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Nutr Hosp. 2014;30(3):514-518
ISSN 0212-1611 • CODEN NUHOEQ
S.V.R. 318
Revisión
Interactions between drugs and drug-nutrient in enteral nutrition:
A review based on evidences
1 2
Renata Ferreira Silva and Maria Rita Carvalho Garbi Novaes
1Nurse, Master’s student in Health Sciences at the Foundation for Research and Education in Health Sciences - Brasilia, Federal
District, Brazil. 2Pharmaceuticals; PhD in Pharmacology from the University of Brasilia and Post-doctorate in Ethics in Clinical
Trials by University of Chile. Professor of Medicine, School of Health Sciences - ESCS / FEPECS, in the post-graduation Strictu
Sense Sciences for Health FEPECS and at the University of Brasilia. Brazil.
Abstract INTERACCIONES ENTRE FÁRMACOS Y ENTRE
Introduction: Enteral nutrition (EN) provides calories, FÁRMACOS Y NUTRIENTES EN LA NUTRICIÓN
macronutrients and micronutrients in adequate quantity ENTERAL: UNA REVISIÓN BASADA EN EVIDENCIAS
and quality to meet the patient’s needs. Some drugs when Resumen
crushed and diluted may have their properties altered, Introducción: La nutrición enteral (NE) aporta calorías,
including the reduction of bioavailability causing the macronutrientes y micronutrientes en una cantidad y cua-
reduction of the serum concentration of the drug; tube lidad adecuada para cubrir las necesidades del paciente.
obstruction; drug-drug interaction or drug-nutrient in- Algunos fármacos, al ser aplastados y diluidos, pueden ver
teraction. sus propiedades alteradas, incluyendo la reducción de su
Methods: The study was conducted through review of biodisponibilidad que da lugar a una reducción de la con-
submitted articles in the databases of the Virtual Health centración sérica del medicamento, obstrucción de la sonda,
Library (VHL): MEDLINE (National Library of Medi- interacción con otros fármacos o interacción entre el fárma-
cine, USA), Lilacs (Latin American and Caribbean Lite- co y los nutrientes.
rature on Health Sciences) PUBMED - NCBI (National Métodos: El estudio fue llevado a cabo mediante revisión de
Center for Biotechnology Information) and COCHRANE. artículos enviados a las bases de datos de la Biblioteca virtual
Results: For this survey, 42 articles were identified de la Salud (Virtual Health Library -VHL): MEDLINE (Biblio-
during database searching. After applying the inclusion teca Nacional de Medicina, EE. UU.), Lilacs (Literatura Lati-
and exclusion criteria, 08 articles were selected, obtained no Americana en Ciencias de la Salud) PUBMED – Centro
from the MEDLINE and Lilacs. nacional para la información sobre biotecnología (NCBI –Na-
Discussion: Some interactions were found such as the tional Center for Biotechnology Information) y COCHRANE.
aluminium hydroxide and lactulose with the enteral nu- Resultados: Para este estudio, fueron identificados 42 artí-
trition, which may result in a precipitation and reduction culos en la búsqueda en las bases de datos. Después de la apli-
of drug bioavailability. Mineral oil will alter the absorp- cación de los criterios de inclusión y exclusión, se selecciona-
tion of fat-soluble vitamins and reduces the tube light. ron 08 artículos, procedentes de MEDLINE y de Lilacs.
Others results were found as phenytoin, warfarin, cap- Debate: Se encontraron ciertas interacciones como la del
topril and furosemide with enteral nutrition may reduce hidróxido de aluminio y lactulosa con la nutrición enteral,
the maximum serum concentration. lo que podría dar lugar a una precipitación y reducción de
Conclusion: Drug interactions are more common in la biodisponibilidad del fármaco. El aceite mineral altera la
day-to-day activities than health professionals may su- absorción de vitaminas liposolubles y reduce la luz del tubo
ppose. Knowledge on the matter may also assist in redu- digestivo. Se encontraron otros resultados como que la fe-
cing cases of obstruction of tubes, through which enteral nitoína, warfarina, captopril y furosemida con la nutrición
nutrition and medications are administered. Thus, the enteral podrían reducir la máxima concentración sérica.
multidisciplinary team, acting together, may have more Conclusión: Las interacciones farmacológicas son más
beneficial effects to the patient. comunes en las actividades cotidianas de lo que los profe-
(Nutr Hosp. 2014;30:514-518) sionales de la salud podrían suponer. El conocimiento de
DOI:10.3305/nh.2014.30.3.7488 la materia también podría ayudar a reducir casos de obs-
Key words: Enteral nutrition. Drug interactions. Food trucción de las sondas que sirven para la nutrición enteral y
interactions. Food-drug interactions. también para la administración de medicación. Así, el equi-
po multidisciplinar, actuando en conjunto, resultaría una
estrategia más beneficiosa para el paciente.
