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Nutrition > Drug Nutrient Interactions > Flashcards

Drug Nutrient Interactions Flashcards

1
Q

Drugs and nutrients can interact by affecting the following:

A

Absorption, Distribution, Metabolism, Excretion

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2
Q

What is absorption?

A

transportation of the unmetabolized drug from the site of administration to the body’s circulation (Ex. bisphosphonate)

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3
Q

Absorption requires movement of medication from _ to _

A

GI tract, general circulation

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4
Q

(T/F) All of a drug dose is absorbed

A

False

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5
Q

(T/F) All drug reaches systemic circulation as active drug

A

False

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6
Q

What is bioavalibility?

A

the rate and extent to which that drug is absorbed

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7
Q

What is the rate limiting step for most solid dose forms from being absorbed?

A

Disintegration and Dissolution

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8
Q

What is the rate limiting step for liquid medications being absorbed?

A

Blood perfusion of the intestines

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9
Q

What can decrease blood perfusion of the intestines?

A

Disease states, Edema, Surgery, Sepsis

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10
Q

What factors can alter medication absorption?

A 
1. Drug drug interaction
2 Gastric emptying rate 
3. ROA
4. Location of the distal top of the enteral tube
5. Presence of food
6. Formulation of medication
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11
Q

How can we enhance absorption?

A
  1. Use liquid medications to bypass the dissolution step
  2. Administer liquid medications or pulverized tablets with adequate fluid
    - Administer additional free water flushes in conjunction with scheduled medication
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12
Q

What factors can inhibit absorption?

A
  1. Placement of distal tip of enteral tube
  2. Medications taken on a empty stomach
  3. GI intolerances during tube feedings (N/V/D, cramping, increased gastric residuals)
  4. Review medication profile for causes
  5. Medications that decrease gastric transit time (prokinetic agents)
  6. Medications delaying gastric emptying/decrease GI motility
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13
Q

What medications must be taken on an empty stomach for better absorption?

A

Penicillins, Tetracycline, Rifampin, Levothyroxine

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14
Q

How should Penicillins, Tetracyclines, Rifampin, and Levothyroxine be administered?

A
  • Hold feeds 30-60 min before medication administration
  • Hold feeds 30 minutes after medication administration
  • Readjust feeding schedule to ensure patient receives 24 hr nutritional needs
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15
Q

What drugs decrease gastric transit time (prokinetic agents)?

A
  • Metoclopramide

- Erythromycin

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16
Q

What drugs delay gastric emptying/decrease GI motility?

A
  • Anticholinergics
  • Aluminum containing antacids
  • Narcotics
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17
Q

How does protein binding affect distribution?

A
  • May increase half life of drug

- Decrease hepatic metabolism

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18
Q

How does solubility affect tissue distribution?

A
  • Hydrophilic substances are distributed in fluid compartments of the body (vise versa)
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19
Q

What enzyme system is primarily used in metabolism?

A

Cytochrome P450 enzyme system

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20
Q

What Cytochrome P450 enzyme is involved in metabolism of most currently marketed drugs?

A 
***CYP3A4***
Others: 
- CYP1A2
- CYP2C9
- CYP2D6
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21
Q

What food induces CYP1A2?

A
  • Broccoli
  • Brussels sprouts
  • Charcoal-broiled meats
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22
Q

What drugs are metabolized by CYP1A2?

A
  • Check other sheet
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23
Q

What Cytochrome P450 enzyme is inhibited by grapefruit juice?

A
  • CYP1A2

- CYP3A4

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24
Q

What Cytochrome P450 enzyme is inhibited by cranberry juice?

A
  • CYP2C9 (Warfarin metabolism - results in increased INR and bleeding)
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25
Q

What drugs are metabolized by CYP3A4?

A
  • Check other sheet
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26
Q

What is the major elimination pathway for most water-soluble drugs and metabolites?

A

Urinary (renal)

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27
Q

Alterations in _ function have profound effects on drug clearance

A

Urinary (renal)

28
Q

What drugs undergo enterhepatic cycling?

A

Macrolides, ceftriazone, nafcillin, doxycycline, amiodarone

29
Q

How does gastrointestinal (bile) excretion work?

A

Drugs enter duodenum via common bile duct

30
Q

What are the 5 types of enteral incompatibilities?

A

physical, pharmaceutical, physiologic, pharmacologic, pharmacokinetic

31
Q

What is physical incompatibility?

A

Chemical instability that occurs when two susceptible substances are mixed together and results in a physical change between two substances

32
Q

What types of physical incompatibilities can occur?

A
  • Precipitate formation: curdling, flocculation (flaking), altered enteral formation consistency, viscosity
33
Q

What is pharmaceutical incompatibility?

A

Alteration in the drug form itself that interferes with efficacy, potency, and tolerance

34
Q

What medications in specialized dosage forms cannot be used in feeding tube administration?

A
  • Enteric coated (cannot crush)
  • Extended release
  • Sustained release
  • Sublingual
35
Q

What is physiologic incompatibility?

A

result from nonpharmacologic action incurred by the medication or by the suspending medium

36
Q

What does physiologic incompatibility typically occur with?

