Administration of Direct Oral Anticoagulants Through Enteral Feeding Tubes

Objective: To review literature regarding direct oral anticoagulants (DOACs) and determine their viability of administration in solution or via enteral tubes. Data Sources: MEDLINE literature searches identified articles published 2007-present using MeSH terms: factor Xa inhibitors, antithrombins, biological availability, and enteral nutrition. Package inserts were included. Manufacturers were asked to provide literature. Study Selection and Data Extraction: We included studies emphasizing bioavailability or enteral administration. Data Synthesis: Dabigatran and edoxaban package inserts recommend against altering the dosage form, and against enteral administration. One rivaroxaban study was identified. Given with food, enteral administration was comparable to the oral tablet. The mean AUC (0.889, 90% CI 86.12-91.84%) was within the equivalency margins; however Cmax (0.820, 90% CI 78.84-85.86%) was slightly below the 80% threshold. One apixaban study was identified. They showed bioequivalence between oral and enteral administration in different vehicles, but decreased bioavailability when crushed tablets were given along with nutritional support. AUC and Cmax were 32% and 19% lower, respectively, when apixaban solution was given via nasogastric (NG) tube with nutritional supplement versus oral administration of solution. Conclusions: Dabigatran capsules should not be altered, due to large variations in drug exposure. Rivaroxaban can be given as oral solution or via NG tube. Larger doses must be given with nutritional supplementation and enteral tubes must not be distal to the stomach. Apixaban can be given as oral solution or via nasogastric or gastric tube on an empty stomach. Food impairs bioavailability of the crushed tablets. There are insufficient data to recommend enteral administration of edoxaban and the package insert recommends against altering tablets.