for 5 min, to give a fine dispersion that must be immediately administered
Divisible tablets
Be careful when handling
[10]
D05BB02Acitretin
(10, 25 mg)
NEOTIGASON
(AUROBINDO)
CapsulesYesOpen the capsule, disperse the content in water and administer immediately together with EN
If possible change the drug
D10BA01Isotretinoin
(10 mg)
ISOTRETINOINA DIF
(DIFA COOPER)
Soft gelsNo [8,9]
D11AH04Alitretinoin
(30 mg)
TOCTINO
GLAXOSMITHKLINE
Soft gelsNo [8,9]
G02AB01Methylergometrine maleate
(0.125 mg)
METHERGIN
(NOVARTIS)
Coated tabletsNoAlternative: solution for injection
G02CB01Bromocriptine mesylate
(2.5 mg)
PARLODEL
(MEDA PHARMA)
TabletsYesAdminister together with EN[10]
G02CB03Cabergoline
(0.5 mg)
DOSTINEX
(PFIZER)
TabletsNo
G03AA10Ethinylestradiol
Gestodene
GINODEN
(BAYER)
Coated tabletsNoAlternative: transdermal patches[8,9]
ESTINETTE
(EFFIK)
G03AD01Levonorgestrel
(1.5 mg)
NORLEVO
(LABORATOIRE HRA PHARMA)
TabletsNoAlternative: transdermal patches[8,9]
G03DA04Prgesterone
(100, 200 mg)
PROGEFFIK
(EFFIK)
CapsluesNoAlternatives: insert the capsule vaginally or use the solution for injection[8,9]
G03DB04Nomegestrol acetate
(5 mg)
LUTENYL
(RATIOPHARM)
TabletsNo
G03DC02Norethisterone acetate
(10 mg)
PRIMOLUT NOR
(BAYER)
TabletsYesDisperse the tablet in 10 mL water under stirring for 5 min, to give a fine dispersion that must be immediately administered
Be careful when handling
[10]
G03HA01Cyproterone acetate
(50 mg)
ANDROCUR
(BAYER)
TabletsYesGrind, disperse the tablet in 10 mL water and administer immediately. Where possible switch to intramuscular administration
G03XB01Mifepristone
(200 mg)
MIFEGYNE
(EXELGYN)
TabletsYes
G03XB02Ulipristal acetate
(5 mg)
ESMYA
(GEDEON RICHTER)
TabletsYesCrushable tablets
G04BDFlavoxate
Propyphenazone
(200 + 30 mg)
CISTALGAN
(MEDA PHARMA)
Coated tabletsNo [8,9]
G04BD04Oxybutynin hydrochloride
(5 mg)
DITROPAN
(SANOFI)
TabletsYes
G04BD08Solifenacin succinate
(5 mg)
VESIKER
(ASTELLAS)
Coated tabletsNo
G04BD12Mirabregon
(50 mg)
BETMIGA
(ASTELLAS)
Modified
release tablets
No [8,9]
G04BE03Sildenafil citrate
(20 mg)
REVATIO
(PFIZER)
Coated tabletsNoAlternative: oral suspension
Sildenafil citrate
(50, 100 mg)
VIAGRA
(PFIZER)
TabletsYesGrind, disperse the tablet in 10 mL water and administer immediately
G04BE08Tadalafil
(5, 10, 20 mg)
CIALIS
(ELI LILLY)
Coated tabletsNo
Tadalafil
(20 mg)
ADCIRCA
(ELI LILLY)
G04CA01Alfuzosin hydrochloride
(2.5 mg)
MITTOVAL
(SANOFI)
Modified
release tablets
NoAlternative: Doxasozin[8,9]
XATRAL
(SANOFI)
G04CA01Alfuzosin hydrochloride
(2.5 mg)
XATRAL
(SANOFI
Coated tabletsYesAlternative: Doxasozin
G04CA02Tamsulisin hydrochloride
(0.4 mg)
PRADIF
(BOEHRINGER INGELHEIM)
CapsulesNoRisk of blockage of the tube
Alternative: Doxasozin
G04CA03Terazosin hydrochloride
(5 mg)
TERAPROST
(MALESCI)
TabletsYes
Terazosin hydrochloride
(2, 5 mg)
TERAZOSINA TEV
(TEVA)
TabletsNo
G04CA04Silodosin
(4, 8 mg)
UROREC
(RECORDATI)
CapsulesYesOpen the capsule and suspend the content in water
G04CB01Finasteride
(5 mg)
FINASTERIDE (NEOPHARMED GENTILI)Coated tabletsYesCrushable tablets
Teratogen drug
[10]
G04CB02Dutasteride
(0.5 mg)
AVODART
(GLAXOSMITHKLINE)
CapsulesNoContent of the capsule liquid, irritant and teratogen
H01BA02Desmopressin acetate
(60, 120 µg)
MINIRIN/DDAVP
(FERRING)
Sublingual
tablets
NoDo not crush the tablet
Reduction of the absorption of the drug due to the hepatic first pass effect
[8,9]
H02AB01Betamethasone sodium phosphateBENTELAN
(SIGMATAU)
Effervescent
tablets
YesDissolve the tablet in 10 mL water and administer immediatelySmPC
H02AB04Methylprednisolone
(4, 16 mg)
MEDROL
(PFIZER)
TabletsYesGrind the tablet, dissolve it in 10 mL water and administer immediately[10]
H02AB07Prednisone
(5, 25 mg)
DELTACORTENE
DELTACROTENE FTE
(BRUNO FARMACEUTICI)
TabletsYesGrind the tablet, dissolve it the tablet in 10 mL water and administer immediately[10]
H02AB07Prednisone
(5 mg)
LODOTRA
(MUNDIPHARMA)
Modified
release tablets
NoAlternative: Deltacortene 5 mg[8,9]
H02AB09Hydrocortisone
(5, 20 mg)
PLENADREN
(SHIRE)
Modified release tabletsNo [8,9]
H02AB10Cortisone acetate
(25 mg)
CORTONE ACETATO (TEOFARMA)TabletsYes
H03AA01Levothyroxine sodium
(50, 100 µg)
TIROSINT
(IBSA FARMACEUTICI)
TabletsYesGrind the tablet, dissolve it in 10 mL water.
Interaction with EN: suspend it 1 h before and resume it 2 h later drug administration
Alternative: Tirosint oral solution which is not affected by simultaneous food intake
SmPC
H03AA01Levothyroxine sodium
(25, 50, 75, 100 µg)
EUTIROX
(MERCK SERONO)
TabletsYesGrind the tablet and dissolve it in 10 mL water, then administer immediately
Suspend EN 1 h before and resume it 2 h later drug administration
Monitor TSH levels
Divisible tablets
[10]
Levothyroxine sodium
(25 µg)
LEVOTIROXINA TEV
(TEVA)
H03BB02Thiamazole (Methimazole)
(5 mg)
TAPAZOLE
(TEOFARMA)
TabletsYesGrind the tablet and disperse it in 10 mL water, then administer immediately
Divisible tablets
H05BX01Cinacalcet hydrochloride
(30, 60, 90 mg)
MIMPARA
(AMGEN)
Coated tabletsNo
H05BX02Paricalcitol
(1 µg, 2 µg)
ZEMPLAR
(ABBVIE)
CapsulesNoAlternative: Zemplar solution for injection
J01AA02Doxycycline hyclate
(100 mg)
BASSADO
(PFIZER)
TabletsYesGrind the tablet and dissolve it in 10 mL water. Administer immediately with plenty of water to prevent irritation[10]
J01AA08Minocycline hydrochloride
(100 mg)
MINOCIN
(TEOFARMA)
CapsulesNo
J01CA01Ampicillin
(500 mg)
AMPLITAL
(PFIZER)
CapsulesNoAlternative: powder for solution for injection
J01CA04Amoxicillin trihydrate
(1 g)
ZIMOX
(PFIZER)
TabletsNoAlternatives: switch to other formulations (drops, oral suspension, powder for oral suspension)
J01CA04Amoxicillin trihydrate
(1 g)
ZIMOX
(PFIZER)
Chewable
tablets
YesDissolve the tablets in a half glass of waterSmPC
J01CR02 Amoxicillin trihydrate
Clavulanate potassium
(875 + 125 g)
ABBA
(FIDIA FARMACEUTICI)
Powder for oral suspensionYesDissolve the powder in 50 mL water
Administer together with EN to minimize the gastrointestinal side effects
SmPC
AUGMENTIN (GLAXOSMITHKLINE)
J01CR02Amoxicillin trihydrate
Clavulanate potassium
(875 + 125 g)
NEODUPLAMOX
(VALEAS)
Coated tabletsNoAlternatives: switch to other formulations (suspension, powder for oral suspension)[8,9]
J01CR04Sultamicillin tosylate
(750 mg)
UNASYN
(PFIZER)
Coated tabletsNoAlternatives: powder for oral solution, or solution for injection[8,9]
J01DB01Cephalexin monohydrate
(1 g)
KEFORAL
(CRINOS)
TabletsNoSwitch to another cephalosporin or use the oral suspension available on the market[8,9]
Cephalexin
(1 g)
CEPOREX
(TEOFARMA)
Coated tablets
J01DC02Cefuroxime acetoxyethyl
(250 mg)
ZINNAT (GLAXOSMITHKLINE)Coated tabletsNoUse the syrup which must be diluted with 60 mL water and administered immediately[8,9]
J01DD08Cefixime
(400 mg)
UNIXIME
(F.I.R.M.A.)
