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1
Medication Route Interchange – Adult – Inpatient
Clinical Practice Guideline
Table of Contents
SCOPE ...................................................................................................................................... 4
METHODOLOGY ...................................................................................................................... 5
INTRODUCTION ....................................................................................................................... 5
RECOMMENDATIONS .............................................................................................................. 6
UW HEALTH IMPLEMENTATION ............................................................................................. 7
REFERENCES: ......................................................................................................................... 8
APPENDIX A ............................................................................................................................. 9
CPG Contact for Content:
Name: Cindy Gaston, PharmD, BCPS
Phone Number: 265-8161
Email Address: cgaston@uwhealth.org
Guideline Update Author:
Cindy Gaston, PharmD, BCPS
Coordinating Team Members:
Cindy Gaston, PharmD, BCPS
Review Individuals/Bodies:
Paul Rutecki, MD; Joseph Holt, MD; Barry Fox, MD; Luke Schultz, PharmD
Committee Approvals/Dates:
Medication Use Evaluation Committee – August 2015
Pharmacy & Therapeutics Committee – September 2015
Release Date: September 2015
Next Review Date: September 2018
Note: Active Table of Contents -- Click to follow link
CPG Contact for Changes:
Name: Philip Trapskin, PharmD, BCPS
Phone Number: 265-0341
Email Address: ptrapskin@uwhealth.org
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2
Executive Summary
Guideline Overview
This purpose of this guideline is to identify medications clinically appropriate to automatically change the
route of administration based on bioavailability, safety and efficacy data. This document provides criteria
for safe and effective change in route of medication administration for inpatients (between parenteral and
enteral and within the enteral route including administration via various feeding tubes).

Key Practice Recommendations
1. Parenteral to enteral
1.1. To initiate the parenteral to enteral interchange, which includes medications administered orally
or via feeding tubes, the medication must be listed in Table 1. In addition, patients must meet all
inclusion criteria and none of the exclusion criteria.
1.2. Inclusion Criteria (Class 1, Level C)
1.2.1. Patient must have a diet order and be tolerating either a clear liquid or more advanced
diet or must be tolerating enteral tube feedings.
1.2.2. For antibiotic route interchange, patient’s fever and white blood cell count must be
downtrending for the past 24 hours.
1.3. Exclusion Criteria (Class 1, Level C)
1.3.1. Patient is strict NPO, unable to swallow and without feeding tube, or refuses oral
medications.
1.3.2. Severe vomiting or diarrhea has been documented within the past 24 hours or patient
has an acute condition that affects gastrointestinal absorption (i.e., gastrointestinal
obstruction or bleed, ileus, grade III or IV mucositis, gastrointestinal transit time too short
for absorption, malabsorption syndromes, partial/total removal of the stomach, or short
bowel syndrome.
1.3.3. Patient is hemodynamically unstable (sustained heart rate >100 beats/minute, respiratory
rate >24 breaths/minute, systolic blood pressure <90 mmHg or on high-doses of
vasopressors in presence of shock).
1.3.4. Patient requires continuous tube feedings that cannot be interrupted and patient requires
a medication known to bind to enteral nutrition formulas (e.g., phenytoin, ciprofloxacin).
1.3.5. Patient with endocarditis, meningitis, brain abscess, orbital cellulitis, CNS infection,
osteomyelitis, or endophthalmitis that should be treated with intravenous antibiotic
therapy.
2. Enteral to parenteral
2.1. For a patient to be eligible for the enteral to parenteral interchange the medication must be
listed in Table 1 and the patient must meet inclusion and exclusion criteria.
2.2. Inclusion Criteria (Class 1, Level C)
2.2.1. Patient is unable to tolerate oral medications or has failed a swallow study and does not
have a feeding tube in place.
2.2.2. Patient has an acute condition that affects gastrointestinal absorption (i.e.,
gastrointestinal obstruction or bleed, severe diarrhea, ileus, severe vomiting or grade III
or IV mucositis).
2.2.3. Patient is nutritionally compromised and parenteral administration of medication is
clinically warranted to minimize the amount of time the enteral nutrition is interrupted
(e.g., phenytoin, fluoroquinolones, etc.).
2.2.4. Patient has had an NPO order for greater than two days.
2.2.5. Patient requires continuous gastric suctioning.
2.3. Exclusion criteria
2.3.1. Acetaminophen, isavuconazole, posaconazole, and voriconazole cannot be converted
from enteral to parenteral formulation without a prescribing provider order.

