When we all think about medication administration our mind naturally goes to swallowing a pill or a teaspoon of cough syrup, for example. This route of medication administration is by far the most common and preferred. However, there are often circumstances that prevent the oral use of medications. These can include the inability to swallow, whether due to a decreased level of consciousness or an oral or gastrointestinal lesion, severe nausea and/or vomiting, or bowel obstruction. When these issues arise, prescribers must look to alternative routes of medication administration to meet patients’ needs. We will systematically review several of these options below.
Intravenous & Subcutaneous Administration
The other most familiar route is via intravenous administration. While this is remarkably common in an inpatient setting, hospice use of IVs is less familiar to many. This is a very useful choice when patients have permanent IV access, such as a port or a PICC line. Intravenous administration works for almost all medications used in hospice care. However, a line “hook up” limits patient mobility and freedom. The IV site itself can also be a possible source of infection.
For those patients who do not have permanent intravenous access, medications and fluids can be administered via the subcutaneous route. Administration under the skin has similar results as administering through a vein. However, the infusion is not as fast, and external tubing still limits patient mobility.
If the patient happens to have a pre-existing enteral tube, such as a PEG tube, crushed medication is an alternative option for administration. Crushing or altering extended-release medications is not possible; thus, precluding their use. Enteral tube placement, in and of itself, has surgical risk, and typically the sole purpose of medication administration in the hospice setting is not enough to initiate placement.
Transdermal & Transmucosal Administration
Transdermal patches have become more common due to their ease of use, typical extended duration of action, up to three days for many products, and their painless nature. The medication is systemically absorbed. However, many types of patches require the patient to have an adequate amount of subcutaneous fat under the patch placement area to ensure absorption. Oftentimes, our hospice patients have lost a large amount of weight, and this can be a limiting factor. Some patients may also develop local irritation to the adhesive. Heat exposure, such as heating pads and personal fever, can also increase medication absorption causing untoward effects.
Topical administration differs from transdermal in that these products are typically gels, creams, or ointments. They constitute direct application to the problem area and minimal systemic absorption. In other words, they work where you put them, but absorption into the bloodstream is not efficient. Thus, they have limited usefulness in hospice care.
Some medications can be absorbed via the transmucosal route, such as under the tongue and via the inside of the cheek. A volume of 1ml is the limit on this alternative, due to aspiration risk. However, this method is very simple for families to utilize and can often be used with the same medications that are already present in the home.
Many respiratory medications, such as albuterol, require a nebulizer machine to help with wheezing or shortness of breath. However, other categories of medications, such as opioids and diuretics, might be given this way if needed. Their effectiveness can vary from patient to patient.
The intranasal route can have extremely rapid absorption, similar to intravenous administration, but the dose must be 1.5 to 2 times higher than the parenteral dose. Volume, of up to 1 ml, limits this route, and these medications can be quite expensive.
Lastly, the rectal route is a useful method. Oral administration and rectal administration constitute the same dosage with the same effectiveness. This route is simple to utilize, though many patients may find it unpleasant. Patients with either low white blood cell counts or low platelets should avoid rectal administration due to the risk of infection and bleeding risk, respectively.
In summary, oral administration of medication is the most common and most palatable route of medication administration for most patients. However, when that route becomes unavailable, there are multiple other avenues that prescribers and caregivers can pursue to ensure patient comfort and symptom management. At Hospice of Southern Illinois, we are regularly evaluating our patients with our interdisciplinary team to ensure that our care measures are effective for our patients and manageable for their caregivers. We are proud to be your choice as a community not-for-profit hospice provider.
Kestenbaum MD M, Vilches RPh A, Messersmith MS M, Connor PhD S, Fine MD, P, Murphy MD B, Davis M, Muir MD JC. Alternative Routes to Oral Opioid Administration in Palliative Care: A Review and Clinical Summary. Pain Medicine 2014; 15: 1129-1153.