Coated tabletsNoAlternatives: dispersible tablets or oral suspension. Stop the EN at least 1 h before and resume it 2 h after drug administration[8,9]
J01DD13Cefpodoxime proxetil
(100, 200 mg)
CEFODOX
(SCHARPER)
Coated tabletsYesBetter to switch to the oral suspension[8,9]
J01EE01Trimethoprim
Sulfamethoxazole
(160 + 800 mg)
BACTRIM
(ROCHE)
TabletsNoAlternative: oral suspension[8,9]
J01FA09Clarithromycin
(250, 500 mg)
KLACID
(BGP PRODUCTS)
Coated tabletsNoAlternatives: oral suspension, solution for injection
Photosensitive drug
[8,9]
Clarithromycin
(500 mg)
CLARITROMICINA TEV
(TEVA)
Alternative: oral suspension which must be diluted with 60 mL water and administered immediately
J01FA10Azithromycin monohydrate
(500 mg)
AZITROMICINA EG
(EG)
Coated tabletsNoAlternative: oral suspension which must be diluted with 60 mL water and administered immediately
It does not interact with EN
[8,9]
Azithromycin monohydrate
(500 mg)
AZITROMICINA MYL
(MYLAN)
Alternative: oral suspension which must be diluted
Administer 1 h before or 2 h after EN
Azithromycin dihydrate
(500 mg)
ZITROMAX
(PFIZER)
Alternative: oral suspension which must be diluted
Administer 1 h before or 2 h after EN
Azithromycin dihydrate
(500 mg)
AZITROMICINA PRG
(PROGE FARM)
Alternative: oral suspension which must be diluted
Administer 1 h before or 2 h after EN
Azithromycin monohydrate
(500 mg)
AZITROMICINA SAN
(SANDOZ)
Alternative: oral suspension which must be diluted
Administer 1 h before or 2 h after EN
J01FA10Azithromycin dihydrate
(500 mg)
TROZAMIL
(SO.SE.PHARM)
Coated tabletsYesAlternative: oral suspension which must be diluted
Administer 1 h before or 2 h after EN
J01FF01Clindamycin hydrochloride
(150 mg)
DALACIN-C
(PFIZER)
CapsulesYesDisperse the content in water and then administer Alternatives: solution for injection or other route of administration (cutaneous gel)
J01MA02Ciprofloxacin hydrochloride
(250, 500, 750, 1000 mg)
CIPROXIN
(BAYER)
Coated tabletsNoEN-drug interaction: decreased absorption and therapeutic failure
Alternatives: solution for infusion or granules for oral suspension (EN must be suspended 30 min before and 30 min after drug administration)
Ciprofloxacin hydrochloride monohydrate
(250 mg)
CIPROFLOXAC.RAT (RATIOPHARM)
Ciprofloxacin hydrochloride monohydrate
(750 mg)
CIPROFLOXAC.SAN (SANDOZ)
J01MA12Levofloxacin hemihydrate
(500 mg)
LEVOFLOXACINA SAN (SANDOZ)Coated tabletsNoAlternatives: solution for injection or switch to more bioavailable Ofloxacin
J01MA14Moxifloxacin hydrochloride
(400 mg)
AVALOX
(BAYER)
Coated tabletsYesThe coating exerts only taste masking
J01MA17Prulifloxacin
(600 mg)
UNIDROX
(ANGELINI)
Coated tabletsyesAdminister immediately after dissolution of the tablet in water
J01XE01Nitrofurantoin macrocrystals
(50 mg)
NEOFURADANTIN (GRUNENTHAL)CapsulesNoRisk of tube blockage
J01XX01Fosfomycin trometamol salt
(3 g)
BERNY
(SO.SE.PHARM)
Granules for oral solutionYesAdminister away from the EN, usually at bedtime
J01XX08Linezolid
(600 mg)
ZYVOXID
(PFIZER)
Coated tabletsYesGrind the tablet, dissolve the powder in 20 mL water then administer immediately
Prefer oral suspension or solution for infusion
Any interaction with EN
[10]
J02AC01Fluconazole
(100 g)
FLUCONAZOLO EG
(EG)
CapsulesYesOpen the capsule, disperse the content in 20 mL water, then administer immediately
Prefer oral suspension or solution for injection
If dietary product is rich in fiber, suspend EN 1 h before and 1 h after drug administration
[10]
DIFLUCAN
(PFIZER)
FLUCONAZOLO SAN
(SANDOZ)
FLUCONAZOLO HEX
(SANDOZ)
FLUCONAZOLO RAT
(TEVA)
J02AC02Itraconazole
(100 g)
SPORANOX
(JANSSEN CILAG)
CapsulesNoAlternatives: solution for infusion or oral solution to be diluted with water
The absorption occurs at acidic pH
Administer together with EN
J02AC03Voriconazole
(200 mg)
VFEND
(PFIZER)
Coated tabletsYesGrind the tablet, disperse the powder in water and administer away from EN (1 h before or 2 h after EN)
Alternatives: oral suspension or powder for solution for injection
[10]
J04AB02Rifampicin
(300, 400 mg)
RIFADIN
(SANOFI)
CapsulesNoAlternative: syrup to be diluted and administered away from EN[8,9]
J04AC01Isoniazid
(200 mg)
NICOZID
(PIAM FARMACEUTICI)
TabletsYesGrind the tablet, dissolve the powder in 20 mL water then administer immediately
Stop EN 1 h before and 2 h after drug administration
[10]
J04AK01Pyrazinamide
(500 mg)
PIRALDINA
(BRACCO)
TabletsYesGrind the tablet, dissolve the powder in 10 mL water then administer immediately[10]
J04AK02Ethambutol hydrochloride
(400 mg)
ETAPIAM
(PIAM FARMACEUTICI)
Coated tabletsYesGrind the tablet, dissolve the powder in 10 mL water then administer immediately 2 h after EN[10]
J04AM02Rifampicin
Isoniazid
(300 + 150 mg)
RIFINAH 300
(SANOFI)
Coated tabletsNoAdminister the two drugs separately
Flush with 10 mL water between each one
[8,9]
J04AM05Isoniazid
Pyrazinamide
Rifampicin
(50 + 300 +120 mg)
RIFATER
(SANOFI)
Coated tabletsYesSuspend EN 1 h before drug administration
J05AB01Acyclovir
(400 mg)
ACICLOVIR EG
(EG)
TabletsYesGrind the tablet, dissolve it in 30 mL water then administer immediately
Alternatives: oral suspension or solution for injection
[10]
Acyclovir
(800 mg)
ACICLIN
(FIDIA FARMACEUTICI)
Acyclovir
(400 mg)
ACICLOVIR DRM
(TEVA)
J05AB04Ribavirin
(200 mg)
REBETOL
(MSD)
CapsulesNoAlternative: Ribavirin (Rebetol) oral solution[8,9]
COPEGUS
(ROCHE)
Coated tablets
RIBAVIRINA SAN
(SANDOZ)
Capsules
RIBAVIRINA TEV
(TEVA)
Capsules
J05AB11Valacyclovir hydrochloride
(1 g)
ZELITREX (GLAXOSMITHKLINE)Coated tabletsYesBetter to switch to Acyclovir
The tablets are difficult to crush and the powder does not suspend well
Alternative: galenic suspension of Valaciclovir 50 mg/mL, by triturating the tablets and using simple syrup (good stability up to 21 days at 2–8 °C)
VALACICLOVIR MYL (MYLAN)
J05AB14Valgancyclovir hydrochloride
(450 mg)
DARILIN
(ROCHE)
Coated tabletsNoAlternative: Valgancyclovir oral suspension (Novir)[8,9]
J05AE03Ritonavir
(100 mg)
NORVIR
(ABBVIE)
Coated tabletsNoAlternative: Ritonavir oral suspension
Tablets not crushable
[8,9]
J05AE07Fosamprenavir calcium
(700 mg)
TELZIR
(VIIV HEALTHCARE)
Coated tabletsNoAlternative: Fosamprenavir oral suspension (Telzir)[8,9]
J05AE08Atazanavir sulfate
(200, 300 mg)
REYATAZ
(BRISTOL-MYERS SQUIBB)
CapsulesYesOpen the capsule, dissolve the content in water, administer it via tube, then continue with EN
J05AE10Darunavir ethanolate
(600, 800 mg)
PREZISTA
(JANSSEN CILAG)
Coated tabletsNoAlternative: Darunavir ethanolate oral suspension
J05AE11Telaprevir
(375 mg)
