July 2010 FAQs
July 2010 FAQs
What is the available evidence for the use of sodium thiosulfate for calciphylaxis?
What is the available evidence for the use of sodium thiosulfate for calciphylaxis?
Calcific uremic arteriolopathy, also known as calciphylaxis, is a condition caused by disruption of calcium/phosphate homeostasis and endothelial dysfunction.1-4 Calcification of arterioles and soft tissue occurs as a result of calcium phosphate precipitation and oxidative stress which then leads to subcutaneous (SC) ischemia and necrosis. Painful skin lesions, SC nodules, and/or plaques typically develop on the lower limbs, abdomen, buttocks, breasts, and/or thighs. Progression to painful deep ulcers, amputations, calcification of internal organs leading to organ failure, and sepsis are complications of calciphylaxis that contribute to significant morbidity and high mortality rates (60% to 80%). Calciphylaxis most commonly occurs in patients with chronic kidney disease but has also been reported in patients with normal renal function. Other risk factors and medications associated with calciphylaxis are listed in Table 1.
Table 1. Risk factors associated with calciphylaxis1-4
Elevated alkaline phosphatase
Low serum albumin
Increased aluminum levels
Long term dialysis
Calcium-containing phosphate binders
Vitamin K antagonists
Treatment of calciphylaxis involves multiple measures.1-4 Wound care, antibiotics, and pain control provide supportive care. For patients with chronic kidney disease or renal failure, the National Kidney Foundation’s recommendations should be followed by achieving corrected calcium concentrations between 8.4 and 9.5 mg/dL, phosphate levels between 3.5 and 5.5 mg/dL, and intact parathyroid hormone (PTH) concentrations between 50 and 300 pg/mL. Efforts to reduce calcium and phosphate serum levels include increasing the frequency of dialysis, reducing the dialysate calcium, avoiding calcium and vitamin D supplementation, using non-calcium containing phosphate binders, and using bisphosphonates and/or cinacalcet. Prevention of calcium phosphate precipitation with the use of sodium thiosulfate has also been reported to be successful, which is discussed here in further detail.
Sodium thiosulfate is approved by the Food and Drug Administration for prophylaxis of cisplatin nephropathy and as an antidote for cyanide poisoning.4,5 Off label uses include urolithiasis, nephrocalcinosis, tumoral calcinosis, calciphylaxis, nephrogenic fibrosing dermopathy, and as a topical antifungal. Doses are typically administered intravenously (IV) either as an injection or continuous infusion. It is commercially available as 10 mL (100 mg/mL) and 50 mL (250 mg/mL) single-dose vials. Proposed mechanisms that support the use of sodium thiosulfate in calciphylaxis include formation of water soluble calcium-thiosulfate complexes that prevent calcium phosphate precipitation and dissolve existing calcium deposits.1-4,19 In addition, its antioxidant activity improves endothelial function and enhances vasodilation.
Summary of evidence
Details of 14 adult case reports of the use of sodium thiosulfate for calciphylaxis are described in Table 2.4,6-18 Over 90% of these patients were female with 9 of 14 patients on dialysis. Of the other 5 cases, only 1 patient presented with normal renal function and the remainder exhibited varying degrees of renal dysfunction. The presenting symptom in all cases was painful lesions that progressed despite wound care, antibiotics, interventions to normalize calcium, phosphorus and PTH, and/or increasing dialysis frequency. The most common dose of sodium thiosulfate used was 25 g IV given over 30 to 60 minutes 3 times per week after hemodialysis. In 3 cases, this dose was not tolerated due to metabolic acidosis, hypotension, or nausea and vomiting. In 2 of these patients, a lower dose of 12.5 g was tolerated and effective. In the third case, the 25 g IV dose improved skin ulcerations but was discontinued after 2 months due to nausea and vomiting. Sodium thiosulfate was restarted intra-peritoneally after new skin lesions formed but was not effective. In 11 of the 14 cases, sodium thiosulfate produced successful outcomes. Pain relief was most commonly observed within 2 weeks of starting treatment. The time to ulcer healing ranged between 4 and 42 weeks.
