Immunosuppressives and enteral feeding tubes: An integrative review

Immunosuppression is the main goal in the treatment of autoimmune diseases, chronic inflammatory diseases, and solid organ and tissue transplantation. However, due to a lack of liquid-form medications, it is challenging to achieve adequate immunosuppression when the patient is using enteral feeding tubes. It is necessary to transform solid oral medications into other forms for administration. Besides that, the occupational risk should be considered, and safety-handling measures should be taken. This review aimed to investigate the available evidence regarding the use of immunosuppressive drugs through enteral feeding tubes, focusing on the administration technique, efficacy and treatment safety.

We performed an integrative review using the databases PubMed, LILACS, SciELO, Cochrane and Google Scholar, including papers published between 1997 and 2017 in Portuguese, English and Spanish. We excluded editorials, theoretical reflections, abstracts presented at events, dissertations, theses, monographs and studies with extemporaneous formulations administered only by the oral route. In addition, we investigated the references of the included papers, as well as pharmaceutical guides, books and package inserts of selected drugs for additional evidence. Information and recommendations found were analysed and classified according to the GRADE system.

Fifty papers were identified, and 14 met the selection criteria. Among the assessed immunosuppressive drugs, we observed that tacrolimus, mycophenolic acid derivatives and azathioprine were the most studied, and they have more guided recommendations regarding their use through enteral feeding tubes. We noted the need for personal protective equipment for the conversion of the solid oral dosage forms, along with special caution during administration, due to occupational hazard. Other important factors identified were the position of the tube and interactions with the enteral nutrition, because they may compromise absorption, bioavailability and serum blood levels of immunosuppressive agents. However, the studies found have methodological limitations and poor quality, and this was taken into consideration during the classification of the evidence.

The lack of information about the administration of immunosuppressive drugs through enteral feeding tubes should not be a limiting factor, considering the need for treatment of patients in these circumstances. Risks and benefits must be carefully analysed, and factors regarding compounding and administration through the enteral tube must be considered before beginning treatment. Hence, more primary studies are necessary for better fundamental clinical management.