INCIVO
(JANSSEN CILAG)
Coated tabletsNo
J05AE12Boceprevir
(200 mg)
VICTRELIS
(MSD)
CapsulesNo
J05AE14Simeprevir
(150 mg)
OLYSIO
(JANSSEN CILAG)
CapsulesNo
J05AF02Didanosine
(250 mg)
VIDEX 250
(BRISTOL-MYERS SQUIBB)
CapsulesNo
J05AF05Lamivudine
(100 mg)
ZEFFIX (GLAXOSMITHKLINE)Coated tabletsYesDisperse the tablet in 10 mL water, a pale orange solution is obtained, then administer immediately
Prefer: Lamivudine oral solution
[10]
J05AF05Lamivudine
(100 mg)
LAMIVUDINA MYL
(MYLAN)
Coated tabletsNoPrefer liquid formulation[8,9]
J05AF07Tenofovir Disoproxil Fumarate
(245 mg)
VIREAD
(GILEAD SCIENCES)
Coated tabletsYesDissolve the tablet in 100 mL water or orange juice and administerSmPC
J05AF08Adefovir dipivoxil
(10 mg)
HESPERA
(GILEAD SCIENCES)
Coated tabletsNoSwitch to Tenofovir
J05AF09Emtricitabine
(200 mg)
EMTRIVA
(GILEAD SCIENCES)
CapsulesNoAlternative: Emtricitabine oral solution
Increase the dose by 20% with respect to the tablets, due to reduced bioavailability of the oral solution
J05AF10Entecavir
(0.5, 1 mg)
BARACLUDE
(BRISTOL-MYERS SQUIBB)
Coated tabletsNoSwitch to oral solution[8,9]
J05AG01Nevirapine
(400 mg)
VIRAMUNE
(BOEHRINGER INGELHEIM)
TabletsNoSwitch to oral suspension[8,9]
Nevirapine
(200 mg)
NEVIRAPINA TEV
(TEVA)
Alternative: liquid formulation
J05AG03Efavirenz
(200 mg)
SUSTIVA
(BRISTOL-MYERS SQUIBB)
CapsulesYes
J05AG03Efavirenz
(600 mg)
EFAVIRENZ MYL
(MYLAN)
Coated tabletsNoAlternative: liquid formulation[8,9]
J05AG04Etravirine
(200 mg)
INTELENCE
(JANSSEN CILAG)
TabletsYesDissolve the tablet in 10 mL water and administerSmPC
J05AG05Rilpivirine hydrochloride
(25 mg)
EDURANT
(JANSSEN CILAG)
Coated tabletsNo
J05AH02Oseltamivir phosphate
(30, 45 mg)
TAMIFLU
(ROCHE)
CapsulesNoAlternative: oral suspension[8,9]
J05AR01Lamivudine
Zidovidine
(150 + 300 mg)
LAMIV+ZIDOV MYL
(MYLAN)
Coated tabletsNoAdminister the two drugs separately in liquid form[8,9]
J05AR02Abacavir sulfate
Lamivudine
(600 + 300 mg)
KIVEXA
(VIIV HEALTHCARE)
Coated tabletsNoSeparate preparations of the two drugs are available in the form of oral suspension[8,9]
J05AR03Emtricitabine
Tenofovir disoproxil
(200 + 245 mg)
TRUVADA
(GILEAD SCIENCES)
Coated tabletsYesThe tablets can be dissolved in about 100 mL of water, orange juice or grape juice and taken immediatelySmPC
J05AR04Abacavir sulfate
Lamivudine
Zidovudine
(300 + 150 + 300 mg)
TRIZIVIR
(VIIV HEALTHCARE)
Coated tabletsNoSeparate preparations of the three drugs are available in the form of oral suspension[8,9]
J05AR06Efavirenz
Emtricitabine
Tenofovir disoproxil
(600 +200 +245 mg)
ATRIPLA
(GILEAD SCIENCES)
Coated tabletsNo [8,9]
J05AR08Emtricitabine
Rilpivirine hydrochloride
Tenofovir disoproxil fumarate
(200 + 25 + 245 mg)
EVIPLERA
(GILEAD SCIENCES)
Coated tabletsNo [8,9]
J05AR09Emtricitabine
Tenofovir disoproxil fumarate
Elvitegravir
Cobicistat
(200 + 300 + 150 + 150 mg)
STRIBILD
(GILEAD SCIENCES)
Coated tabletsNo [8,9]
J05AR10Lopinavir
Ritonavir
(200 + 50 mg)
KALETRA
(ABBVIE)
Coated tabletsNoTablet crushing reduces AUC by approximately 40% Preferred alternative: Kaletra oral solution (slightly viscous, contains alcohol and propylene glycol)[8,9]
J05AX08Raltegravir potassium
(400 mg)
ISENTRESS
(MSD)
Coated tabletsNoDrug insoluble in water
J05AX09Maraviroc
(150, 300 mg)
CELSENTRI
(VIIV HEALTHCARE)
Coated tabletsNo
J05AX12Dolutegravir sodium
(50 mg)
TIVICAY
(VIIV HEALTHCARE)
Coated tabletsYesGrind the tablet, disperse it in water and administer away from EN (2 h before or 6 h after EN)
J05AX14Daclatasvir dihydrochloride
(60 mg)
DAKLINZA
(BRISTOL-MYERS SQUIBB)
Coated tabletsYesThe coating serves only to cover the drug bitter taste
J05AX15Sofosbuvir
(400 mg)
SOVALDI
(GILEAD SCIENCES)
Coated tabletsYesThe coating serves only to cover the drug bitter taste
The tablets can be triturated and administered via tube concurrently with EN
J05AX16Dasabuvir
(250 mg)
EXVIERA
(ABBVIE)
Coated tabletsNoNot crushable tablet
J05AX65Ledipasvir
Sofosbuvir
(90 + 400 mg)
HARVONI
(GILEAD SCIENCES)
Coated tabletsNo [8,9]
J05AX67Ombitasvir
Paritaprevir
Ritonavir
(12.5 + 75 + 50 mg)
VIEKIRAX
(ABBVIE)
Coated tabletsNoNot crushable tablet[8,9]
L01AA01Cyclophosphamide
(50 mg)
ENDOXAN
(BAXTER)
Coated tabletsNoAlternative: solution for injection[8,9]
L01AA02Chlorambucil
(2 mg)
LEUKERAN
(GLAXOSMITHKLINE)
Coated tabletsNo
L01AA03Melfalan
(25 mg)
ALKERAN
(ASPEN PHARMA)
Coated tabletsNoAlternative: solution for injection[8,9]
L01AB01Busulfan
(2 mg)
MYLERAN
(ASPEN PHARMA)
Coated tabletsNoAlternative: galenic suspension of Busulfan 2 mg/mL by triturating the tablet
Shelf life 30 days if stored between 2–8 °C
L01AX03Temozolomide
(100 mg)
TEMODAL
(MSD)
CapsulesNo
Temozolomide
(100 mg)
TEMOZOLOMIDE SUH (RANBAXY ITALIA)
Temozolomide
(5, 20, 140, 180, 250 mg)
TEMOZOLOMIDE SUH
(SUN PHARMACEUTICALS)
L01BA01Methotrexate
(2.5 mg)
METHOTREXATE
(PFIZER)
TabletsNoAlternative: Methotrexate solution for injection
Tablets are divisible but not crushable
[8,9]
L01BB05Fludarabine phosphate
(10 mg)
FLUDARA
(GENZYME)
Coated tabletsNoAlternative: solution for injection[8,9]
L01BC06Capecitabine
(150, 500 mg)
CAPECITABINA ACC
(ACCORD HEALTHCARE)
Coated tabletsYesDisperse the tablet in 200 mL warm water and then administer immediately
Attention to handling, use individual protection measures
CAPECITABINA MYL
(MYLAN)
XELODA
(ROCHE)
L01CA04Vinorelbine ditartrate(20, 30 mg)NAVELBINE
(PIERRE FABRE PHARMA)
Soft gelsNoAlternative: concentrate for solution for infusion[8,9]
L01XE01Imatinib mesylate
(100 mg)
GLIVEC
(NOVARTIS)
CapsulesYesOpen the capsule, dilute the content in water or apple juice
Attention to handling, use individual protection measures
SmPC
L01XE02Gefitinib
(250 mg)
IRESSA
(ASTRAZENECA)
Coated tabletsYesDisperse the tablet in half glass water (it takes 20 min)
Administer the suspension immediately
SmPC
L01XE03Erlotinib hydrochloride
(100, 150 mg)
TARCEVA
(ROCHE)
Coated tabletsNo
L01XE04Sunitinib maleate
(12.5, 25, 50 mg)
SUTENT
(PFIZER)
CapsulesYesAttention to handling, use individual protection measures
L01XE05Sorafenib tosilate
(200 mg)
NEXAVAR
(BAYER)
Coated tabletsNoNo specific data are available
L01XE06Dasatinib monohydrate
(50, 100, 140 mg)
BRISTOL-MYERS SQUIBBCoated tabletsNoNo specific data are available
Attention to handling, use individual protection measures
L01XE07Lapatinib ditosylate monohydrate
(250 mg)
TYVERB
(NOVARTIS)
Coated tabletsNo
L01XE08Nilotinib hydrochloride
(150, 200 mg)
TASIGNA
(NOVARTIS)
CapsulesYes
L01XE10Everolimus
(5, 10 mg)
AFINITOR
(NOVARTIS)
TabletsNo
L01XE11Pazopanib hydrochloride