Additional reports of successful sodium thiosulfate use in patients with calciphylaxis have been described in 3 pediatric patients and as secondary prophylaxis for calciphylaxis.19,20 Araya and colleagues describe the successful use of thrice weekly IV sodium thiosulfate 25 g/1.73 m2 in 3 patients on a pediatric hemodialysis unit.19 Two patients (1 male and 1 female) were aged 21 years and the other was a 12 year old male. In addition to sodium thiosulfate, interventions included calcium and vitamin D, use of calcium-free phosphate binders and a low calcium dialysate, and increasing the frequency of dialysis. The number of sodium thiosulfate infusions ranged from 35 to 92.
After successful treatment with IV sodium thiosulfate for 11 months of the 57 year old female patient described by Musso and colleagues (see Table 2), oral thiosulfate was initiated as secondary prophylaxis due to the patient’s multiple risk factors.20 An initial oral dose of 2.6 g per day was reduced to 2.6 g 3 times per week after hemodialysis since the patient developed diarrhea with the daily dose. A 2 molar oral product was prepared using 75.5 g in 150 mL of water. During the course of treatment, the patient remained free of recurring pain except when there was a brief interruption in therapy for 1 month. Re-initiation of oral sodium thiosulfate was successful at treating the recurrent pain.
The evidence to support use of sodium thiosulfate for the treatment of calciphylaxis is limited to case reports. Its use was effective in controlling pain and healing ulcers in a majority of the published case reports. Although similar doses were used in most patients, the duration of therapy was highly variable and was guided by patient response. Adverse effects to monitor include metabolic acidosis, nausea and vomiting, and hypotension.
Although the evidence is limited, sodium thiosulfate should be considered for treatment of calciphylaxis that is unresponsive to conventional measures.
Table 2. Summary of case reports involving use of sodium thiosulfate for calciphylaxis.4,6-18
Level of renal dys-
Calciphylaxis signs & symptoms
Other treatments and associated outcomes
Sodium thiosulfate dose
Kalisiak et al
61 y, female
Severe pain in legs, ulcers on both calves and the right thigh; palpable calcification of SC tissue
Daily HD, opiates and sevelamer. Calcium and phosphorus normalized but ulcers did not heal and pain was not controlled.
25 g IV 3 times a week for 4 weeks and reduced to 12.5 g IV 3 times a week with continued wound care
Pain improved over the first 4 weeks and opiates were discontinued after 6 weeks. Improvement in ulcer healing was evident at week 10 with complete healing at week 30.
Dose of sodium thiosulfate was reduced due to metabolic acidosis.
Musso et al
57 y, Caucasian female
Painful SC nodules in inguinal region, legs, thighs, and abdomen
Parathyroid-ectomy that helped to normalize the Ca x P product and analgesics for pain control. Calciphylaxis progressed and pain was not controlled.
25 g IV 3 times per week immediately after dialysis and reduced to 12.5 g after the first dose with continued wound care
Injuries improved in 12 weeks with continued improvement after 6 months and complete resolution of lesions in 10 months.
Dose of sodium thiosulfate was reduced due to hypotension.
Hackett et al
44 y, female
Painful SC nodules on abdomen and thighs
Warfarin and calcium were discontinued and daily wound care, high dose opiates and pamidronate were initiated. Ulceration progressed and pain was uncontrolled.
25 g IV 3 times per week over 30 to 60 minutes
Opiate requirement decreased significantly in 2 months and complete healing of ulcers was achieved by week 42.
Subramaniam et al
55 y, female
SC nodules on the abdomen, buttock, and hip
Daily HD with low calcium dialysate, sevelamer, pain control and wound care were initiated. New lesions developed and pain was not controlled.
25 g IV 3 times per week after dialysis
Pain improved within 2 weeks and lesions completely healed in 12 weeks. Symptoms recurred 1 month after cessation of treatment. Sodium thiosulfate was restarted and similar improvement followed.
No adverse effects were reported.
Tindni et al
60 y, Caucasian female
Pain in the medial thigh that progressed to necrosis with vascular calcifications.
HD and analgesics initially followed by parathyroid-ectomy. Lesions and pain were not controlled.
