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Canadian ALS guidelines

Feeding tubes play a critical role in ensuring that people with ALS who have difficulty swallowing can get proper nutrition, stay hydrated, and take their medications. One of the significant challenges with feeding tubes is that they become clogged. Approximately one-third of all patients who have a PEG tube experience an obstruction, often caused by crushed tablets. If a clog cannot be cleared, then the tube needs to be replaced. It can take hours or even days before patients receive a new tube, during which time the patient is unable to take their medication, get proper nutrition, or stay hydrated. For some people with ALS, replacing a tube can be a risky procedure requiring an overnight stay at the hospital.

Why Liquid Medications Makes Sense for People with ALS
Liquid formulations should be used whenever available with feeding tubes. Unlike crushed tablets, liquids flow smoothly through feeding tubes. For people prescribed riluzole, there is a liquid suspension formulation that has been approved for use with PEG tubes. This medication has a mildly thick consistency and can also be taken orally, which is helpful because most people with ALS will experience difficulty swallowing.

Crushing Tablets Can be Challenging
Crushing tablets appears to be a straight-forward process – but it is not. Often, the way the tablets are formulated and manufactured increases the likelihood that the particles will stick together and clump when exposed to water. Further, there are over 400 medications that should not be crushed for a variety of reasons. Before crushing a medication, patients should check with their pharmacist to ensure that it is safe to do.

Tablets are made from chemicals and consist of two main components. One part is the actual drug that provides the therapeutic benefit. This component is called the active pharmaceutical ingredient, or API. The other part consists of inactive ingredients such as fillers, binders, and flavorings to mask the taste, as well as coloring agents. Both the active and inactive ingredients are blended and then compressed under high pressure to fuse the materials to form a hard tablet. Tablets are intended to be hard, so they don’t fall apart during packaging, shipping, or pharmacist or patient handling.

Common Components of a Tablet

  • Active ingredient: Provides the therapeutic benefit of the medicine
  • Filler: Makes the tablet bigger so it can be handled
  • Binder: Helps keep the tablet together
  • Disintegrant: Allows the tablet to break-up when it contacts stomach acid
  • Lubricant: Prevents the tablet from sticking to the machine that forms the tablet’s shape
  • Flavoring/Coloring: Masks the taste and makes the tablet easier to identify

Additionally, some tablets have coatings to protect them from moisture or a film to prevent the active ingredient from coming into contact with the mouth and begin dissolving before the medication is swallowed. Others have coatings that prevents the medication from dissolving in the stomach so that it can instead dissolve in the small intestine.

Why Do Crushed Tablets Clog Feeding Tubes?
Feeding tubes have a diameter of about the same size as a drinking straw. They are usually made out of polyurethane or silicone, and the walls of the tube are relatively rigid so that liquids smoothly flow through them. When tablets are crushed, the particles tend to stick and clump together, especially when mixed with water. Many of the ingredients don’t readily dissolve in water, so instead of flowing through the tube, they are prone to clogging the tube.

Whether using liquid medications or crushed tablets, patients should administer one medication at a time through the feeding tube. The tube should be flushed with 1 ounce (30 mL) of water between each medication. Additionally, the water temperature used for crushed tablets is critical. Because medications consist of chemicals, many medications are sensitive to temperature and can become deactivated even in lukewarm water. Patients should check with their pharmacist about the appropriate water temperature for use with their medications.

PEG tubes play an essential role in helping people with ALS get proper nutrition, stay hydrated, and safely take their medications. Liquid medications should be used whenever possible to prevent feeding tubes from getting clogged from crushed tablets. A liquid suspension formulation of riluzole is one such available medication. Patients with PEG tubes should ask their doctor about liquid options for their medications.