(400 mg)
VOTRIENT
(NOVARTIS)
Coated tabletsNo
L01XE13Afatinib dimaleate
(40 mg)
GIOTRIF
(BOEHRINGER INGELHEIM)
Coated tabletsYesDisperse the tablet in water without breaking it, under stirring for 15 min until a fine dispersion is obtained, then administer immediately away from the EN
Be careful when handling
SmPC
L01XE16Crizotinib
(250 mg)
XALKORI
(PFIZER)
CapsulesNo
L01XE18Ruxolitinib phosphate
(5, 15 mg)
JAKAVI
(NOVARTIS)
TabletsNo
L01XE21Regorafenib
(40 mg)
STIVARGA
(BAYER)
Coated tabletsNo
L01XX05Hydroxycarbamide
(500 mg)
ONCO CARBIDE
(TEOFARMA)
CapsulesYesAttention to handling, use individual protection measures
Antineoplastic drug
[10]
L01XX14Tretinoin
(10 mg)
VESANOID
(CHEPLAPHARM ARZNEIMITTEL)
CapsulesNo
L01XX23Mitotane
(500 mg)
LYSODREN
(HRA PHARMA)
TabletsYesThe company confirms that the tablet can be crushed and the API dissolves in water
Use gloves for handling
Antineoplastic drug
Manufacturer upon request
L01XX35Anagrelide hydrochloride
(0.5 mg)
XAGRID
(SHIRE)
CapsulesNo
L02AB01Megestrol acetate
(160 mg)
GESTROLTEX
(PHARMATEX)
TabletsNo
L02BA01Tamoxifen citrate
(20 mg)
NOMAFEN
(ITALIAN DEVICES)
Coated tabletsNo
KESSAR
(ORION)
Tablets
L02BB01Flutamide
(250 mg)
FLUTAMIDE FDI
(FIDIA FARMACEUTICI)
TabletsYesTablet disaggregates slowly, maintain it under stirring in 10 mL water for 10 min
Attention to handling
[10]
L02BB03Bicalutamide
(50, 150 mg)
CASODEX
(ASTRAZENECA)
Coated tabletsYesIf possible use other antiandrogens administered as a subcutaneous implant
Grind the tablet and disperse the powder in water
Work in a closed system (disperse the tablet in the body of a syringe)
Administer immediately after the EN
Attention to handling
[10]
Bicalutamide
(150 mg)
BICALUTAMIDE HIK
(HIKMA FARMACEUTICA)
Coated tabletsNoIf possible use other antiandrogens administered by subcutaneous implant[10]
L02BB03Bicalutamide
(50, 150 mg)
BICALUTAMIDE TEV
(TEVA)
Coated tabletsNoIf possible use other antiandrogens administered by subcutaneous implant
L02BG03Anastrozole
(1 mg)
ANASTROZOLO ACC
(ACCORD HEALTHCARE)
Coated tabletsNoData not available
ARIMIDEX
(ASTRAZENECA)
YesDisperse the tablet in 10 mL water in a closed system (disperse the tablet in the body of a syringe)
Drug slightly soluble in water
L02BG04Letrozole
(2.5 g)
LETROZOLO ACC
(ACCORD HEALTHCARE)
Coated tabletsNo
LETROZOLO SAN
(SANDOZ)
L02BG06Exemestane
(25 mg)
AROMASIN
(PFIZER)
Coated tabletsNo
L02BX03Abiraterone acetate
(25 mg)
ZYTIGA
(JANSSEN CILAG)
Coated tabletsNo
L04AA06Mycophenolate sodium
(180, 360 mg)
MYFORTIC
(NOVARTIS)
Gastro-resistant tabletsNoAlternative: Mycofenolate mofetil (Cellept) oral solution[8,9]
Mycofenolate mofetil
(250, 500 mg)
CELLCEPT
(ROCHE)
Capsules
Mycofenolate mofetil
(250, 500 mg)
MYFENAX
(TEVA)
Coated tablets
L04AA10Sirolimus
(0.5, 1 mg)
RAPAMUNE
(PFIZER)
Coated tabletsNoAlternative: Sirolimus (Rapamune) oral solution[8,9]
L04AA13Leflunomide
(20 mg)
ARAVA
(SANOFI)
Coated tabletsYesDissolve the tablet in 10 mL water and administer immediately[10]
L04AA18Everolimus
(0.25, 0.75 mg)
CERTICAN
(NOVARTIS)
TabletsNoAlternative: orosoluble tablets to be dissolved in 10 mL water
Stop EN 1 h before and 2 h after drug administration
[8,9]
L04AA27Fingolimod hydrochloride
(0.5 mg)
GILENYA
(NOVARTIS)
CapsulesNo
L04AA31Teriflunomide
(14 mg)
AUBAGIO
(GENZYME)
Coated tabletsNo
L04AD01Cyclosporine
(10, 25, 50, 100 mg)
SANDIMMUN NEORAL (NOVARTIS)CapsulesNoAlternative: Cyclosporine oral solution[8,9]
L04AD02 Tacrolimus
(1 mg)
TACROLIMUS ACC
(ACCORD HEALTHCARE)
CapsulesNoAlternatives: Porgraf capsules or Tacni capsules
Tacrolimus monohydrate
(0, 5, 1, 3, 5 mg)
ADVAGRAF
(ASTELLAS)
Tacrolimus monohydrate
(0, 5, 1, 5 mg)
PROGRAF
(ASTELLAS)
YesOpen the capsule and dissolve the content in water
Administer through an 8 Fr caliber tube
Do not use a PVC tube
Beware of handling
Take on an empty stomach or at least 1 h before or 2–3 h after eating
Tacrolimus
(0.5 mg)
TACROLIMUS MYL
(MYLAN)
NoAlternative: Porgraf capsules
Tacrolimus monohydrate
(1 mg)
ADOPORT
(SANDOZ)
NoAlternative: Porgraf capsules
L04AX01Azathioprine
(50 mg)
AZATIOPRINA
(ASPEN PHARMA)
Coated tabletsYesDisperse the tablet in 10 mL water in the body of a syringe (closed system)
Cytotoxic drug
Use personal protective equipment
[10]
L04AX02Thalidomide
(50 mg)
THALIDOMIDE CELGENE (CELGENE)CapsulesNoThe capsules must not be opened
Teratogen drug
L04AX04Lenalomide
(5, 10, 15, 25 mg)
REVLIMID
(CELGENE)
CapsulesNoThe capsules must not be opened
Teratogen drug
L04AX05Pirfenidone
(267 mg)
ESBRIET
(ROCHE)
CapsulesNo
L04AX06Pomalidomide
(4 mg)
IMNOVID
(CELGENE)
CapsulesNoNot available data on drug manipulation
M01AB01Indomethacin
(25, 50 mg)
INDOXEN
(SIGMATAU)
CapsulesNoAlternative: suppositories[8,9]
M01AB05Diclofenac sodium
(50, 150 mg)
FLOGOFENAC (A.MENARINI)Modified
release capsules
NoAlternatives: dispersible tablets, solution for injection, cutaneous formulations[8,9]
M01AB05Diclofenac sodium
(50, 150 mg)
DICLOREUM
(ALFA WASSERMANN)
Gastro-resistant tabletsNoAlternatives: dispersible tablets, solution for injection, cutaneous formulations[8,9]
M01AB15Ketorolac tromethamine
(10 mg)
TORADOL
(RECORDATI)
Coated tabletsNoAlternatives: drops, solution for injection[8,9]
M01AC01Piroxicam
(20 mg)
FELDENE SOL
(PFIZER)
Soluble tabletsYes [8,9]
M01AE01Ibuprofen
(600 mg)
BRUFEN
(BGP PRODUCTS)
Coated tabletsNoAlternatives: effervescent granules, oral suspension to be diluted with the same water amount[8,9]
Ibuprofen
(600 mg)
BRUFEN
(BGP PRODUCTS)
Effervescent granulesYesDissolve the granules in plenty of water
Ibuprofen
(200 mg)
NUROFEN
(RECKITT BENCKISER)
Coated tabletsNoAlternative: oral suspension
Ibuprofen arginine salt
(400 mg)
SPIDIDOL
(ZAMBON)
Coated tabletsNoAlternative: oral suspension
M01AE03Ketoprofen lysine salt
(80 mg)
OKI
(DOMPE’ FARMACEUTICI)
Granules for oral solutionYesAlternatives: solution for injection, suppositories, cutaneous gel[8,9]
Ketoprofen
(200 mg)
KETOPROFENE EG
(EG)
CapsulesNo
Ketoprofen lysine salt
(80 mg)
KETOPROFENE MYL (MYLAN)Powder for oral solutionYes
Ketoprofen
(200 mg)
ORUDIS RETARD
(SANOFI)
CapsulesNo
M01AH01Celecoxib
(200 mg)
CELEBREX
(PFIZER)
CapsulesYesOpen the capsule and disperse the content in 10 mL water[10]
M01AH05Etoricoxib
(60, 90 mg)
TAUXIB
(ADDENDA)
Coated tabletsYesThe tablet immersed in 10 mL water, swells and then releases fine granules that must be administered in an 8 Fr caliber tube[10]
Etoricoxib
(60 mg)
ARCOXIA
(MSD)
Etoricoxib
(60, 90 mg)
ALGIX
(NEOPHARMED GENTILI)
M01AX17Nimesulide
(100 mg)
AULIN
(HELSINN BIREX PHARMAC.)