25 g IV 3 times per week over 30 to 60 minutes
Pain improved in 2 weeks but skin lesions continued to progress and no improvement was achieved. Patient was transferred to hospice care.
Baker et al
68 y, African-American female
GFR: 60 to 89 mL/min
Painful, indurated, necrotic plaques on both outer thighs and arteriolar calcification.
Normal calcium, phosphorus, and PTH.
25 g IV 3 times per week then reduced to 2 times per week after lesions healed
Pain relief occurred in 3 to 4 weeks, and lesions healed by week 10.
Ackermann et al
Chronic allograft nephro-pathy
Painful ulcerations of left leg first and then the right leg.
Elevated calcium and phosphate.
Wound care, analgesics, and antibiotics failed and led to left leg amputation. Lesions appeared on the right leg.
Cinacalcet, calcium-free phosphate binders and HD 3 times per week with no improvement.
25 g IV 3 times per week for 8 weeks along with daily HD with low calcium dialysate
Pain decreased within 2 weeks, calcium and phosphate normalized, and most lesions were healed by week 6.
Meissner et al
35 y, female
HD x 2 y
Painful necrotic ulcers on thighs, buttocks, and abdomen.
Elevated calcium, phosphate, and PTH
HD 3 times per week for 5 hours each, antibiotics, and wound care with no improvement in pain or healing.
Calcium acetate, calcidiol, and warfarin were discontinued.
25 g IV over 60 minutes 3 times per week after HD for 6 weeks
Pain resolved in 2 weeks and ulcers healed by week 12.
Mataic et al
26 y, Caucasian female
Painful ulcerations on left arm and thighs
CCPD with low calcium dialysate, sevalamer, wound care, antibiotics and IV sodium thiosulfate, then IP sodium thiosulfate.
IV 3 times per week for 2 months.
25 g IP added to 2 L of low calcium Dianeal repeated every other day for 3 months
Skin ulcerations improved but treatment was discontinued after 2 months due to nausea and vomiting.
Despite IP use of sodium thiosulfate, lesions did not improve, and the patient developed sepsis and died.
Thang et al
53 y, Moroccan female
PD x 3 y
Tenderness and redness of breasts which progressed to ulceration and intolerable pain
Parathyroid-ectomy, bilateral mastectomy, and
normalization of calcium and phosphorus.
Symptoms progressed to her hips and legs.
No reduction in skin ulcerations was noted, and patient developed sepsis and died.
Tokashiki et al.
57 y, Japanese male
HD x 30 y
Multiple painful ulcers on toes and hand
Wound care, vasodilating agents, hyperbaric oxygen therapy with continued progression of ulcers and no pain resolution.
20 g IV 3 times per week after HD but reduced to 10 g due to side effects
Pain relief began within 1 week of treatment, and patient was ambulatory within in 2 weeks. Pain and tenderness resolved after 16 infusions
With the higher dose, patient experienced nausea and vomiting, heightened smell sensation, and loss of appetite.
Brucculeri et al
48 y, Caucasian female
HD x 5 y
Painful skin ulcerations on the abdomen, breasts, hips, and thighs. Elevated PTH.
HD frequency increased to 4 times per week (5 hours each), increased dosage of calcium-free phosphate binders, and use of a calcium-free dialysate. PTH improved but symptoms did not.
5 g IV over 10 minutes 4 times per week after HD for 34 months
Wound healing occurred over 6 months.
Patient experienced mild nausea and rare emesis. Bicarbonate concentrations were decreased.
Guerra et al
46 y, Caucasian female
GFR: 19 mL/min
Multiple painful skin lesions on legs
Sevelamer and HD
Skin lesions progressed and pain worsened.
25 g IV over 60 minutes every other day along with CVVH
As an outpatient, the patient continued to receive this drug 3 times per week after HD for at least 6 months
Symptoms improved within 2 days of sodium thiosulfate and CVVH. At 1 month, the lesions were mostly healed.
Cicone et al
69 y, Caucasian female
CAPD x 3 months
Painful SC lesion on the leg
Calcium acetate and calcitriol were discontinued. Sevelamer was initiated. Prednisone 40 mg every other day was started.
