Prescribing practice and evaluation of appropriateness of enteral nutrition in a university teaching hospital

Xiu-Ping Zhu,¹ Ling-Ling Zhu,² Quan Zhou<sup>1

1</sup>Department of Pharmacy, ²Cadre Department, Division of Nursing, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang Province, People’s Republic of China

Background: A retrospective utilization study was performed to evaluate utilization patterns for enteral nutrition in a university teaching hospital.
Methods: Enteral nutrition was divided into three types according to the nitrogen source, ie, total protein type [Nutrison Fibre^®, Fresubin Energy Fibre^®, Fresubin^®, Supportan^® (a special immunonutrition for cancer patients or patients with increased demands for omega-3 fatty acids), Fresubin Diabetes^® (a diabetes-specific formula), Ensure^®]; short peptide type (Peptison^®); and amino acid type (Vivonex^®). A pharmacoeconomic analysis was done based on defined daily dose methodology.
Results: Among hospitalized patients taking enteral nutrition, 34.8% received enteral nutrition alone, 30% concomitantly received parenteral nutrition, and 35.2% received enteral nutrition after parenteral nutrition. Combined use of the different formulas was observed in almost all hospitalized patients receiving enteral nutrition. In total, 61.5% of patients received triple therapy with Nutrison Fibre, Fresubin Diabetes, and Supportan. Number of defined daily doses (total dose consumed/defined daily dose, also called DDDs) of formulas in descending order were as follows: Nutrison Fibre, Fresubin Energy Fibre, Fresubin Diabetes > Supportan > Peptison, Ensure > Vivonex, Fresubin. The ratio of the cumulative DDDs for the three types of enteral nutrition was 35:2.8:1 (total protein type to short peptide type to amino acid type). Off-label use of Fresubin Diabetes was also observed, with most of this formula being prescribed for patients with stress hyperglycemia. Only 2.1% of cancer patients received Supportan. There were 35 cases of near misses in dispensing look-alike or sound-alike enteral nutrition formulas, and one adverse drug reaction in an elderly malnourished patient who did not receive vitamin K1-enriched enteral nutrition during treatment with cefoperazone. After 4 months of the trial intervention, off-label use of Fresubin Diabetes was no longer endorsed by the Drug and Therapeutics Committee for nondiabetic patients, and the proportion of this formula prescribed for patients with stress hyperglycemia decreased by 20%, with a 10-fold increase in the amount of Supportan prescribed for cancer patients. Near misses in dispensing look-alike or sound-alike enteral nutrition were successfully abolished, and no severe coagulation disorders occurred after prophylactic administration of vitamin K1-enriched enteral nutrition in elderly malnourished patients receiving cefoperazone.
Conclusion: This utilization study indicates that continuous quality improvement is necessary and that a Drug and Therapeutics Committee can play an important role in promoting rational and safe use of enteral nutrition. Appropriateness of this therapy still needs to be improved, especially in addressing the issues of non-evidence-based combined use of multiple enteral nutrition formulas, the relatively high rate of concomitant use of enteral and parenteral nutrition, off-label use of diabetes-specific Fresubin Diabetes, insufficient use of Supportan in cancer patients, and unnecessary use of Supportan in intensive care patients not suffering from cancer.

Keywords: enteral nutrition, drug utilization, indications, parenteral nutrition, pharmacoeconomics, rational drug use