Granules for oral solutionYesDisperse the tablet in 30 mL water and then administer immediately
Administer together with EN to reduce gastrointestinal side effects
M03BX01Baclofen
(10, 25 mg)
LIORESAL
(NOVARTIS)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately[10]
M03BX03Pridinol mesilate
(4 mg)
LYSEEN (GLAXOSMITHKLINE)TabletsYesAlternative: solution for injection
M03BX05Thiocolchicoside
(4 mg)
MUSCORIL
(SANOFI)
CapsulesNoAlternative: solution for injection[8,9]
M04AA01Allopurinol
(100, 300 mg)
ALLOPURINOLO TEV
(TEVA)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately[10]
M04AA03Febuxostat
(80 mg)
ADENURIC
(A.MENARINI)
Coated tabletsNoAlternative: Allopurinol tablets
M04AC01Colchicine
(1 mg)
COLCHICINA LIRCA (PHARMAFAR)TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately[10]
M05BA04Alendronate sodium
(10 mg)
ALENDROS
(ABIOGEN PHARMA)
TabletsNoInteraction with EN
Irritant for mucosal membranes
If necessary grind the tablet and dissolve the powder in 50 mL water, then administer 30 min before the first daily administration of EN keeping the patient in a semi-sitting position
Rinse the tube with 100 mL water after administration
Alendronate sodium trihydrate
(70 mg)
ADRONAT
(NEOPHARMED GENTILI)
Alendronate sodium
(10 mg)
DRONAL
(SIGMATAU)
Alendronate sodium monohydrate
(70 mg)
ALENDRONATO TEV
(TEVA)
M05BA06Ibandronate sodium monohydrate
(150 mg)
BONVIVA
(ROCHE)
Coated tabletsNo
AC.IBANDR.TEV
(TEVA)
M05BB03Alendronate sodium trihydrate
Cholecalciferol
(70 mg + 5600 IU)
FOSAVANCE
(MSD)
TabletsNo
M05BX03Strontium ranelate
(2 g)
PROTELOS
(SERVIER)
Granules for oral
suspension
Yes
N02AA01Morphine sulfate
(10, 30 mg)
MS CONTIN
(MUNDIPHARMA)
Modified
release tablets
NoAlternative: drops to be diluted with 50 mL water and administered immediately[8,9]
N02AA03Hydromorphone hydrochloride
(4, 8, 16 mg)
JURNISTA
(JANSSEN CILAG)
Modified
release tablets
No [8,9]
N02AA05Oxycodone hydrochloride
(5, 10, 20 mg)
OXYCONTIN
(MUNDIPHARMA)
Modified
release tablets
No [8,9]
Oxycodone hydrochloride
(40 mg)
OXICODONE SAN
(SANDOZ)
N02AA55Oxycodone hydrochloride
Paracetamol
(10 + 325/20 + 325 mg)
DEPALGOS
(MOLTENI & C. F.LLI ALITTI)
Coated tabletsNo [8,9]
N02AA55Oxycodone hydrochloride
Naloxone hydrochloride dihydrate
(10 + 325/20 + 325 mg)
TARGIN
(MUNDIPHARMA)
Modified
release tablets
NoAlternative: switch to another analgesic opioid transdermal formulation[8,9]
N02AA59Paracetamol
Codeine phosphate
(500 + 30 mg)
ANGELINIEffervescent granulesYesAdminister only after the end of the effervescence
Coated tabletsThe tablet can be triturated and dispersed in water
N02AB03Fentanyl citrate
(100, 200, 300, 400, 600 µg)
ABSTRAL
(PROSTRAKAN)
Sublingual
tablets
No [8,9]
Fentanyl citrate
(100, 200, 300, 400 µg)
EFFENTORA
(TEVA)
Orosoluble tabletsYes
N02AX02Tramadol hydrochloride
(100 mg)
CONTRAMAL (GRUNENTHAL)Modified
release tablets
NoAlternatives: suppositories, orosoluble tablets, suppositories, drops to be diluted with 50 mL water[8,9]
N02AX06Tapentadol hydrochloride
(50, 100 mg)
PALEXIA
(GRUNENTHAL)
Modified
release tablets
No [8,9]
N02AX52Tramadol hydrochloride
Paracetamol
(37.5 + 325 mg)
PATROL
(ALFA WASSERMANN)
Coated tabletsNoAlternative: effervescent tablets to be dissolved in water and administered after the end of the effervescence[8,9]
KOLIBRI
(ALFA WASSERMANN)
N02BA01Acetylsalicylic acid
(100 mg)
ASPIRINETTA
(BAYER)
TabletsYesImmerse directly the tablet in water
Administer together with EN to reduce gastrointestinal side effects
SmPC
N02BE01Paracetamol
(500 mg)
TACHIPIRINA
(ANGELINI)
TabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
Alternatives: orosoluble tablets, granules, suppositories, syrup or solution for injection
Paracetamol
(1000 mg)
Effervescent tabletsDissolve the tablet in 30 mL water and administer only at the end of the effervescence
Alternatives: orosoluble tablets, granules, suppositories or solution for injection
N02BE01Paracetamol
(250, 500 mg)
TACHIPIRINA FLASHTAB
(ANGELINI)
Orodispersible tabletsYes [8,9]
Paracetamol
(250, 1000 mg)
TACHIPIRINA OROS (ANGELINI)Orosoluble granules
N02CC01Sumatriptan succinate
(50 mg)
SUMATRIPTAN DOC
(DOC GENERICI)
Coated tabletsYesAlternatives: solution for injection or nasal spray[8,9]
N03AA02Phenobarbital
(100 mg)
LUMINALE BRACCO
(BRACCO)
TabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
Administer together with EN to reduce gastrointestinal side effects
Do not administer solution for injection via tube due to the presence of glycol
SmPC
N03AA02Phenobarbital
(100 mg)
GARDENALE
(SANOFI)
TabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
Administer together with EN to reduce gastrointestinal side effects
Do not administer solution for injection via tube due to the presence of glycol
N03AA03Primidone
(250 mg)
MYSOLINE
(SIT LABORATORIO FARMACEUTICO)
TabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
N03AB02Phenytoin sodium
(100 mg)
DINTOINA
(RECORDATI)
Coated tabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
Stop EN 2 h before and 2 h after drug administration
Wash the tube with 50 mL water
Alternative: solution for injection
[10]
N03AB52Phenytoin
Methylphenobarbital
(100 + 40 mg)
DINTOINALE
(RECORDATI)
TabletsYes
N03AE01Clonazepam
(2 mg)
RIVOTRIL
(ROCHE)
TabletsYesAlternative: Clonazepam drops to be diluted with 50 mL water and administered immediately
N03AF01Carbamazepine
(200, 400 mg)
CARBAMAZEPINA
(EG)
TabletsYesGrind the tablet and disperse the powder in 10 mL sterile water, then administer immediately
Stop EN 1 h before and 2 h after drug administration
Requires close monitoring, it interacts with the EN Can adhere to the walls of the tube and have a reduced absorption
Better to use syrup
[10]
N03AF01Carbamazepine
(400 mg)
TEGRETOL
(NOVARTIS)
Modified
release tablets
NoAlternatives: syrup or tablets[8,9]
N03AF01Carbamazepine
(400 mg)
TEGRETOL
(NOVARTIS)
TabletsYesGrind the tablet and disperse the powder in 10 mL sterile water, then administer immediately
Stop EN at least 1 h before and 2 h after the dose
Requires close monitoring, it interacts with the EN Can adhere to the walls of the tube and have a reduced absorption
Better to use syrup
[10]
N03AF02Oxcarbazepine
(300, 600 mg)
TOLEP
(NOVARTIS)
TabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
N03AG01Valproic acid
Valproate sodium
(300, 500 mg)
AC VAL/S.VALP.RAT
(RATIOPHARM)
Modified
release tablets
NoAlternatives: oral solution or drops to be diluted with 100 mL water[8,9]
Valproic acid
Valproate sodium
(500 mg)
AC VALPROICO/SOD VALPR SAN
(SANDOZ)
Modified
release tablets
Valproate sodium
(200, 500 mg)
DEPAKIN
(SANOFI)
Gastro-resistant tablets
Valproic acid
Valproate sodium
(100, 250, 500, 750, 1000 mg)
DEPAKIN
(SANOFI)
Modified
release granules
Valproate magnesium
(500 mg)
DEPAMAG
(SIGMATAU)
Gastro-resistant tablets
N03AG02Valpromide
(300 mg)
DEPAMIDE
(SANOFI)
Gastro-resistant tabletsNo [8,9]
N03AG04Vugabatrin
(500 mg)
SABRIL
(SANOFI)
Coated tabletsNoAlternative: granules
N03AX09Lamotrigine
(25, 200 mg)
LAMOTRIGINA EG
(EG)
Dispersible
tablets
YesDissolve the tablet in 10 mL water and administer the solution immediately
N03AX09Lamotrigine
(25, 50, 100, 200 mg)
LAMICTAL (GLAXOSMITHKLINE)Dispersible
tablets
Yes SmPC
N03AX11Topiramate
(25 mg)
TOPIRAMATO DOC
(DOC GENERICI)
Coated tabletsYesThe tablet is not easily dispersed in water, due to the coating, but requires gentle stirring for 5 min
A fine suspension is obtained which should be administered immediately
Better to use capsules
[10]
Topiramate
(25, 50, 100 mg)
TOPIRAMATO EG
(EG)
Topiramate
(25, 50, 100 mg)
TOPAMAX
(JANSSEN CILAG)
Topiramate
(25 mg)
TOPIRAMATO SAN (SANDOZ)
N03AX11Topiramate
(25 mg)
TOPAMAX
(JANSSEN CILAG)
CapsulesYesOpen the capsule, disperse the content in 20 mL water, then administer immediatelySmPC
N03AX12Gabapentin
(400 mg)
DOC GENERICICapsulesYesOpen the capsule, disperse the content in 20 mL water, then administer immediately[10]
