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The solution was the problem
Clinical Nutrition (2002) 21(6): 531–532 r 2002 Elsevier Science Ltd. All rights reserved. doi:10.1054/clnu.2002.0599, available online at http://www.idealibrary.com on
SHORT REPORT
The solution was the problem S. M. MADIGAN,* D. E. COURTNEY,w D. MACAULEYz *School of Nursing, Faculty of Life and Health Sciences, University of Ulster, Jordanstown, Antrim, UK, wHolywood Arches Health Center,WestministerAvenue, Belfast, UK and zDepartment of Epidemiology, Queens University Belfast, Belfast, Royal V ictoria Hospital, UK (Correspondence to: SMM, Room 12J05A, School of Nursing, Faculty of Life and Health Sciences, University of Ulster, Jordanstown, Co. Antrim BT37 0QB, UK)
AbstractFThere are increasing numbers of adults living in the community who require enteral tube feeding.While there is signi¢cant evidence of the importance of this treatment, there are side e¡ects which can cause di⁄culties for patients, their carer tabers and health professionals. Gastrointestinal complications are the most common side e¡ects with feed formula being cited as the main culprit, often without investigating other potential causes. Many patients requiring aggressive nutrition support also require concurrent drug therapy to manage underlying disease. Drugs are often given via tubes in liquid form.These elixirs often contain large quantities of sorbitol, which will increase the osmolar concentration. There is a lack of awareness from primary health-care professionals about the di⁄culties that can arise when giving medications to patients receiving enteral feeding which may a¡ect patient care and the nutritional outcomes. r 2002 Elsevier Science Ltd. All rights reserved.
caretaker, managed the feeding regime of 1000 ml of high-energy feed and 500 ml of a standard feed, a total intake of 8.5 MJ (2000 kcal) and 102.5 g protein per day. After a long trouble-free period, he reported that his wife had become bloated and that regular use of a flatus tube brought no improvement. She was agitated and her bowels were irregular. The caretaker asked if a change in feed may improve her symptoms. The only change in treatment had been in her medication with an increase in baclofen (Lioresal) to 90 ml per day and the addition of trimethoprim (Monotrim) liquid 10 ml per day. Her prescription also included one 30 mg sachet of zoton per day and one effervescent solpadol (500 mg) tablet per day. She had not been taking solpadol at the time and her husband reported that it was given very infrequently (1–2 tablets per month). The regional drug information center reported that the total sorbitol content for these medicines was 38.73 g (2.75 g of a 70% solution of sorbitol BP in 5 ml of lioresal and 2.04 g in 5 ml of Trimethoprim). The community pharmacy changed her medication providing it in crushed form so it could be flushed down the feeding tube with water. The patients symptoms improved and she continues to have her medication crushed and flushed down her feeding tube on a daily basis. A medication re-challenge was considered inappropriate.
Key words: tube feeding; sorbitol; medications; general practice Introduction Hospital at home means that about 18,500 patients in the UK, at least one patient in every general practice, have home enteral feeding via the nasogastric (NG), percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) routes (1). This is usually because of the loss of swallow or deterioration in their nutritional status from neurological disease or cancer (1). It is a useful tool in the treatment of patients who are or may become nutritionally compromised in both the hospital and the home environment, and its growth in primary care over the last number of years has been fuelled by the discharge of patients to the home environment when previously they would have remained in hospital. Although enteral feeding is safer than parenteral nutrition, it is not always trouble free. In the absence of appropriate and regular monitoring, significant problems can arise. Gastrointestinal symptoms are common (2) with diarrhoea being the most frequently cited (3, 4). Patients and health-care professionals often want to change the feeding formula in an attempt to correct the problem (5). Case report A 66-year-old lady, with a degenerative neurological disorder (corticobasal ganglionic degeneration), had enteral feeding at home for 22 months by PEG tube. After some initial difficulties, her husband, the main
Discussion Gastrointestinal upsets do occur with enteral feeding, the most common being diarrhoea (3–6). The etiology of 531
532
THE SOLUTION WAS THE PROBLEM
gastrointestinal upsets in enteral feeding is unknown, but factors such as antibiotic treatment, bacterial contamination, the formula, medications, infection and gastrointestinal complications have been suggested (6, 7). One might assume that the best way to administer a medication to a patient who is fed enterally would be in a liquid form via the feeding tube. But, liquid formulations are not always the best option. Sorbitol is commonly added to elixirs to improve palatability but it is not well absorbed and can cause gastrointestinal side effects. Sorbitol is a sugar alcohol absorbed slowly by the intestine (8). Following oral administration, it aids to increase osmotic pressure in the bowel by drawing in free water, becoming an effective osmotic laxative. Bacterial fermentation of sorbitol in the large bowel is also associated with increased flatulence and abdominal cramps (9). Malabsorption of sorbitol and other carbohydrate substitutes such as fructose and xylitol have been identified using hydrogen breath tests (10–13). Individual tolerance varies and depends on the dosage and previous exposure. Ingestion of as little as 10 g of sorbitol may cause flatulence and bloating. Stomach cramps and osmotic diarrhoea can occur at intakes of about 20–30 g/day and sometimes much less, especially in children (6, 14–17). The patients’ medication labels gave no indication that Sorbitol was present, something which has been previously reported (9, 17). The lesson from this patient was that even in patients with complex medical conditions, there are sometimes simple answers. And, it is not just the medication itself that can cause the problem but the solution. All possible causes of gastrointestinal distress should be investigated before the feed formula is reduced or discontinued.
