What is the data on crushing rifaximin for feeding tube administration?

Comment by InpharmD Researcher

There is a limited amount of literature describing the preparation of rifaximin (Xifaxan) tablets for feeding tube administration. According to the Handbook of Drug Administration via Enteral Feeding Tubes, product information for a European rifaximin product indicates that nasogastric administration has been shown not to affect the therapeutic effect of rifaximin; however, it is unknown whether similar outcomes would be observed with the U.S. product. For intragastric administration, the tablet may be dispersed in 10 mL of water in a syringe, administered through the feeding tube, and followed by appropriate water flushes; data regarding jejunal administration were not identified, although intrajejunal administration was suggested not to affect the therapeutic effect. Due to the limited available evidence, a Bausch Medical Information specialist was contacted and reported that no clinical studies specifically evaluating the safety or efficacy of crushing, splitting, chewing, or compounding Xifaxan tablets were identified in their literature search.

rifaximin crush tube feed

Background

According to the Handbook of Drug Administration via Enteral Feeding Tubes (3rd edition), there is a lack of data available for administration of rifaximin via alternative routes. However, product information for a rifaximin product available in Europe, Targaxa, indicates that nasogastric administration of rifaximin has been shown not to affect the therapeutic effect of the drug. It is unknown if similar outcomes would be observed with the U.S. product, Xifaxan. If administration via a feeding tube is necessary, it is recommended that, depending on the indication, an alternative antibacterial available as a parenteral product may be appropriate. If the decision is made to administer via feeding tube, it is recommended to use the following steps for intragastric administration:

1. Stop the enteral feed.
2. Flush the enteral feeding tube with the recommended volume of water.
3. Place the rifaximin tablet in the barrel of an appropriate size and type of syringe.
4. Draw 10 mL of water into the syringe and allow the tablet to disperse, shaking if necessary.
5. Flush the medication dose down the feeding tube.
6. Draw another 10 mL of water into the syringe and also flush this via the feeding tube (this will rinse the syringe and ensure that the total dose is administered).
7. Finally, flush with the recommended volume of water.
8. Re-start the feed unless a prolonged break is required.

There are no data on the jejunal administration of rifaximin, but it is suggested that intrajejunal administration should not affect the therapeutic effect since rifaximin is not absorbed via this route. [1]

A 2023 article describes the efforts of a research pharmacy at a cancer hospital in which they examined and documented the suitability of all non-narcotic oral formulary medications for feeding tube administration. The primary goal of this study was to develop guidance for the extemporaneous compounding of dosage forms appropriate for passage through a feeding tube. It was indicated that rifaximin is poorly soluble and requires extra rinsing but is suitable for administration via gastric feeding tube. However, rifaximin was listed as not suitable for administration via jejunal feeding tube based on a drug pH of 7.2. The strength of the rifaximin tablet evaluated was not specified. Due to the lack of safety and efficacy data regarding the administration of rifaximin via feeding tube within this study, recommendations should be interpreted with caution. [2]

A study published in 2010 describes the stability of extemporaneously prepared rifaximin 20 mg/mL oral suspensions. Preparation involved thoroughly grinding six 200-mg rifaximin tablets in a glass mortar and mixing with 30 mL of Ora-Plus and 30 mL of either Ora-Sweet or Ora-Sweet SF to yield a final volume of 60 mL. A 1-mL sample was drawn immediately after preparation and at regular intervals for 60 days. At least 99% of the initial rifaximin remained throughout the 60-day study period. There were no detectable changes in color, odor, taste, or pH, and no visible microbial growth in any sample. Extemporaneously prepared suspensions of rifaximin were stable for at least 60 days when stored in a 2-ounce amber plastic bottle at room temperature. Evaluation of the administration of this preparation via feeding tube was not within the scope of this study. [3]

A Bausch (Salix Pharmaceuticals) Medical Information specialist was contacted regarding crushing Xifaxan (rifaximin) tablets and administration through enteral feeding tubes. The manufacturer reported that the prescribing information does not provide instructions for crushing Xifaxan tablets, and its literature search identified no clinical studies specifically evaluating the efficacy or safety of crushing, splitting, chewing, or compounding the tablets. However, published literature describes administration of rifaximin 550 mg twice daily via NG tube in patients with overt hepatic encephalopathy and rifaximin 400 mg three times daily via an enteral feeding tube in patients with pancreatitis; the specific preparation or manipulation of the tablets before tube administration was not reported. The manufacturer additionally noted that published evidence was not identified for administration through nasoduodenal, jejunostomy, orogastric, gastrostomy, or percutaneous endoscopic gastrostomy (PEG) tubes. [4]

Full manufacturer response available in the documents' below.