Pain relief was minor and temporary.
25 g IV over 30 to 60 minutes 3 times per week for a total of 8 months
Pain improved within 2 weeks; by 8 weeks there was no pain, and lesions were smaller.
Side effects included rhinorrhea, congestion, and rare nausea/vomiting. Serum bicarbonate concentrations were lowered.
y=years, HD=hemodialysis, SC=subcutaneous, IV=intravenous, GFR=glomerular filtration rate, PTH=parathyroid hormone, CCPD=continuous cycling peritoneal dialysis, IP=intraperitoneal, PD=peritoneal dialysis, CVVH=continuous venovenous hemofiltration, CAPD=continuous ambulatory peritoneal dialysis
1. Schlieper G, Brandenburg V, Ketteler M, Floege J. Sodium thiosulfate in the treatment of calcific uremic arteriolopathy. Nat Rev Nephrol. 2009;5(9):539-543.
2. Raymond CB, Wazny LD, Sood AR. Sodium thiosulfate, bisphosphonates, and cinacalcet for calciphylaxis. CANNT J. 2009;19(4):25-27.
3. Raymond CV, Wazny LD. Sodium thiosulfate, bisphosphonates, and cinacalcet for calciphylaxis. Am J Health Syst Pharm. 2008;65(15):1419-1429.
4. Kalisiak M, Courtney M, Lin A, Brassard A. Calcific uremic arteriolopathy (calciphylaxis): successful treatment with sodium thiosulfate in spite of elevated serum phosphate. J Cutan Med Surg. 2009;13(supp 1):S29-S34.
5. Wickersham RM, ed. Drug Facts and Comparisons. St. Louis, MO: Wolters Kluwer Health; 2009. http://online.factsandcomparisons.com/MonoDisp.aspx?monoID=fandc-hcp13577&quick=677642|21&search=677642|21&isstemmed=true. Accessed June 22, 2009.
6. Musso CG, Enz P, Vidal F, et al. Use of sodium thiosulfate in the treatment of calciphylaxis. Saudi J Kidney Dis Transpl. 2009;20(6):1065-1068.
7. Hackett BC, McAleer MA, Sheehan G, Powell FC, O’Donnell BF. Calciphylaxis in a patient with normal renal function: response to treatment with sodium thiosulfate. Clin Exp Dermatol. 2009;34(1):39-42.
8. Subramaniam K, Wallace H, SinniahR, Saker B. Complete resolution of recurrent calciphylaxis with long-term intravenous sodium thiosulfate. Australas J Dermatol. 2008;49(1):30-34.
9. Tindni A, Gaurav K, Panda M. Non-healing painful ulcers in a patient with chronic kidney disease and role of sodium thiosulfate: a case report. Cases J. 2008;1(1):178.
10. Baker BL, Fitzgibbons CA, Buescher LS. Calciphylaxis responding to sodium thiosulfate therapy. Arch Dermatol. 2007;143(2):269-270.
11. Ackermann F, Levy A, Daugas E, et al. Sodium thiosulfate as first-line treatment for calciphylaxis. Arch Dermatol. 2007;143(10):1336-1337.
12. Meissner M, Bauer R, Beier C, et al. Sodium thiosulphate as a promising therapeutic option to treat calciphylaxis. Dermatology. 2006;212(4):373-376.
13. Mataic D, Bastani B. Intraperitoneal sodium thiosulfate for the treatment of calciphylaxis. Ren Fail. 2006;28(4):361-363.
14. Thang OHD, Jaspars EH, ter Wee PM. Necrotizing mastitis caused by calciphylaxis. Nephrol Dial Transplant. 2006;21(7):2020-2021.
15. Tokashiki K, Ishida A, Kouchi M, et al. Successful management of critical limb ischemia with intravenous sodium thiosulfate in a chronic hemodialysis patient. Clin Nephrol. 2006;66(2):140-143.
16. Brucculeri M, Cheigh J, Bauer G, Serur D. Long-term intravenous sodium thiosulfate in the treatment of a patient with calciphylaxis. Semin Dial. 2005;18(5):431-434.