Acknowledgements SMM is supported by a National Primary Care Award from the Research and Development Office, Northern Ireland. We thank Mr Martin Ferguson, The Regional Medicines and Poisons Information Submission date: 20 August 2002 Accepted: 5 September 2002
Service, for his help in retrieving the data on the Sorbitol content of the medications.
References 1. Elia M, Russell C A, Stratton R J et al. Trends in artificial nutrition support in the UK during 1996–2000. British Artificial Nutrition Survey, BAPEN, 2001 2. Kohn C, Keithley J. Enteral nutrition: potential complications and patient monitoring. Nursing Clin N Am 1989; 24(2): 339–353 3. Bowling T E, Silk D B A. Colonic responses to enteral tube feeding. GUT 1998; 42: 147–151 4. Mobarhan S, DeMeo M. Diarrhea induced by enteral feeding. Nutr Rev 1995; 53(3): 67 5. Bowling T E, Silk B A. Diarrhoea and enteral feeding. In: Rombeau J L, Rolandelli R H (eds). Enteral and Tube Feeding, 3rd ed. Philadelphia: W B Saunders, 1997: 540–553 6. Varella L, Jones E, Meguid M M. Drug-nutrient interactions in enteral feeding: a primary care focus. Nurse Pract 1997; 22: 98–104 7. Eisenberg P G. Causes of diarrhoea in tube-fed patients: a comprehensive approach to diagnosis and management. Nutr Clin Pract 1993; 8(3): 119–123 8. Beaugerie L, Flourie B, Pernet P, Achour L, Franchisseur C, Rambaud J C. Glucose does not facilitate the absorption of sorbitol perfused in situ in the human small intestine. J Nutr 1997; 127: 341–344 9. Lutomski D M, Gora M L, Wright S M et al. Sorbitol content of selected oral liquids. Ann Pharmacother 1993; 27: 269–273 10. Born P, Zech J, Stark M, Classen M, Lorenz R. Carbohydrate substitutes: comparative study of intestinal absorption of fructose, sorbitol and xylitol. Med Klin 1994; 89(11): 575–578 11. Hyams J S. Sorbitol intolerance: an unappreciated cause of functional gastrointestinal complaints. Gastroenterology 1983; 84(1): 30–33 12. Jain N K, Rosenberg D B, Ulahannan M J, Glasser M J, Pitchumoni C S. Sorbitol intolerance in adults. Am J Gastroenterology 1985; 80(9): 678–681 13. Rumessen J J. Fructose and related food carbohydrates. Sources, intake, absorption and clinical implications. Scand J Gastroenterol 1992; 27(10): 819–828 14. Thomas B, Jefferson A. In: Thomas B (ed). Manual of Dietetic Practice, 3rd ed. London: Blackwell Science, 2001: 154–161 15. Lourenco R. Enteral feeding: drug/nutrient interaction. Clin Nutr 2001; 20(2): 187–193 16. Johnson D R, Nyffeler M S. Drug-nutrient considerations for enteral Nutrition. In: American Society for Parenteral and Enteral Nutrition (eds). The ASPEN Nutrition Support Practice Manual, 1st ed. Silver Spring: American Society for Parenteral and Enteral Nutrition, 1998; 6(1): 6–20 17. Edes T E, Walk B E, Austin J L. Diarrhoea in tube fed patients: feeding formula not necessarily the cause. Am J Med 1990; 87: 352–360
SHORT REPORT
The solution was the problem S. M. MADIGAN,* D. E. COURTNEY,w D. MACAULEYz *School of Nursing, Faculty of Life and Health Sciences, University of Ulster, Jordanstown, Antrim, UK, wHolywood Arches Health Center,WestministerAvenue, Belfast, UK and zDepartment of Epidemiology, Queens University Belfast, Belfast, Royal V ictoria Hospital, UK (Correspondence to: SMM, Room 12J05A, School of Nursing, Faculty of Life and Health Sciences, University of Ulster, Jordanstown, Co. Antrim BT37 0QB, UK)
AbstractFThere are increasing numbers of adults living in the community who require enteral tube feeding.While there is signi¢cant evidence of the importance of this treatment, there are side e¡ects which can cause di⁄culties for patients, their carer tabers and health professionals. Gastrointestinal complications are the most common side e¡ects with feed formula being cited as the main culprit, often without investigating other potential causes. Many patients requiring aggressive nutrition support also require concurrent drug therapy to manage underlying disease. Drugs are often given via tubes in liquid form.These elixirs often contain large quantities of sorbitol, which will increase the osmolar concentration. There is a lack of awareness from primary health-care professionals about the di⁄culties that can arise when giving medications to patients receiving enteral feeding which may a¡ect patient care and the nutritional outcomes. r 2002 Elsevier Science Ltd. All rights reserved.