Correspondence: Renata Ferreira Silva. (Nutr Hosp. 2014;30:514-518)
SQS 411 Bloco H Apto 205 – Asa Sul, Brasília/DF DOI:10.3305/nh.2014.30.3.7488
CEP: 70277-080
E-mail: renataferreirasilva@yahoo.com.br Palabras clave: Nutrición enteral. Interacciones farmaco-
Recibido: 4-IV-2014. lógicas. Interacciones de los alimentos. Interacciones entre
Aceptado: 19-VI-2014. fármacos y alimentos.
514
006_7488 Interacciones entre medicamentos.indd 514 08/09/14 18:03
Introduction Methods
Nutritional therapy constitutes a set of procedures The study was conducted through the review of sub-
aimed at maintaining or restoring the nutritional status mitted articles in the databases of the Virtual Health
of the patient by administering food artificially. The Library (VHL): MEDLINE (National Library of Me-
critically ill patient requires the use of nutritional the- dicine, USA), Lilacs (Latin American and Caribbean
rapy (enteral or parenteral), mainly to minimize the Literature on Health Sciences), PUBMED - NCBI
reduction of physiological stress and adverse effects of (National Center for Biotechnology Information) and
1,2
protein catabolism . COCHRANE.
Enteral nutrition (EN) is performed by means of a na- Health sciences descriptors were used - DECS and
sogastric tube or ostomies, through which calories and MeSH (Medical Subject Headings) in Portuguese:
nutrients are provided in adequate quantity and quality, “nutrição enteral”, “interações medicamentosas”,
according to the patient’s needs. This nutritional thera- “interações medicamentos e interações medicamen-
py is indicated when oral food intake is undesirable or tosas/alimento”; in Spanish: “nutrición enteral”,
insufficient to maintain the nutritional status, so as to “interacciones medicamentosas”, “interacciones far-
1-4
prevent the patient from malnutrition process . Enteral macológicas y interacciones entre medicamentos y
nutrition is regulated by Resolution 63/2000 of the Bra- alimentos” and in English: “enteral nutrition”, “drug
1
zilian Health Surveillance Agency (ANVISA) . interactions”, “drug/food interactions”.
The medication administration by tubes is a com- The inclusion criteria, included original and review
mon practice in the hospital routine, which should be articles related to medications use in hospitalized and/
taken into accident in order to choose the best pharma- or household patients with enteral nutrition. Published
ceutical form of drug administration or to select or the articles from January 1990 to April 2013 with the fo-
drugs which may be crushed, given the high incidence llowing study designs were selected: literature review,
of patients who use multiple medications. Some drugs prospective, retrospective, analytical and descriptive.
when crushed and diluted alter some of their effects, Articles characterized as letters to the editor, reports
including the reduction of bioavailability causing the or case series and sketches were excluded from the
reduction of the serum concentration of the drug; tube survey.
obstruction; the drug-drug interaction when there are
simultaneous administration of two or more drugs; or
5,6
the drug-nutrient interaction . Results
Insofar as changes occur, there may be an interferen-
ce in the therapy proposed to the patient, since many For this survey 42 articles were identified during
drugs have pharmaceutical forms which permit a slow database searching. After applying the inclusion and
release in the body, or whose formulation is intended exclusion criteria, 08 articles were selected, obtained
to be release in another portion of the gastrointestinal from the MEDLINE and Lilacs. These were about tho-
tract other than the stomach. Some drugs may alter the se topics: drug-drug interactions, drug nutrient interac-
absorption of nutrients; even to the point of inhibiting tions, changes that occur when a new item is added
the metabolic process of the latter, as well as the con- and the stability of enteral nutrition. Table 1 presents
comitant intake of food may affect the bioavailability the selected studies emphasizing the reference, the me-
6,7
of the drug through interactions . thod, the casuistry, if drugs were added the observed
Aiming for the promotion of rational and safe use of chemical interactions and the observed clinical results.