17. Guerra G, Shah RC, Ross EA. Rapid resolution of calciphylaxis with intravenous sodium thiosulfate and continuous venovenous hemofiltration using low calcium replacement fluid: case report. Nephrol Dial Transplant. 2005;20(6):1260-1262.
18. Cicone JS, Petronis JB, Embert CD, Spector DA. Successful treatment of calciphylaxis with intravenous sodium thiosulfate. Am J Kidney Dis. 2004;43(6):1104-1108.
19. Araya CE, Fennell RS, Neiberger RE, Dharnidharka VR. Sodium thiosulfate treatment for calcific uremic arteriolopathy in children and young adults. Clin J Am Soc Nephrol. 2006;1(6):1161-1166.
20. Musso CG, Enz P, Vidal F, et al. Oral sodium thiosulfate solution as a secondary preventive treatment for calciphylaxis in dialysis patients. Saudi J Kidney Dis Transpl. 2008;19(5):820-821.
What products can be used to unclog feeding tubes?
What products can be used to unclog feeding tubes?
Tube occlusion is a common complication of enteral feeding tubes, which can be caused by high protein or viscous feeding formula, medications, improper flushing technique, small lumen tubing, or a combination of factors. In most cases, this obstruction will result in delayed administration of medications and nutrition. If not corrected, the patient may require additional surgical intervention to replace tubes, which is associated with increased costs and trauma to the patient. Severe tube occlusions have also resulted in tearing of the tube and direct administration of feeds to the esophagus and possible formation of esophageal bezoars.1-3
Prevention is the preferred solution to this common problem. If possible, elixir and solution forms of medications should be used.4 If not commercially available, appropriate formulations can be compounded as long as all medications are adequately crushed and/or dissolved. Refer to your pharmacy policy and procedure, or resources such as Drug Topics Red Book, Lexicomp’s Drug Information Handbook, and/or the Pharmacist’s Letter for a list of medications that cannot be crushed or opened. These lists will primarily include any medication that is time-released and/or enteric-coated.
If an appropriate oral formulation is not available, consider an alternative to enteral administration.4 While more invasive and/or potentially costly, many drugs can be given by other routes such as parenteral, transdermal, sublingual, inhaled, or rectal. Additionally, flushing of the tubing has been established as an effective preventative measure. Tubes should be flushed with at least 30 mL of sterile water with every bolus feed and before and after medication administration.4,5 If using continuous feeds, flushing should occur every 4 hours to maintain patency.5 Even when these preventative measures are taken, tube occlusion can occur at a rate as high as 15%.4,6 Finally, the formula used as a feeding solution should be evaluated for protein and fiber content, and overall viscosity and the diameter of the tube lumen should be considered in order to maximize flow rate.
The use of pancreatic enzyme and sodium bicarbonate solutions has been shown to be effective in the prevention and treatment of clogged enteral feeding tubes, and in many institutions this had become common practice.7 The studies evaluating this method used the pancrelipase brand Viokase with sodium bicarbonate to reach optimal pH. The solution was then injected into the tube, clamped, and flushed.4 In 2004, due to concerns about consistency, safety, and effectiveness of pancreatic enzyme products, it was mandated that all products must meet standard formulation guidelines and undergo clinical trials to obtain Food and Drug Administration (FDA) approval.8 Only 3 brands of enzymes, Pancreaze, Creon, and Zenpep, fulfilled these requirement and received approval. These are the only preparations currently marketed in the United States. Unfortunately, these products are now produced as delayed-release capsule dosage forms, whereas Viokase was produced as powder or crushable tablet. Therefore, due to the reformulation of the products, results of prior clinical studies cannot be directly applied. There is no information to support similar efficacy of the new preparations for use in clogged feeding tubes; furthermore, the new release characteristics of the products are not likely conducive to instillation in the feeding tube.
Although, the appropriate course of action to manage a clogged feeding tube has not been universally established there are studies, some of which will be discussed below, that can help guide treatment options.