caretaker, managed the feeding regime of 1000 ml of high-energy feed and 500 ml of a standard feed, a total intake of 8.5 MJ (2000 kcal) and 102.5 g protein per day. After a long trouble-free period, he reported that his wife had become bloated and that regular use of a flatus tube brought no improvement. She was agitated and her bowels were irregular. The caretaker asked if a change in feed may improve her symptoms. The only change in treatment had been in her medication with an increase in baclofen (Lioresal) to 90 ml per day and the addition of trimethoprim (Monotrim) liquid 10 ml per day. Her prescription also included one 30 mg sachet of zoton per day and one effervescent solpadol (500 mg) tablet per day. She had not been taking solpadol at the time and her husband reported that it was given very infrequently (1–2 tablets per month). The regional drug information center reported that the total sorbitol content for these medicines was 38.73 g (2.75 g of a 70% solution of sorbitol BP in 5 ml of lioresal and 2.04 g in 5 ml of Trimethoprim). The community pharmacy changed her medication providing it in crushed form so it could be flushed down the feeding tube with water. The patients symptoms improved and she continues to have her medication crushed and flushed down her feeding tube on a daily basis. A medication re-challenge was considered inappropriate.
Key words: tube feeding; sorbitol; medications; general practice Introduction Hospital at home means that about 18,500 patients in the UK, at least one patient in every general practice, have home enteral feeding via the nasogastric (NG), percutaneous endoscopic gastrostomy (PEG) or percutaneous endoscopic jejunostomy (PEJ) routes (1). This is usually because of the loss of swallow or deterioration in their nutritional status from neurological disease or cancer (1). It is a useful tool in the treatment of patients who are or may become nutritionally compromised in both the hospital and the home environment, and its growth in primary care over the last number of years has been fuelled by the discharge of patients to the home environment when previously they would have remained in hospital. Although enteral feeding is safer than parenteral nutrition, it is not always trouble free. In the absence of appropriate and regular monitoring, significant problems can arise. Gastrointestinal symptoms are common (2) with diarrhoea being the most frequently cited (3, 4). Patients and health-care professionals often want to change the feeding formula in an attempt to correct the problem (5). Case report A 66-year-old lady, with a degenerative neurological disorder (corticobasal ganglionic degeneration), had enteral feeding at home for 22 months by PEG tube. After some initial difficulties, her husband, the main
Discussion Gastrointestinal upsets do occur with enteral feeding, the most common being diarrhoea (3–6). The etiology of 531
532
THE SOLUTION WAS THE PROBLEM
gastrointestinal upsets in enteral feeding is unknown, but factors such as antibiotic treatment, bacterial contamination, the formula, medications, infection and gastrointestinal complications have been suggested (6, 7). One might assume that the best way to administer a medication to a patient who is fed enterally would be in a liquid form via the feeding tube. But, liquid formulations are not always the best option. Sorbitol is commonly added to elixirs to improve palatability but it is not well absorbed and can cause gastrointestinal side effects. Sorbitol is a sugar alcohol absorbed slowly by the intestine (8). Following oral administration, it aids to increase osmotic pressure in the bowel by drawing in free water, becoming an effective osmotic laxative. Bacterial fermentation of sorbitol in the large bowel is also associated with increased flatulence and abdominal cramps (9). Malabsorption of sorbitol and other carbohydrate substitutes such as fructose and xylitol have been identified using hydrogen breath tests (10–13). Individual tolerance varies and depends on the dosage and previous exposure. Ingestion of as little as 10 g of sorbitol may cause flatulence and bloating. Stomach cramps and osmotic diarrhoea can occur at intakes of about 20–30 g/day and sometimes much less, especially in children (6, 14–17). The patients’ medication labels gave no indication that Sorbitol was present, something which has been previously reported (9, 17). The lesson from this patient was that even in patients with complex medical conditions, there are sometimes simple answers. And, it is not just the medication itself that can cause the problem but the solution. All possible causes of gastrointestinal distress should be investigated before the feed formula is reduced or discontinued.