Gabapentin
(100, 300, 400 mg)
GABAPENTIN TEV
(TEVA)
N03AX14Levetiracetam
(500 mg)
LEVETIRACETAM DOC
(DOC GENERICI)
Coated tabletsYesGrind the tablet and dissolve the powder in 20 mL water, then administer immediately
Better to use oral solution
[10]
Levetiracetam
(500, 1000 mg)
LEVETIRACETAM SAN (SANDOZ)
N03AX15Zonisamide
(50, 100 mg)
ZONEGRAN
(EISAI)
CapsulesYes
N03AX16Pregabalin
(25, 75, 150 mg)
LYRICA
(PFIZER)
CapsulesYesOpen the capsules and dissolve the content in water
Drug water soluble
N03AX18Lacosamide
(50, 100 mg)
VIMPAT
(UCB PHARMA)
Coated tabletsYesAlternative: solution for injection
N04AA02Biperiden hydrochloride
(4 mg)
AKINETON
(SIT LABORATORIO FARMACEUTICO)
Modified
release tablets
NoAlternative: Biperiden hydrochloride
2 mg
[8,9]
N04AA02Biperiden hydrochloride
(2 mg)
AKINETON
(SIT LABORATORIO FARMACEUTICO)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
N04AA11Bornaprine hydrochloride
(4 mg)
SORMODREN
(TEOFARMA)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Wash the tube with 50 mL water
N04BA02Levodopa
Carbidopa
(100 + 25/200 + 50 mg)
SINEMET
(MSD)
Modified
release tablets
NoAlternative: dispersible tablets[8,9]
N04BA02Levodopa
Carbidopa
(100 + 25/250 + 25 mg)
SINEMET
(MSD)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Stop EN 2 h before and 2 h after drug administration
Do not administer together with high-protein diets
Photosensitive drug
[10]
N04BA02Levodopa
Benserazide hydrochloride
(100 + 25 mg)
MADOPAR
(ROCHE)
Modified
release capsules
NoAlternative: dispersible tablets[8,9]
Levodopa
Benserazide hydrochloride
(100 + 25 mg)
MADOPAR
(ROCHE)
Capsules
Levodopa
Benserazide hydrochloride
(100 + 25 mg)
MADOPAR
(ROCHE)
Tablets
N04BA02Levodopa
Benserazide hydrochloride
(100 + 25 mg)
MADOPAR
(ROCHE)
Dispersible
tablets
YesDisperse the tablet in 25–50 mL water until a fine opalescent suspension is obtained
Stop EN 1 h before drug administration
SmPC
N04BA02Levodopa
Carbidopa
(200 + 50 mg)
LEVOD/CARB HEXAL
(SANDOZ)
Modified
release tablets
NoAlternative: dispersible tablets[8,9]
N04BA02Levodopa
Benserazide hydrochloride
(200 + 50 mg)
LEVODOPA/BENSERAZIDE TEV
(TEVA)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Stop EN 2 h before and 2 h after drug administration
Do not administer together with high-protein diets Splittable tablet
[10]
N04BA03Levodopa
Carbidopa
Entecapone
(all dosages)
STALEVO
(NOVARTIS)
Coated tabletsNo [8,9]
N04BA05Melevodopa hydrochloride
Carbidopa hydrate
(12.5 + 125/25 + 100 mg)
SIRIO
(CHIESI FARMACEUTICI)
Effervescent
tablets
YesDissolve in 150 mL water
and wait until the end of the effervescence
N04BB01Amantadine hydrochloride
(100 mg)
MANTADAN
(BOEHRINGER INGELHEIM)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately[10]
N04BC04Ropirinole hydrochloride
(4, 8 mg)
REQUIP
(GLAXOSMITHKLINE)
Modified
release tablets
NoAlternative: Requip tablets[8,9]
N04BC04Ropirinole hydrochloride
(0.25, 0.5, 1, 2 mg)
REQUIP
(GLAXOSMITHKLINE)
Coated tabletsYesDissolve quickly the tablet in 10 mL water to obtain a fine dispersion to be administered immediately[10]
N04BC04Ropirinole hydrochloride
(4 mg)
ROPINIROLO SAN
(SANDOZ)
Modified
release tablets
NoAlternative: Requip tablets[8,9]
N04BC05Pramipexole dihydrochloride monohydrate
(0.26, 0.52, 1.05, 2.1, 3.15 mg)
MIRAPEXIN
(BOEHRINGER INGELHEIM)
Modified
release tablets
NoAlternative: Pramipexol tablets[8,9]
N04BC05Pramipexole dihydrochloride monohydrate
(0.7 mg)
PRAMIPEXOLO EG
(EG)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Photosensitive drug
Pramipexole dihydrochloride monohydrate
(0.18, 0.7 mg)
PRAMIPEXOLO
(TEVA)
N04BC06Cabergoline
(2 mg)
CABASER
(PFIZER)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately[10]
N04BD01Selegiline hydrochloride
(5, 10 mg)
JUMEX
(CHIESI FARMACEUTICI)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Administer in the morning before starting EN
N04BD02Rasagiline mesylate
(1 mg)
AZILECT
(TEVA)
TabletsYes
N04BX01Tolcapone
(100 mg)
TASMAR
(MEDA PHARMA)
Coated tabletsYes
N04BX02Entacapone
(200 mg)
COMTAN
(NOVARTIS)
Coated tabletsYesGrind the tablet and dissolve the powder in 20 mL water, then administer immediately[10]
N05AA01Chlorpromazine hydrochloride
(100 mg)
PROZIN
(IST.LUSOFARMACO)
Coated tabletsNoAlternatives: drops or oral solution[8,9]
N05AA02Levomepromazine maleate
(25, 100 mg)
NOZINAN
(SANOFI)
Coated tabletsNo
N05AB03Perfenazine
(2, 4, 8 mg)
TRILAFON
(NEOPHARMED GENTILI)
Coated tabletsYes
N05AB06Trifluoperazine dihydrochloride
(1 mg)
MODALINA
(IST LABORATORIO FARMACEUTICO)
Coated tabletsNo
N05AD01Haloperidol
(1, 5 mg)
HALDOL
(JANSSEN CILAG)
TabletsYesBetter to use drops diluted in 50 mL water and administered 1 h before or 2 h after EN
N05AF05Zuclopenthixol dihydrochloride
(10 mg)
CLOPIXOL
(LUNDBECK)
Coated tabletsYesImmerse the tablet in water, after 10 min a fine suspension is obtained, then administer immediately
Alternative: solution for injection
N05AH02Clozapine
(25 mg)
CLOZAPINA CHS
(CHIESI FARMACEUTICI)
Coated tabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Clozapine
(25, 100 mg)
LEPONEX
(NOVARTIS)
Tablets
Clozapine
(100 mg)
CLOZAPINA
(ORION)
Tablets
N05AH03Olanzapine
(5, 10 mg)
ZYPREXA VELOTAB
(ELI LILLY)
Orodispersible
tablets
YesDissolve in 30 mL water, apple juice, orange juice, or milk
Irritant drug
Use personal protective equipment
SmPC
N05AH03Olanzapine
(2.5 mg)
ZYPREXA
(ELI LILLY)
Coated tabletsYesBetter to use orodispersible tablets
Irritant to mucous membranes and eyes
Olanzapine
(5, 10 mg)
OLANZAPINA SUN
(SUN PHARMACEUTICALS)
Orodispersible tabletsYesDissolve the tablet in water and administer immediately
Olanzapine
(2.5, 5, 10 mg)
OLANZAPINA TEV
(TEVA)
Coated tabletsNoBetter to use orodispersible tablets
N05AH03Olanzapine
(5, 10 mg)
OLANZAPINA TEV
(TEVA)
Orodispersible
tablets
YesDissolve the tablet in water and administer immediatelySmPC
N05AH04Quetiapine fumarate
(50, 150, 200, 300, 400 mg)
SEROQUEL
(ASTRAZENECA)
Modified
release tablets
NoAlternative: Seroquel coated tablets[8,9]
N05AH04Quetiapine fumarate
(100, 200, 300 mg)
SEROQUEL
(ASTRAZENECA)
Coated tabletsYesGrind the tablet and dissolve the powder in 25 mL water, then administer immediately
Quetiapine fumarate
(50, 200, 300, 400 mg)
QUETIAPINA TEV
(TEVA)
No
N05AH04Quetiapine fumarate
(50, 200, 300, 400 mg)
QUETIAPINA TEV
(TEVA)
Modified
release tablets
No [8,9]
N05AH05Asenapine maleate
(5, 10 mg)
SYCREST
(LUNDBECK)
Sublingual
tablets
No [8,9]
N05AH06Clotiapine
(40 mg)
ENTUMIN
(LAB.JUVISE’ PHARMACEUTICALS)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Alternative: Entumin drops to be diluted with 50 mL water
N05AL03Tiapride hydrochloride
(100 mg)
SEREPRILE
(SANOFI)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Administer at a fixed time
N05AL05Amilsupride
(50 mg)
AMISULPRIDE EG
(EG)
TabletsYesAlternative: oral solution[10]
Amilsupride
(50, 200, 400 mg)
AMISULPRIDE MYL
(MYLAN)
Tablets
Amilsupride
(400 mg)
AMISULPRIDE SAN
(SANDOZ)
Coated tablets
Amilsupride
(400 mg)
SOLIAN
(SANOFI)
Coated tablets
N05AL07Levosulpride
(50, 100 mg)
LEVOPRAID
(TEOFARMA)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately[10]
N05AN01Lithium carbonate
(300 mg)
LITIO CARBONATO
(NOVA ARGENTIA)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately
Attention drug with a narrow therapeutic index
CARBOLITHIUM
(TEVA)
Capsules
N05AX08Risperidone
(1, 2 mg)
RISPERIDONE SAN
(SANDOZ)
Coated tabletsNoAlternative: liquid formulation[8,9]
Risperidone
(2, 3, 4 mg)
RISPERIDONE TEV
(TEVA)
N05AX12Aripripazole
(5, 10, 15 mg)
ABILIFY
(OTSUKA)
TabletsYesAlternatives: orodispersible tablets or oral solution[8,9]
Aripripazole
(10, 15 mg)
ABILIFY
(OTSUKA)
Orodispersible tablets [8,9]
N05AX13Paliperidone
(3, 6, 9 mg)
INVEGA
(JANSSEN CILAG)
Modified
release tablets
NoAlternative: Xeplion modified release suspension for injection[8,9]
N05BADelorazepam
(0.5, 1, 2 mg)
DELORAZEPAM
(AUROBINDO)
TabletsNoAlternative: drops[8,9]
Delorazepam
(0.5, 1, 2 mg)
EN