Several irrigants including carbonated soda, cranberry juice, and water have been studied to resolve an existing clog. In a study of 30 male patients receiving continuous nasogastric small bore tube feeds, subjects were randomized to receive irrigations with either 30 mL of water or cranberry juice every 4 hours.9 Of the 15 tubes irrigated with water, none occluded. However, 73.3% (11/15) of the tubes irrigated with cranberry juice were occluded, and the remaining 4 were discontinued from the study for various reasons. This difference in occlusion rates was statistically significant in favor of water when considering the mean duration of tube use (403.5 hours with water vs. 130.1 hours for cranberry juice, p<0.001). These results were later confirmed in a in vitro study of 108 feeding tubes irrigated with water, Coca-Cola, or water over 3 days.10 The effectiveness of water was shown to be similar to Coca-Cola, and cranberry juice was consistently inferior to both. Although water and Coca-Cola were similar, the authors recommended that water be considered the first-line irrigant based on cost and accessibility. The American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.) Practice Recommendations also consider water as the preferred irrigant due to proven efficacy, easy accessibility, and low cost.5 Overall, use of acidic beverages such as cola or cranberry juice is considered controversial in that such beverages may denature proteins within the feeding formula, therefore contributing to clogging.4,9
In one study, 9 substances (Pancrease, Viokase, pork pancreatin, bromelain, papain, cranberry juice, chymotrypsin, and distilled water) were evaluated in 3 feeding tubes each to determine their ability to resolve a clog after 4 hours.11 The methods of this study conducted in the laboratory involved an isotonic nutrition formula injected into 41 feeding tubes. The tubes were incubated until they clogged; the tubes clogged within 7 days. Once the clogs formed, each substance listed above was used in an attempt to clear the clog by injecting 1 mL of the substance into the clogged tube. The investigators attempted to flush the tubes every 30 minutes after the substances were injected. If the flush attempt was unsuccessful, another 1 mL of the substance was injected into the clogged tube. This was repeated until the tube could be irrigated or 4 hours elapsed. None of these substances declogged the feeding tubes within the 4-hour period; however, the chymotrypsin and papain substances were most effective. Both substances resulted in movement of the clog. Since papain is often found in meat tenderizer it is easily accessible and was therefore considered a viable option.
Another in vitro study evaluated the ability of 6 solutions to resolve an occlusion: Adolf’s meat tenderizer (papain), Viokase (trypsin, chymotrypsin, amylase and lipase), Sprite, Pepsi, Coca-Cola, or Mountain Dew.7 The investigators formed a clot and then transferred the clot to the solutions mentioned above in an attempt to dissolve the clot. Unlike the previous study, the authors reported the pH of each mixture. They adjusted Viokase, using sodium bicarbonate, to a level of 7.9 and adjusted the pH of papain to a level of 6.5. The results of this study showed that the Viokase pH 7.9 was significantly better than the other products (p<0.01), while Viokase pH 5.9 and papain were the lowest scoring products. In order to determine if the pH or Viokase was responsible for the significant effects, the investigators compared the Viokase results to distilled water adjusted to the same pH (7.9). Viokase was superior to pH adjusted distilled water, leading the authors to speculate that Viokase itself and not the pH was responsible for the efficacy. Applying the results of their in vitro study, the authors used Viokase pH 7.9 to attempt to clear 10 patients’ clogged feeding tubes. Five tubes were cleared with 1 attempt with 2 more becoming clear with the second attempt. Three tubes could not be cleared. These results suggest that Viokase pH 7.9 was the most effective solution for clearing a clogged feeding tube and that papain, or meat tenderizer, may not be as effective as previously reported.
Commercially available products
Clog Zapper is a commercially available product, which has also shown efficacy in clearing occlusions.4,12 This system includes a syringe filled with powder consisting of papain and a variety of enzymes that is then reconstituted with water and instilled into the clogged tube through a catheter. The solution is then allowed to dwell for 30 to 60 minutes before being flushed with water. A company study of 17 occluded tubes showed Clog Zapper to be successful in clearing formula-related clots with the first or second attempt. While effective, this product does have a high cost and has not been studied for drug- related occlusions.