medications concomitant to enteral and parenteral nu-
tritional therapy, the formation of a multidisciplinary
team of Nutritional Therapy (MTNT) became manda- Discussion
tory in Brazilian hospitals, composed mainly by nurse,
pharmaceutical, physician, nutritionist, and other pro- Studies about drug-nutrient and drug-drug interac-
1
fessionals . tions, have been growing in number and collaborating
For the professional nurse, in the condition of res- to increase effectiveness therapy. As REIS et al. 2010
ponsible for the supervision and/or administration of showed in their study of descriptive nature, explorato-
drugs via enteral feeding tubes, it is important to hold ry field with qualitative approach, in which the pre-
knowledge about those interactions, conduct training scriptions of 24 hospitalized patients were analyzed,
with the team for the correct administration of drugs, 62.5% used enteral nutrition for more than 10 days
provide protocols to be followed and thus support the and 42% were using more than five drugs per day.
8-10
decisions for a safe patient care . The most commonly prescribed drugs were: mineral
The objective of this study was to analyze clinica- oil in liquid form; dimethicone, dipyrone and parac-
lly relevant possible interactions, between drugs and etamol; in solid form: folic acid, pyrimethamine and
nutrients in enteral nutrition in order to increase safe- sulfadiazine acid. Regarding to drugs which are ad-
ty and in the concomitant administration medications ministered concomitantly with enteral nutrition, the
with nutritional therapy. changes that occur are the following: (a) ciprofloxacin
Interactions between drugs and Nutr Hosp. 2014;30(3):514-518 515
drug-nutrient in enteral nutrition:
A review based on evidences.
006_7488 Interacciones entre medicamentos.indd 515 08/09/14 18:03
- there is a reduction in the bioavailability of the drug, coagulants, in a study with warfarin, it was revealed
(b) chlorpromazine – there is precipitation and reduc- that when there was no interruption of nutrition, INR
tion in bioavailability of the drug, (c) phenytoin - the (international normalized ratio - one of the parameters
decrease in bioavailability is 50-75%, (d) aluminum for evaluating the clotting) decreased by 73 % in com-
hydroxide leads to the precipitation and reduction of parison with the period nutrition was interrupted for
the bioavailability of the drug, (e) lactulose - gener- the drug administration. It was suggested, therefore,
ates precipitated particles and reduction of absorption enhancing the knowledge of the subject by the nursing
of nutrients, and (f) mineral oil – alters the absorp- staff and the proposition of management protocols en-
11
tion of fat-soluble vitamins, adheres to tube reducing suring an effective treatment .
the light even when washing with water there are no GORZONI et al. 2010, through their retrospective
great results because they have different polarities. observational study where medical prescriptions of
Omeprazole comes in capsule form and its release is patients were analyzed, with the inclusion criteria of
gastric, and differentiated administration is required. patients undergoing enteral nutrition for more than 48
The ferrous sulfate due to its viscosity may cause tube hours and the objective of defining the prevalence in
7
obstruction . the use of drugs that are incompatible with the tube
The inclusion of interactions in the matter of drug used in the feed. 57 patients were selected in use of
adminsitration and nutrition, motivate the manage- feeding tubes, with an average of 5.7 drugs adminis-
ment of recommendations for there effectiveness of tered by this means per patient. The most commonly
the treatment proposed to the patient. Given this si- prescribed medications, but with contraindications to
tuation, the authors suggest some recommendations, be crushed for their administration are: captopril, clon-
such as to take into account the nutritional status of idine, digoxin, spironolactone, phenytoin, furosemide,
the patient, to avoid over or underestimation in nu- haloperidol, midazolam, prednisone, propranolol, and
trient retention and pay attention to the prescriptions, ranitidine. The location of drug release also alters the
to prevent unexpected therapeutic response. With re- desired effect, for example, the drugs which are pre-
gard to medicines and nutrition, they advise stopping pared for action in the stomach are not suitable for the
the administration of the diet one hour before and two tubes whose distal end is located in the small intestine,
hours after drug therapy to avoid the afore said chan- since there is an increase of bioavailability of the drugs
ges, paying attention to the rhythm of dripping after with extensive first-pass metabolism by the liver. The
restarting no as to administered the full volume and study proposes specific cares while administering be-
proposal energy7. cause some medications when crushed may release
In vitro studies are conducted in order to promote airborne particles and intoxicate those who are manip-
greater confidentiality to what is already known on the ulating them. It is also important not to mix medica-
clinical and laboratory evaluation. SILVA and LISBOA tions in the same dilution and to wash the tube before
12
2011, in their integrative literature review identified an and after the completion of the medication .
