A 2019 systematic review examined the administration of chloroquine and hydroxychloroquine via feeding tubes, a challenge exacerbated by the COVID-19 pandemic. A total of 1,784 articles were found, though only 4 studies met inclusion criteria related to drug administration techniques and potential interactions. Two studies included data on the administration of hydroxychloroquine specifically; one study demonstrated full dispersion of hydroxychloroquine tablets after crushing with a mortar and pestle (Table 1), suggesting the feasibility of enteral administration, while another study provided no information regarding the administration of hydroxychloroquine through postpyloric feeding tubes. The review highlighted the absence of specific data regarding drug-enteral nutrition interactions for hydroxychloroquine in critically ill patients, although the potential for interaction with multivalent ions such as magnesium was noted. Despite the lack of direct pharmacokinetic studies in adults, authors emphasized that immediate-release hydroxychloroquine formulations currently available in Brazil are likely to dissolve adequately, minimizing complications during administration. This study’s findings may also have limited generalizability to hydroxychloroquine oral tablets available in the United States formulations. Due to the lack of studies, authors suggest it is more adequate to withhold from the administration of hydroxychloroquine along with enteral nutrition. [1]
A 2021 letter to the editor on the administration of potential COVID-19 treatments through feeding tubes noted that, although hydroxychloroquine with or without azithromycin is no longer preferred in current clinical practice, it remained in some COVID-19 treatment algorithms. The authors note that hydroxychloroquine is available as a film-coated tablet and that, while the manufacturer recommends avoiding tablet crushing, literature suggests crushing may be considered if no alternative option is available. Unfortunately, a reliable reference within the letter directly providing evidence to support this was not identified. [2]
A 2021 article described the preparation of an extemporaneous hydroxychloroquine sulfate 25 mg/mL oral suspension using Ora-Plus and Ora-Sweet SF (1:1 ratio) for patients unable to swallow commercially available hydroxychloroquine tablets. The formulation may be prepared using hydroxychloroquine sulfate tablets or powder. When tablets are used, they are to be soaked in a small amount of vehicle to cover the tablets for 15 minutes and then mixed to form a smooth paste before additional vehicle is added to achieve the final volume. The suspension should be packaged in tight, light-resistant containers and labeled to shake well before use. The article reported that hydroxychloroquine sulfate is freely soluble in water and that the suspension may have a beyond-use date of up to 90 days when stored at refrigerated or controlled room temperature conditions. Quality control assessments may include evaluation of weight/volume, pH, specific gravity, drug assay, color, rheological properties, pourability, physical appearance, and stability. Although this compounded suspension provides an alternative oral dosage form for patients unable to swallow tablets, the article did not specifically evaluate administration of the compounded oral suspension through enteral feeding tubes. [3]