Acknowledgements SMM is supported by a National Primary Care Award from the Research and Development Office, Northern Ireland. We thank Mr Martin Ferguson, The Regional Medicines and Poisons Information Submission date: 20 August 2002 Accepted: 5 September 2002
Service, for his help in retrieving the data on the Sorbitol content of the medications.
References 1. Elia M, Russell C A, Stratton R J et al. Trends in artificial nutrition support in the UK during 1996–2000. British Artificial Nutrition Survey, BAPEN, 2001 2. Kohn C, Keithley J. Enteral nutrition: potential complications and patient monitoring. Nursing Clin N Am 1989; 24(2): 339–353 3. Bowling T E, Silk D B A. Colonic responses to enteral tube feeding. GUT 1998; 42: 147–151 4. Mobarhan S, DeMeo M. Diarrhea induced by enteral feeding. Nutr Rev 1995; 53(3): 67 5. Bowling T E, Silk B A. Diarrhoea and enteral feeding. In: Rombeau J L, Rolandelli R H (eds). Enteral and Tube Feeding, 3rd ed. Philadelphia: W B Saunders, 1997: 540–553 6. Varella L, Jones E, Meguid M M. Drug-nutrient interactions in enteral feeding: a primary care focus. Nurse Pract 1997; 22: 98–104 7. Eisenberg P G. Causes of diarrhoea in tube-fed patients: a comprehensive approach to diagnosis and management. Nutr Clin Pract 1993; 8(3): 119–123 8. Beaugerie L, Flourie B, Pernet P, Achour L, Franchisseur C, Rambaud J C. Glucose does not facilitate the absorption of sorbitol perfused in situ in the human small intestine. J Nutr 1997; 127: 341–344 9. Lutomski D M, Gora M L, Wright S M et al. Sorbitol content of selected oral liquids. Ann Pharmacother 1993; 27: 269–273 10. Born P, Zech J, Stark M, Classen M, Lorenz R. Carbohydrate substitutes: comparative study of intestinal absorption of fructose, sorbitol and xylitol. Med Klin 1994; 89(11): 575–578 11. Hyams J S. Sorbitol intolerance: an unappreciated cause of functional gastrointestinal complaints. Gastroenterology 1983; 84(1): 30–33 12. Jain N K, Rosenberg D B, Ulahannan M J, Glasser M J, Pitchumoni C S. Sorbitol intolerance in adults. Am J Gastroenterology 1985; 80(9): 678–681 13. Rumessen J J. Fructose and related food carbohydrates. Sources, intake, absorption and clinical implications. Scand J Gastroenterol 1992; 27(10): 819–828 14. Thomas B, Jefferson A. In: Thomas B (ed). Manual of Dietetic Practice, 3rd ed. London: Blackwell Science, 2001: 154–161 15. Lourenco R. Enteral feeding: drug/nutrient interaction. Clin Nutr 2001; 20(2): 187–193 16. Johnson D R, Nyffeler M S. Drug-nutrient considerations for enteral Nutrition. In: American Society for Parenteral and Enteral Nutrition (eds). The ASPEN Nutrition Support Practice Manual, 1st ed. Silver Spring: American Society for Parenteral and Enteral Nutrition, 1998; 6(1): 6–20 17. Edes T E, Walk B E, Austin J L. Diarrhoea in tube fed patients: feeding formula not necessarily the cause. Am J Med 1990; 87: 352–360