A
  • High osmolality liquid medications

- Sorbitol containing medications

37
Q

Patients with a physiologic incompatibility typically experience:

A

nausea, bloating, increased gastric residuals, cramping, diarrhea

38
Q

What is pharmacologic incompatibility?

A

Results when a medication alters tolerance of the EN or PN regimen because of its mechanism of action

39
Q

What typically occurs from a pharmacologic incompatibility?

A
  • Leads to greater than expected pharmacologic effect of medication (ex. prokinetic agent)
  • Lead to unintended side effects of medication (ex. Narcotic analgesics)
40
Q

What is pharmacokinetic incompatibility?

A

EN or PN regimen alters the bioavalibility, absorption, distribution, metabolism, and/or elimination of a medication

41
Q

What common medications cause pharmacokinetic incompatibility?

A

phenytoin, warfarin, ciprofloxacin, meds that should be taken on empty stomach (levothyroxine)

42
Q

What medications can be administered via enteral feeding tubes? and how?

A
  • IR forms: Oral tabs, Hard gelatin capsules, Soft gelatin capsules, Liquid formulations
  • Mix with appropriate diluent and administer separately.
  • Flush feeding tube with water befoer and after each medication is administered
43
Q

How are IR tablets administered via enteral feeding tubes?

A
  • Crushed to a fine powder

- Mix with water before administration

44
Q

How are IR hard gelatin capsules administered via enteral feeding tubes?

A
  • Open and mix thoroughly with water
45
Q

How are IR soft gelatin capsules administered via enteral feeding tubes?

A
  • Empty by creating a pin-hole in one end of capsule

- Squeeze contents out and mix with water

46
Q

What is the preferred alternative for administration via enteral tubes? Why?

A

Liquid medications

  • Better absorption
  • Decreased potential for enteral tube occlusion
  • Potential for producing adverse effects
47
Q

What are physiologic incompatibilities pertaining to liquid medications?

A
  • Sorbitol containing (present in all liquids except tinctures and emulsions)
  • Hyperosmolar liquid (stomach more tolerant, dilute with appropriate amounts of water
48
Q

What physiologic incompatibility pertains to suspensions?

A
  • Few incompatibility concerns!

- Can be hyperosmolar

49
Q

What are granular type medications?

A
  • Psyllium hydrophilic mucilloid

- Cholestyramine resin

50
Q

What is Cholestyramine resin used for?

A
  • To control diarrhea

- Added as hypercholesterolemia agent

51
Q

How should granular-type medications be prepared before administration?

A
  • Requires dilution with water

- Forms gelatinous mixture that can occlude feeding tube (do not use with small bore feeding tubes)

52
Q

What dosage forms are not recommended for administration via tube?

A
  • Enteric coated medications
  • Sublingual/buccal medications
  • Sustained release/ER
  • Syrups
53
Q

What is the purpose of enteric coating?

A
  • Protect stomach lining

- Protect from destruction in acidic environment

54
Q

Why is enteric coated medications not recommended for administration via tube?

A
  • May induce pharmaceutical incompatibility

- Therapeutic equivalent or alternative administrative should be considered

55
Q

Why is sublingual/buccal medications not recommended for administration via tube?

A
  • Placed under tongue or cheek pouch for administration (absorbed into systemic circulation)
56
Q

Why is sustained release/ER medications not recommended for administration via tube?

A
  • high peaks/low troughs
  • capsules containing beads can lead to occlusion of tube
  • dissolving in water or saline can affect integrity of beads
57
Q

Why are syrups not recommended for administration via tube?

A
  • Physical incompatibility
  • Denatures protein in EN at pH less than or equal to 4
  • Be aware of protein source of EN (free AA and hydrolyzed formulations or not as affected)
  • Physical incompatibilities cannot be avoided by diluting the syrup
58
Q

How do capsule PPIs containing enteric-coated beads need to be prepared?

A
  • Mix with acidic juice (apple or orange)

- Dissolve beads in 8.4% sodium bicarbonate solution

59
Q

How do enteric coated PPI tablets need to be prepared?

A
  • Dissolve beads in 4.2% sodium bicarbonate solute
60
Q

Phenytoin can have a pharmacokinetic incompatibility (impaired absorption) with _

A

protein; its highly protein bound

  • may need higher doses than usual
  • seizure are a consequence of low blood concentrations
61
Q

Strategies to Maintain therapeutic phenytoin levels

A
  • Hold tube feeding 2 hours before and 2 hours after phenytoin dose
  • Dilute phenytoin with 30-60 mL of water before administration
  • Monitor blood levels more frequently when changing from established parenteral dose to suspension form
62
Q

What does warfarin do to patients receiving tube feeding?

A
  • Decreased therapeutic dose
  • Highly protein bound
  • Consider bolus or cyclic feeding
63
Q

Compatibility of PN infused with other additives influenced by:

A
  • Exposure time b/w nutrients

- Additives present

64
Q

What is a great reference for PN compatibility?

A

Trissel’s handbook on injectable drugs

65
Q

What two drugs are safe to add to PN?

A

Insulin and famotidine

66
Q

(T/F) Admixing PN with medications is not advised

A

True

67
Q

(T/F) We can use Y-site administration of medications in PN

A

False; PN should be administered via a dedicated line at all times

Nutrition (3 decks)

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