in vitro study and clinical studies with warfarin, which LOPES et al. 2010, through an exploratory de-
showed the reduction in bioavailability of the drug scriptive study of direct observational quantitative ap-
when administered in conjunction with enteral nutri- proach, conducted an analysis of the possible interac-
tion. As recommendations, they suggest that attention tions between nutrients and drugs prescribed, through
to the possible risks in prescribing and administering a list of medications with food, in order to make rec-
medicines. The nurse, in the condition of responsible ommendations in their research. The intake of some
for the nursing staff, should be aware of these risks drugs with food in some cases is recommended (for
and always promote continuing education. Another example, carvedilol, nifedipine, propranolol and di-
study demonstrated the role of the pharmaceutical with clofenac) but not in others, due to interferences both
the team evaluating the medical prescriptions, which in the absorption of the drug as in the absorption of
resulted in the change of presentation of medicines, vitamins and minerals (for example, acetylsalicylic
leading to decreased interactions and incompatibilities acid, omeprazole, ranitidine, mineral oil, aluminum
9
between drugs and enteral nutrition . hydroxide, spironolactone, laxatives and captopril).
SILVA et al. 2010, conducted a literature review, and From the analysis performed in the study, a large num-
selected seven out of 62 articles. The authors divided ber of interactions between foods and nutrients may be
the drugs into three categories: antiepileptic drugs, an- verified, which leads to an increase of interferences in
tibiotics and anticoagulants. Among the antiepileptic the treatment or even an improvement in the therapeu-
drugs, there was the phenytoin whose serum levels are tic process, which requires the evaluation of each case
reduced when administered with enteral nutrition. In individually.
the antibiotics group, the moxifloxacin has its serum SEHN et al. 2003 analyzed the prescriptions of
levels reduced by 5 % when crushed and administered patients of a hospital, in order to conduct the survey
by the tube, and by 12% when administered with nutri- on drugs precriptions and interactions. 81 varieties of
tion; likewise, the ciprofloxacin reduces the maximum drugs were found and 54 interactions were identified.
serum concentration, but the minimum serum concen- From the prescriptions, 65 % had at least one potential
tration is similar intravenously. In the class of anti- drug interaction. The most frequent drug-drug inter-
516 Nutr Hosp. 2014;30(3):514-518 Renata Ferreira Silva and Maria Rita Carvalho Garbi Novaes
006_7488 Interacciones entre medicamentos.indd 516 08/09/14 18:03
actions were: furosemide / paracetamol, furosemide and during this process medications are administered
/ captopril, dipyrone / captopril, digoxin / metoclopr- via tube without paralyzing the process of dieting,
amide, digoxin / captopril, digoxin / furosemide and which is one of the main reasons to conduct studies
acetylsalicylic acid / captopril. Regarding the serious related to this topic. Studies that evaluate the prepara-
interactions, were found: digoxin / amiodarone, di- tion and administration of medication are insufficient.
goxin / verapamil, spironolactone / potassium chloride It was also observed that all selected studies were per-
and sulfamethoxazole + trimethoprim / cyclosporine. formed by Brazilian authors in hospitals in Brazil.
Given those findings, the conclusion was in favor of
the use of computer programs to identify the interac-
tions and assess the profile of prescriptions, as well as Conclusion
in favor of the continuing education of professionals,
which demonstrate being important to reduce the in- From the evidence demonstrated in the chosen stud-
14
teractions . ies, it may be concluded that drug interactions are
LIMA and CASSIANI 2009 conducted an explor- closer and more present in the day-to-day than health
atory descriptive study with cross-sectional design, by professionals could expect. The knowledge about this
investigating the prescriptions of patients who were issue, especially when it comes to drugs that are given
hospitalized for six or more days in an intensive care often to patients in such a hospital sector (ICU), is vital
unit at the University Hospital of Ceará. 102 patients for the appropriate therapy to the patient and all staff
were included in the study, by meeting the inclusion involved in the process of nutritional therapy should
criteria. Among the patients, those who received nine be aware of the risks of interaction, from the time of
or more drugs in the first and sixth day of hospital- prescription to the time of drug administration. Such
ization showed a higher number of drug interactions. knowledge may also assist in reducing cases of tube
Midazolam was the most frequent drug among the po- obstruction, through which enteral nutrition and med-
tential interactions identified. Among the pair of drugs ications are administered. Thus, the multidisciplinary
that interacted more, fentanyl and midazolam were the team (doctor, nurse, pharmaceutical and nutritionist),
ones more frequently identified. Actions that can be acting together, may bring about more beneficial ef-
taken in order to minimize those interactions are as fol- fects to the patient.