Other commercially available products have been designed to mechanically dismantle clogs and may be used regardless of the cause of the clog. Bard offers the “PEG cleaning brush” which is a flexible catheter with a feather cut brush at the distal end meant to scrape and break up the clog.13 The brush prevents perforation that may occur with exposed wires. Bionix has developed the “Enteral Feeding Tube Declogger”, a polypropylene flexible rod, which when inserted and rotated into the feeding tube dislodges the obstruction.14 These products are designed for single-use only, making cost a limitation to use. However, Bionix does offer a Medicare reimbursement code protocol which may improve cost effectiveness.
If all of these agents fail, a gastroenterologist and/or surgeon should be consulted to evaluate the patient for replacement of the feeding tube.
The reformulation of pancreatic enzymes has presented clinicians with a dilemma in that Viokase, a product with demonstrated efficacy in clearing clogged feeding tubes, is no longer on the market. Overall, prevention appears to be the key factor in the management of enteral feeding tube occlusion. At least 30 mL of sterile water flushes should be used every 4 hours or before and after tube feeds and medications. To prevent tube clogging due to medication administration, it is recommended to chose alternate formulations of medications or routes of administration whenever possible.
If an occlusion does occur, sterile water should be used first due to proven efficacy, low cost, and a favorable adverse effect profile. Use of beverages, such as carbonated soda and cranberry juice, are not recommended due risk of worsening the clog and lack of evidence of efficacy. Papain as a sole irrigant has produced varying results. However, the commercially available Clog Zapper, which contains papain along with digestive enzymes, has shown some efficacy in unpublished company research. Other commercial agents, such as the Bard PEG cleaning brush or Bionix Enteral Feeding Tube Declogger, are designed to mechanically dismantle clogs, and can be used for formula or medication-related occlusions. If the clog is not resolved by these methods, it is recommended to change the feeding tube.
- Cremer AS, Gelfand DW. Esophageal bezoar resulting from enteral feedings. JPEN J Parenter Enteral Nutr. 1996;20(5):371-373.
- Garcia-Luna PP. Esophageal obstruction by solidification of the enteral feed: a complication to be prevented. Intensive Care Med. 1997;23(7):790-792.
- Irgau I, Fulda GJ. Esophageal obstruction secondary to concretions of tube-feeding formula. Crit Care Med. 1995;23(1):208-210.
- Beckwith MC, Feddema SS, Barton RG, Graves C. A guide to drug therapy in patients with enteral feeding tubes: dosage form selection and administration methods. Hosp Pharm. 2004;39(3):225-237.
- Bankhead R, Boullata J, Brantley S, et al. A.S.P.E.N. Enteral nutrition practice recommendations. JPEN J Parenter Enteral Nutr. 2009;33(2):122-167.
- Pancorbo-Hidalgo PL, Garcia-Fernandez FP, Ramirez-Perez C. Complications associated with enteral nutrition by nasogastric tube in an internal medicine unit. J Clin Nurs. 2001;10(4):482-490.
- Marcuard SP, Stegall KL, Trogdon S. Clearing obstructed feeding tubes. JPEN J Parenter Enteral Nutr. 1989;13(1):81-83.
- Food and Drug Administration. Guidance for industry exocrine pancreatic insufficiency drug products – submitting NDAs. http://www.fda.gov/OHRMS/DOCKETS/98fr/2003d-0206-gdl0001.pdf. Accessed June 12, 2010.
- Wilson MF, Haynes-Johnson V. Cranberry juice or water? A comparison of feeding-tube irrigants. Nutr Support Serv. 1987;7(7):23-24.
- Metheny NA, Eisenberg P, McSweeney M. Effect of feeding tube properties and three irrigants on clogging rates. Nurs Res. 1988;37(3):165-169.
- Nicholson LJ. Declogging small-bore feeding tubes. JPEN Journal Parenter Enteral Nutr. 1987;11(6):594-597.
- Clog Zapper product information. Wheeling, IL: Corpak Medsystems; 2002.
- BARD PEG Cleaning Brush. http://www.bardaccess.com/feed-peg-brush.php. Accessed June 13, 2010.
- Bionix DeCloggers. https://www.bionix.com/Pages/MedFrameset.html. Accessed June 13, 2010.
By Lauren Dandeles, PharmD