Top 5 must-know meds for every clinical RD

Working in clinical care, I often find myself scanning a patient’s medication list with my eye drawn to the same meds each time. You know the ones—the diuretics, the antihyperglycemics, the anticoagulants, the antibiotics. But you might be overlooking some meds that have important nutrition implications. Here’s a list of the top five need-to-know meds that you shouldn’t pass by.

Methotrexate (trade names: Otrexup, Rasuvo, Rheumatrex, Trexall)

Used to treat:

Cancer, psoriatic and rheumatoid arthritis, ankylosing spondylitis, lupus, Crohn’s disease, psoriasis, arthritis

Nutritional implications

This drug acts as a folic acid antagonist, which means it may lead to a folic acid deficiency. Some patients take methotrexate with leucovorin (Folinic Acid), another drug that provides a source of folic acid for the body’s cells.

If your patient is taking methotrexate…

You may want to monitor for symptoms of a folic acid deficiency. Speak with the patient’s physician if you suspect a deficiency. This is particularly important if your patient is female and of child-bearing age, as a folic acid deficiency during pregnancy can cause birth defects.

Alvimopan (trade name: Entereg)

Similar drugs: methylnaltrexone (Relistor) and naloxegol (Movantik)

Used to treat:

Blocks the “paralyzing” effects of opioids on the GI tract; typically used in the perioperative period for elective surgery patients

Nutritional implications

Alvimopan is often seen in surgical protocols. Patients begin taking the drug pre-operatively and continue through the post-operative period. This drug can reduce the incidence of post-op ileus and allow for faster post-op feeding and diet advancement.

If your patient is taking alvimopan…

You may see faster diet advancement and better tolerance to PO feeding or enteral nutrition. Yay!

Phenytoin (trade name: Dilantin)

Used to treat:

Seizures, subarachnoid hemorrhage

Nutritional implications

Enteral nutrition infusion can affect the absorption of Dilantin.

If your patient is taking Dilantin…

Tube feeding infusion must be held for 1-2 hours before and after administration of Dilantin. This is required for PO (or GI access tube) administration only. Tube feeding infusion does not need to be held for administration of IV Dilantin.

Side note: some facilities also hold tube feeding administration for levothyroxine (Synthroid) and PO levofloxacin (Levaquin). Follow your facility’s protocol for these drugs.

Propofol (trade name: Diprivan)

Used to treat:

Acts as a fast-acting sedation agent for ICU or surgery patients.

Nutritional implications

Propofol exists in a lipid emulsion. This means it provides 1.1 calories/ml. Propofol is often titrated to higher or lower doses to maintain a desired level of sedation. Always check “real-time” infusion rates when calculating the calories provided by propofol.

If your patient is taking propofol…

Subtract the calories from propofol from your enteral or parenteral nutrition regimen. Don’t overfeed patients receiving propofol! If your propofol patient is receiving parenteral nutrition, there is generally no need to provide IV lipids, as the propofol will meet essential fatty acid requirements.

Metoclopramide (trade name: Reglan)

Used to treat:

Nausea, vomiting, gastroparesis; may also be used to promote faster gastric emptying for a tube feeding patient with elevated gastric residual volumes or abdominal distension

Nutritional implications

This is a great medication to keep in your back pocket, especially when a tube feeding patient doesn’t seem to be tolerating gastric feeding. Reglan often does the trick, and it can help to prevent inappropriate holding of tube feeding or a transition to parenteral nutrition. You may also recommend this drug for a patient with intractable nausea and vomiting that is not responsive to traditional antiemetics.

If your patient is taking Reglan…

The medical team may refer to the drug as a “prokinetic.” Use caution with extended treatment with Reglan (for greater than 12 weeks), as it can tardive dyskinesia.

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