(BGP PRODUCTS)
Delorazepam
(2 mg)
DELORAZEPAM RAT (RATIOPHARM)
Delorazepam
(0.5, 1 mg)
DELORAZEPAM WPI (ZENTIVA)
N05BA01Diazepam
(2 mg)
VALIUM
(ROCHE)
CapsulesYesOpen the capsule, disperse the content in 10 mL water, then administer immediately[10]
Diazepam
(5 mg)
VATRAN
(VALEAS)
TabletsDisperse the tablet in 10 mL water, then administer immediately
N05BA04Oxazepam
(15 mg)
SERPAX
(MEDA PHARMA)
TabletsYesGrind the tablet and disperse it in 10 mL water, then administer immediately
Divisible tablet
Better to use Diazepam or Lorazepam
[10]
N05BA06Lorazepam
(1, 2.5 mg)
TAVOR
(PFIZER)
TabletsYesDisperse the tablet in 10 mL water, then administer immediately
Prefer liquid or the orosoluble formulation
[10]
N05BA08Bromazepam
(1.5 mg)
COMPENDIUM
(POLIFARMA)
CapsulesNoAlternative: drops[8,9]
Bromazepam
(3 mg)
BROMAZEPAM RAT
(RATIOPHARM)
Tablets
N05BA09Clobazam
(10 mg)
FRISIUM
(SANOFI)
CapsulesYesOpen the capsule, disperse the content in 10 mL water, then administer immediately[10]
N05BA11Prazepam
(10 mg)
PRAZENE
(PFIZER)
TabletsNoAlternative: drops that must be diluted[8,9]
N05BA12Alprazolam
(0.25, 0.5 mg)
XANAX
(PFIZER)
TabletsYesDisperse the tablet in 10 mL water, then administer immediately
Better to use the drops
[10]
N05BB01Hydroxyzine hydrochloride
(25 mg)
ATARAX
(UCB PHARMA)
Coated tabletsYesPrefer Atarax syrup[10]
N05CD01Flurazepam monohydrochloride
(15, 30 mg)
VALDORM
(VALEAS)
CapsulesYesOpen the capsule, disperse the content in 20 mL water, then administer immediately
Administer before the last EN
[10]
N05CD02Nitrazepam
(5 mg)
MOGADON
(MEDA PHARMA)
TabletsYesDissolve the tablet in a water glass and then administer immediatelySmPC
N05CD05Triazolam
(250 µg)
HALCION
(PFIZER)
TabletsYes
N05CD09Brotizolam
(0.25 mg)
LENDORMIN
(BOEHRINGER INGELHEIM)
TabletsYesDivisible tablets
N05CF02Zolpidem tartrate
(10 mg)
ZOLPIDEM RAT
(RATIOPHARM)
Coated tabletsYesGrind the tablet and disperse it in 10 mL water, then administer immediately
Better to administer at bedtime to have a hypnotic effect
Divisible tablets
N06AA04Clomipramine hydrochloride
(75 mg)
ANAFRANIL
(SIGMATAU)
Modified
release tablets
No [8,9]
N06AA04Clomipramine hydrochloride
(10, 25 mg)
ANAFRANIL
(SIGMATAU)
Coated tabletsYesGrind the tablet and disperse it in 10 mL water, then administer immediately[10]
N06AA09Amitriptyline hydrochloride
(10, 25 mg)
LAROXYL
(TEOFARMA)
Coated tabletsNoAlternative: drops that must be diluted with 50 mL water[8,9]
N06AA10Nortriptyline hydrochloride
(10, 25 mg)
NORITREN
(LUNDBECK)
Coated tabletsYes
N06AB03Fluoxetine hydrochloride
(20 mg)
FLUOXETINA EG
(EG)
CapsulesYesOpen the capsule, disperse the content in 20 mL water, then administer immediately
Prefer liquid formulation or orosoluble tablets
The solution should not be administered in the fast due to the acidic pH
[10]
N06AB03Fluoxetine hydrochloride
(20 mg)
FLUOXETINA FDI
(FIDIA FARMACEUTICI)
CapsulesYesPreferably use the liquid form or the dispersible tablets[8,9]
N06AB03Fluoxetine hydrochloride
(20 mg)
FLUOXETINA RAT (RATIOPHARM)Soluble tabletsYesDissolve the tablet in 50 mL water and administer immediatelySmPC
N06AB03Fluoxetine hydrochloride
(20 mg)
XEREDIEN
(VALEAS)
Dispersible tabletsYesDissolve the tablet in water and administer immediately[8,9]
N06AB04Citalopram hydrobromide
(20 mg)
CITALOPRAM RAT (RATIOPHARM)Coated tabletsYesGrind the tablet and disperse it in 10 mL water, then administer immediately
Preferably use drops
Incompatible with PVC tubes
[10]
CITALOPRAM HEX
(SANDOZ)
[10]
N06AB05Paroxetine hydrochloride
(20 mg)
SEREUPIN (GLAXOSMITHKLINE)Coated tabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
Alternatives: drops or oral suspension
[10]
N06AB06Sertraline hydrochloride
(50 mg)
SERTRALINA MYL
(MYLAN)
Coated tabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
Rinse the tube well after administration
Preferably switch to another selective serotonin reuptake inhibitor
ZOLOFT
(PFIZER)
N06AB08Fluvoxamine maleate
(50 mg)
FEVARIN
(BGP PRODUCTS)
Coated tabletsNoPreferably switch to another selective serotonin reuptake inhibitor in liquid formulation[8,9]
MAVERAL
(BGP PRODUCTS)
N06AB10Escitalopram oxalate
(10, 20 mg)
CIPRALEX
(LUNDBECK)
Coated tabletsYesAlternative: Cipralex drops
Divisible tablets
[10]
Escitalopram oxalate
(20 mg)
ENTACT
(LUNDBECK)
N06AX03Mianserin hydrochloride
(30 mg)
LANTANON
(MSD)
Coated tabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
N06AX05Tradozone hydrochloride
(75, 150 mg)
TRITTICO
(ANGELINI)
Modified
release tablets
NoAlternatives: coated tablets or drops[8,9]
N06AX05Tradozone hydrochloride
(75, 150 mg)
TRITTICO
(ANGELINI)
Coated tabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer immediately
Divisible tablets
N06AX11Mirtazapine
(30 mg)
MIRTAZAPINA SAN
(SANDOZ)
Coated tabletsYes
N06AX12Bupropion hydrochloride
(150 mg)
WELLBUTRIN (GLAXOSMITHKLINE)Modified
release tablets
No [8,9]
N06AX16Venlafaxine hydrochloride
(75, 150 mg)
ZARELIS
(ITALFARMACO)
Modified
release tablets
NoAlternative: oral solution[8,9]
Venlafaxine hydrochloride
(37.5, 75, 150 mg)
EFEXOR
(PFIZER)
Modified
release capsules
Venlafaxine hydrochloride
(37.5 mg)
VENLAFAX TEV
(TEVA)
Modified
release capsules
N06AX21Duloxetine hydrochloride
(30, 60 mg)
CYMBALTA
(ELI LILLY)
Modified
release capsules
NoRisk of probe occlusion[8,9]
Duloxetine hydrochloride
(60 mg)
XERISTAR
(QUINTILES)
Gastro-resistant capsulesNoDo not grind the granules[8,9]
N06BA04Methylphenidate hydrochloride
(10 mg)
RITALIN
(NOVARTIS)
TabletsYes
N06BA04Methylphenidate hydrochloride
(10, 20 mg)
EQUASYM
(SHIRE)
Modified
release capsules
No [8,9]
N06BA07Modafinil
(100 mg)
PROVIGIL
(TEVA)
TabletsYesGrind the tablet and disperse the powder in water, then administer immediately[10]
N06BA09Atomoxetine hydrochloride
(40, 60 mg)
STRATTERA
(ELI LILLY)
CapsulesNo
N06BX12Acetyl-L-carnitine
(500 mg)
NICETILE
(SIGMATAU)
Gastro-resistant tabletsNo [8,9]
N06BX12Acetyl-L-carnitine
(500 mg)
NICETILE
(SIGMATAU)
Powder for oral solutionYes
N06CA01Amitriptyline
Perphenazine
(10 + 4 mg)
MUTABON MITE
(NEOPHARMED GENTILI)
Coated tabletsNo [8,9]
N06DA02Donepezil hydrochloride
(10 mg)
ARICEPT 10
(PFIZER)
Coated tabletsYesGrind the tablet and disperse the powder in 20 mL water, then administer within 15 min
Preferably use Donezepil orodispersible tablets
[10]
Donepezil hydrochloride
(5, 10 mg)
DONEPEZIL ACV
(ACTAVIS)
MEMAC
(BRACCO)
DONEPEZIL EG
(EG)
N06DA02Donepezil hydrochloride monohydrate
(5 mg)
DONEPEZIL MYL
(MYLAN)
Orodispersible tabletsYesDissolve the tablet in 10 mL water and administer immediately[8,9]
Donepezil hydrochloride
(5, 10 mg)
DONEPEZIL TEV
(TEVA)
N06DA03Rivastigmine hydrogen tartrate
(1.5, 3, 4.5 mg)
EXELON
(NOVARTIS)
CapsulesNoAlternatives: transdermal patches or oral solution[8,9]
Rivastigmine hydrogen tartrate
(1.5, 3, 4.5, 6 mg)
RIVASTIGMINA SAN
(SANDOZ)
N06DA04Galantamine hydrobromide
(8, 16, 24 mg)
REMINYL
(JANSSEN CILAG)
Modified
release capsules
NoAlternative: oral solution[8,9]
N06DA04Galantamine hydrobromide
(8, 16, 24 mg)
REMINYL
(JANSSEN CILAG)
Coated tabletsYesGrind the tablet and disperse the powder in 10 mL water, then administer
Preferably use Galantamine oral solution to be diluted before administration
[10]
N06DX01Memantine hydrochloride
(10 mg)
EBIXA
(LUNDBECK)
Coated tabletsNoAlternative: Ebixa oral solution[8,9]
Memantine hydrochloride
(10, 20 mg)
MEMANTINA MYL
(MYLAN)
N07AA02Pyridostigmine hydrobromide
(180 mg)
MESTINON
(MEDA PHARMA)
Modified
release tablets
NoAlternative: Mestinton 60 mg[8,9]
N07AA02Pyridostigmine hydrobromide
(60 mg)
MESTINON
(MEDA PHARMA)
TabletsYesDivisible tablets
N07AX01Pilocarpine hydrochloride
(5 mg)
SALAGEN
(MERUS LABS LUXCO II SARL)
Coated tabletsNo
N07BB01Disulfiram
(400 mg)
ANTABUSE DISPERGETTES (AUROBINDO)Effervescent
tablets
YesDissolve the tablet in 10 mL water and administer at the end of the effervescence
N07BB03Acamprosate calcium
(333 mg)
CAMPRAL
(BRUNO FARMACEUTICI)
Coated tabletsNo