lows: observe signs and symptoms, monitor therapy
response, adjust the timing of medications and avoid
the combination. It is also important that health pro- Acknowledgment
fessionals learn how to identify, classify, be acquainted
with the clinical management, so that the interactions The School of Health Sciences – Foundation for
15
may be avoided . Research and Education in Health Sciences, Distrito
MARTINS et al. 2013, through their descriptive, Fe deral – Brazil, founded this research through the
exploratory and quantitative study, analyzed the pre- process 00.394.700/0001-08.
scriptions from three ICUs within one month. As a
result, some of the drugs with restrictions to be ad- References
ministered by tube were highlighted: amiodarone – to
be avoided due to lack of study, atenolol - reduces 1. Marchini JS, Okano N, Cupo P, Passos NMRRS, Sakamoto
the drug absorption when administered with nutrition, LM, Filho AB. Nutrição parenteral – princípios gerais, for-
phenobarbital – to be avoided due to lack of specif- mulários de prescrição e monitorização. Medicina, Ribeirão
ic data on administration by tubes. Hydrochlorothia- Preto 31: 62 – 72, jan./mar. 1998.
zide - with nutrition, there is a reduction in the drug 2. Kurihayashi AY, Caruso L, Soriano FG. Terapia nutricional
absorption, hydroxyurea - cytostatic, care with the parenteral em UTI: aplicação dos indicadores de qualidade. O
handler, nifedipine retard – it should not be crushed Mundo da Saúde, São Paulo;33(4):480-487, 2009.
so that not to lose the slow release or block the tube, 3. Souza FIS, Teske M, Sarni ROS. Nutrição parenteral no recém
– nascido pré – termo: uma proposta de protocolo prático. Rev
nimodipine - reduces absorption of the drug with the Paul Pediatr 26(3):278-89, 2008.
nutrient. The recommendations the study propos- 4. Vasconcelos MIL, Tirapegui J. Aspectos atuais na terapia nutri-
es are: interruption of nutrition one hour before and cional de pacientes na Unidade de Terapia Intensiva (UTI). Rev
two hours after for administration of the drugs that Bras de Cien Farmac vol. 38, n. 1, jan/mar, 2002.
5. Hinrichsen SL, Vilela TAS, Lira MCC, Moura LCRV. Moni-
have interaction with nutrition; readjustment of the toramento do uso de medicamentos prescritos me uma uni-
infusion pump when it is paralyzed for total caloric dade de terapia intensiva. Rev enferm UERJ, Rio de Janeiro,
intake, rinsing the tube before and after administer- 17(2):159-64, abr/jun, 2009.
ing medications, and avoiding grinding the drugs that 6. Zaban ALRS, Novaes MRCG. Perfil epidemiológico e aspec-
tos econômicos da nutrição enteral domiciliar no Distrito Fede-
17 ral: uma análise histórica de 2000 a 2005. Com. Ciências Saúde
have toxic effects on handler . 20(2):143-150, 2009.
Most studies relate the interactions present between 7. Reis VGO, Cándido MF, Jesús RP, Mendes-Netto RS. Perfil de
drugs and enteral nutrition. It is important to under- utilización de medicamentos administrados por sonda enteral
stand those interactions, because the enteral feedings en el hospital universitário. Rev. Chil. Nutr Vol. 37, nº 3, setem-
are administered continuously in the most of the cases, bro, 2010.
Interactions between drugs and Nutr Hosp. 2014;30(3):514-518 517
drug-nutrient in enteral nutrition:
A review based on evidences.
006_7488 Interacciones entre medicamentos.indd 517 08/09/14 18:03
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