Background References: [1] White R, Bradnam V. Handbook of Drug Administration via Enteral Feeding Tubes (3rd edition). London, UK: Pharmaceutical Press; 2015.
[2] Klang MG. Developing guidance for feeding tube administration of oral medications. JPEN J Parenter Enteral Nutr. 2023;47(4):519-540. doi:10.1002/jpen.2490
[3] Cober MP, Johnson CE, Lee J, Currie K. Stability of extemporaneously prepared rifaximin oral suspensions. Am J Health Syst Pharm. 2010;67(4):287-289. doi:10.2146/ajhp090206
[4] Personal correspondence. Bausch Health Medical Information. September 2, 2026.
Literature Review

A search of the published medical literature revealed 1 study investigating the researchable question:

What is the data on crushing rifaximin for feeding tube administration?

Level of evidence

D - Case reports or unreliable data  Read more→


Please see Table 1 for your response.

Rifaximin, a Rifamycin Derivative for Use in the Treatment of Intestinal Bacterial Infections in Seriously Disabled Patients
Design

Open trial conducted without placebo

N= 30
Objective

To evaluate the effectiveness and tolerability of rifaximin, an intestinal topical antibiotic, administered via nasogastric (NG) tube in patients with severe enterocolitis, bacterial superinfections, and portosystemic encephalopathy
Study Groups

Rifaximin twice daily (n= 20)

Rifaximin three times daily (n= 10)
Inclusion Criteria

Patients with severe enterocolitis, bacterial superinfections causing intestinal inflammatory diseases, or portosystemic encephalopathy, requiring nasogastric tube feeding
Exclusion Criteria Not specified
Methods

All patients received rifaximin 400 mg suspended in 200–400 mL of water and infused through an NG tube over approximately 2 hours; Group 1 received rifaximin twice daily and Group 2 three times daily. Other drugs capable of altering intestinal flora or substantially interfering with study assessments were not administered, while treatments required for underlying clinical conditions were continued.
Duration

5 days for enterocolitis patients

8-10 days for hepatic encephalopathy patients
Outcome Measures Clinical effectiveness and tolerability; changes in clinical symptoms; stool characteristics; ammonia levels
Baseline Characteristics   Rifaximin twice daily (n= 20)

Rifaximin three times daily (n= 10)

Age, years

 47.6 ± 4.2 52.8 ± 9.3
Female 16 2
Results  Rifaximin twice daily (n= 20)

Before treatment

 After treatment

Body temperature, °C

 37.96 ± 0.14 36.96 ± 0.14

No. of stools

 7.70 ± 0.63 2.75 ± 0.19

Mucopus or blood in stools

 2.05 ± 0.17 0.61 ± 0.16

Rectal tenesmus

 3.07 ± 0.22 0.28 ± 0.12

Abdominal cramp-like pain

 3.40 ± 0.16 0.45 ± 0.11

Generalized malaise

 2.75 ± 0.25 0.31 ± 0.12

Nausea/vomiting

 2.75 ± 0.29 0.07 ± 0.07
Among 20 patients with enterocolitis receiving rifaximin 400 mg twice daily for 5 days, assessed clinical parameters significantly improved (p< 0.01); nausea and vomiting resolved by day 2, and complete remission of abdominal pain, tenesmus, and generalized malaise occurred in 55%, 71%, and 68% of patients, respectively.
Among 18 patients with pathogenic bacteria identified before treatment, the previously identified bacteria disappeared in 12, different bacteria were identified in 4, and no change occurred in 2.
Among 7 evaluable patients with hepatic encephalopathy receiving rifaximin 400 mg three times daily for 8 or 10 days, all assessed encephalopathy parameters significantly improved by day 3, neurological symptoms regressed in all patients by the end of treatment, and blood ammonia levels decreased during treatment, with normalization in 4 patients.
Adverse Events

No local or systemic side-effects were reported. One patient initially poorly tolerated the nasogastric tube.
Study Author Conclusions

In conclusion, rifaximin, administered in suspension using a nasogastric tube, is effective at the doses used in this trial for the treatment of patients affected by enterocolitis, primitive or secondary bacterial contamination of ileal loops and hepatic encephalopathy. It is particularly useful in cases of prevention and/or contraindications to oral feeding.
Critique

The study's open design without a placebo control limits the ability to definitively attribute improvements to rifaximin. The small sample size and lack of randomization may also affect the generalizability of the results. However, the study demonstrates the potential utility of rifaximin in a specific patient population where oral administration is not feasible.
Table 1 References:
[5] Alvisi V, D'Ambrosi A, Loponte A, et al. Rifaximin, a rifamycin derivative for use in the treatment of intestinal bacterial infections in seriously disabled patients. J Int Med Res. 1987;15(1):49-56. doi:10.1177/030006058701500106