N07BC01Buprenorphine hydrochloride
(2, 8 mg)
BUPRENORFINA MOL (MOLTENI & C. F.LLI ALITTI)Sublingual
tablets
NoAdminister sublingually only if the patient is conscious[8,9]
N07CA01Betahistine dihydrochloride
(8 mg)
MICROSER
(GRUNENTHAL)
TabletsYesGrind the tablet and disperse the powder in 20 mL water, then administer
Preferably use drops
[10]
N07CA02Cinnarizine
(75 mg)
STUGERON FTE
(JANSSEN CILAG)
CapsulesNoAlternative: drops[8,9]
STUGERON FTE
(JANSSEN CILAG)
Tablets
N07XX02Riluzole
(50 mg)
RILUZOLO SAN
(SANDOZ)
Coated tabletsYesGrind the tablet and disperse the powder in water, then administer
Preferably change therapy
[10]
N07XX06Tetrabenazine
(25 mg)
XENAZINA
(CHIESI FARMACEUTICI)
TabletsYesDivisible and crushable tablet
N07XX09Dimethyl fumarate
(120, 240 mg)
TECFIDERA
(BIOGEN ITALIA)
Gastro-resistant capsulesNoDo not grind the granules[8,9]
P01AB01Metronidazole
(250 mg)
VAGILEN
(ALFA WASSERMANN)
CapsulesYesOpen the capsule, disperse the content in 20 mL water, then administer immediately 1 h before EN
Alternatives: solution for injection or vaginal ovules
FLAGYL
(ZAMBON)
TabletsNoAlternatives: solution for injection or vaginal ovules
P01BA01Chloroquine diphosphate
(250 mg)
CLOROCHINA
(BAYER)
Coated tabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediately preferably after EN[10]
P01BA02Hydroxychloroquine sulfate
(200 mg)
PLAQUENIL
(SANOFI)
Coated tabletsYes [10]
P01BF05Piperaquine tetraphosphate
Dihydroartemisinin
(320 + 40 mg)
EURARTESIM
(SIGMATAU)
Coated tabletsYes
P02CA03Albendazole
(400 mg)
ZENTEL
(GLAXOSMITHKLINE)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer immediatelySmPC
P02DA01Niclosamide
(500 mg)
YOMESAN
(BAYER)
Chewable
tablets
YesDissolve the tablet in water and administerSmPC
R03DA04Theophylline anhydrous
(200, 300 mg)
THEO-DUR
(RECORDATI)
Modified
release tablets
NoAlternative: liquid formulation to be diluted with 20 mL water and administered 1 h after EN
Monitor blood levels and adjust dosage
[8,9]
RESPICUR
(TAKEDA)
Modified
release capsules
R03DA08Bamifylline hydrochloride
(600 mg)
BAMIFIX
(CHIESI FARMACEUTICI)
Coated tabletsNoAlternative: suppositories but only for pediatrics
R03DA11Doxofylline
(400 mg)
ANSIMAR
(ABC FARMACEUTICI)
TabletsYesAlternatives: Ansimar syrup or solution for injection
R03DC03Montelukast sodium
(5 mg)
SINGULAIR
(MSD)
Chewable
tablets
Yes
Montelukast sodium
(10 mg)
SINGULAIR
(MSD)
Coated tabletsDisperse the tablet in 10 mL water under gentle stirring, then administer immediately
Montelukast sodium
(5 mg)
MONTELUKAST SAN
(SANDOZ)
Chewable tablets
Montelukast sodium
(5 mg)
MONTELUKAST TEV
(TEVA)
Coated tabletsGrind the tablet and disperse the powder in water, then administer away from EN
Preferably use oral granules
R05CB01Acetylcysteine
(600 mg)
ACETILCISTEINA RAT (RATIOPHARM)Effervescent
tablets
YesAdminister at the end of the effervescence
FLUIMUCIL
(ZAMBON)
Granules for oral solutionMix with water then administer
FLUIMUCIL
(ZAMBON)
Effervescent
tablets
Administer at the end of the effervescence
R06AE06Oxatomide
(30 mg)
TINSET
(GRUNENTHAL)
TabletsNoAlternative: drops[8,9]
R06AE07Cetirizine hydrochloride
(10 mg)
CERCHIO
(MEDIOLANUM FARMACEUTICI)
TabletsYesAlternative: drops
CETIRIZINA SAN
(SANDOZ)
Coated tablets
R06AX25Mizolastine
(10 mg)
ZOLISTAM
(SANOFI)
Modified
release tablets
No [8,9]
R06AX26Fexofenadine hydrochloride
(180 mg)
TELFAST
(SANOFI)
Coated tabletsNoAlternatives: Cetirizine or Loratadine
R06AX27Desloratadine
(2.5 mg)
AERIUS
(MSD)
Orodispersible tabletsYes
S01EC01Acetazolamide
(250 mg)
DIAMOX
(TEOFARMA)
TabletsYes
V03AC03Deferasirox
(125, 500 mg)
EXJADE
(NOVARTIS)
Dispersible tabletsYesDisperse in 200 mL water until a suspension is obtained
Take on an empty stomach before EN
SmPC
V03AE02Sevelamer hydrochloride
(800 mg)
RENAGEL
(GENZYME)
Coated tabletsNoAlternative: Renvela powder for oral suspension[8,9]
RENVELA
(GENZYME)
V03AE02Sevelamer carbonate
(2.4 g mg)
RENVELA
(GENZYME
Powder for oral suspensionYesDisperse the powder in 60 mL water and administer immediately
Rinse well the tube
V03AE03Lanthanum(III) carbonate hydrate
(1 g)
FOZNOL
(SHIRE)
Oral powderNo
Lanthanum(III) carbonate hydrate
(1 g)
FOZNOL
(SHIRE)
Chewable
tablets
Yes
V03AE04Calcium acetate
Magnesium carbonate
(435 + 235 mg)
OSVAREN
(VIFOR FRESENIUS)
Coated tabletsNo
V03AFCalcium mefolinate
(15 mg)
PREFOLIC
(ZAMBON)
Gastro-resistant tabletsNo [8,9]
V03AF04Calcium levofolinate
(7.5 mg)
LEDERFOLIN
(PFIZER)
TabletsYesGrind the tablet and dissolve the powder in 10 mL water, then administer
Alternative: powder for reconstitution for injection
[10]
V03AF04Calcium levofolinate
(2.5 mg)
LEDERFOLIN
(PFIZER)
Granules for oral solutionYes
Table 4. List of magistral preparations routinely compounded in the hospital pharmacy.
Table 4. List of magistral preparations routinely compounded in the hospital pharmacy.
Magistral PreparationIngredientsStorage/ExpirationMethod of Administration
Captopril 1 mg/mL SyrupCaptopril powder Pharm. Eur.
Simple syrup
5 °C in a well-closed amber glass jar for 10 daysShake, withdraw the required portion of the liquid and dilute with water *
Carbamazepine
40 mg/mL
Suspension
Carbamazepine powder Pharm. Eur.
Simple syrup
Isoniazid
50 mg/mL
Solution
Isoniazid powder Pharm. Eur.
Distilled water
Midazolam
2.5 mg/mL
Syrup
Midazolam powder Pharm. Eur.
Simple syrup
Omeprazole
2 mg/mL
Solution
Omeprazole powder Pharm. Eur.
Sodium bicarbonate 8.4%
Ranitidine
15 mg/mL
Solution
Omeprazole powder Pharm. Eur.
Sorbitol
Purified water
Spironolactone
10 mg/mL
Suspension
Spironolactone powder Pharm. Eur.
Simple syrup
Verapamil
50 mg/mL
Suspension
Verapamil powder Pharm. Eur.
Distilled water
Simple syrup
Glycerol
* 60 mL.
Table 5. General recommendations for medications given by tube.
Table 5. General recommendations for medications given by tube.
Pharmaceutical FormMethod of Administration
Liquid forms (drops, syrups, suspensions)High osmolar or very viscous liquids must be suitably diluted before being administered
If the osmolality is not known, it is advisable to dilute the drug with at least 30 mL of water to make it compatible with gastric administration and to prevent diarrheal phenomena from osmotic effect
Shake and mix the solution or suspension well
Administer directly by tube
Tablets
Chewable tablets
The tablets must be crushed in the crusher until they are reduced to a fine and homogeneous powder to promote better absorption and avoid obstruction of the tube
Transfer the powder to a plastic cup
Effervescent tabletsPut the tablet directly in a plastic cup
Dispersible/soluble tabletsPut the tablet directly in a plastic cup
CapsulesOpen the capsule and insert the powder in a plastic cup, verifying the content first
Soft capsulesThey cannot be administered
Modified-release tablets/capsules
Gastroresistant tablets, enteric-coated tablets
Sublingual tablets
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MDPI and ACS Style

Zuccari, G.; Macis, S.; Alfei, S.; Marchitto, L.; Russo, E. The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients. J. Pers. Med. 2022, 12, 1307. https://doi.org/10.3390/jpm12081307

AMA Style

Zuccari G, Macis S, Alfei S, Marchitto L, Russo E. The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients. Journal of Personalized Medicine. 2022; 12(8):1307. https://doi.org/10.3390/jpm12081307

Chicago/Turabian Style

Zuccari, Guendalina, Sara Macis, Silvana Alfei, Leonardo Marchitto, and Eleonora Russo. 2022. "The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients" Journal of Personalized Medicine 12, no. 8: 1307. https://doi.org/10.3390/jpm12081307

APA Style

Zuccari, G., Macis, S., Alfei, S., Marchitto, L., & Russo, E. (2022). The Role of the Pharmacist in Selecting the Best Choice of Medication Formulation in Dysphagic Patients. Journal of Personalized Medicine, 12(8), 1307. https://doi.org/10.3390/jpm12081307

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