3. Enteral to enteral (oral to feeding tube and feeding tube to oral)
3.1. Medication orders with an enteral route of administration are eligible for this interchange. An
initial medication order must be documented in the medical record to initiate this protocol. The
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3
pharmacist will modify the medication order based on the inclusion criteria below and
evaluation of assessment criteria.
3.2. Assessment Criteria (Class 1, Level C)
3.2.1. Evaluation of available alternative dosage forms including an assessment of
formulation appropriateness and modification of dosage and/or frequency of product if
therapeutically warranted.
3.2.2. Assessment of medication pharmacokinetic parameters including the site of action,
bioavailability, absorption characteristics and the effects of food on absorption.
3.2.3. Evaluation of the type of feeding tube and placement location within the
gastrointestinal tract.
3.2.4. Assessment and modification of dosage and/or frequency if therapeutically warranted
(i.e., phenytoin capsules to phenytoin suspension). A pharmacist can modify an
extended release product to an immediate release product. (i.e., divalproex sodium to
valproic acid solution) as listed in Appendix A, Table 2.
3.3. Oral to Feeding Tube Inclusion Criteria (Class 1, Level C)
3.3.1. To qualify for the oral to enteral interchange via an enteral feeding tube there must be
documentation of appropriate placement or approval for use in the EMR
3.4. Extended Release to Immediate Release Product Inclusion Criteria (Class 1, Level C)
3.4.1. A patient is currently ordered an extended release product and no longer able to take
medications by mouth and qualifies for conversion to administration by feeding tube.
3.4.2. Extended release product for conversion is listed in Appendix A, Table 2.
3.5. Feeding Tube to Oral Inclusion Criteria (Class 1, Level C)
3.5.1. To initiate a feeding tube to oral interchange the patient must have passed a swallow
study as documented in the medical record or approval to use the oral route is
documented in the EMR
3.5.2. Immediate Release to Extended Release Product Inclusion Criteria (Class 1, Level C)
3.5.2.1. A patient who had previously been converted to immediate release product
from extended release product who now qualifies for feeding tube to oral
inclusion criteria (3.2.1).
3.5.2.2. Extended release product for conversion is listed in Appendix A, Table 2.
4. Documentation
4.1. Medication orders meeting the above criteria for the change in the route of administration are
subject to interchange as soon as the patient meets the established criteria.
4.2. Once a patient meets the criteria, the pharmacist discontinues the current medication order and
converts the medication to the appropriate corresponding dosage form by placing an order in
the EMR.
4.3. The pharmacist will document all protocol directed route interchanges in the EMR.

Companion Documents
Medication Route Interchange Protocol
Dosing of Medications in Patients Receiving Continuous Enteral Feedings – Clinical Practice Guideline
Adult Enteral Nutrition Support Handbook
UW Health Electrolytes (Intravenous – Adult – Inpatient Clinical Practice Guideline
UW Health Electrolytes (Oral and Enteral) – Adult – Inpatient Clinical Practice Guidelines
UW Health Fosphenytoin and Phenytoin - Pediatric/Adult – Clinical Practice Guideline
UW Health Intravenous Administration of Formulary Medications – Adult – Inpatient Clinical Practice
Guideline

Pertinent UW Health Policies & Procedures
Hospital Administrative Policy 8.17 - Administration of Medications
Hospital Administrative Policy 8.33 – High Alert Medication Administration

Patient Resources – none

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4
Scope
Intended Users: Pharmacists, nurses, midlevel providers, physicians

CPG objective(s):
1. Identify criteria for safe and effective interchange of medication routes including intravenous, oral and
feeding tube administration.
2. Identify medications clinically appropriate to change the administration route based on bioavailability,
pharmacokinetic, safety and efficacy data.

Target Population:
Adult inpatients

Interventions and Practices Considered:
Providing the safest and most appropriate route of administration for medications included in this
guideline.

Major Outcomes Considered:
Medication orders with the appropriate route of administration

Guideline Metrics:
Compliance with the route interchange guideline and protocol.

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5
Methodology
A modified Grading of Recommendations Assessment, Development and Evaluation (GRADE) developed
by the American Heart Association and American College of Cardiology (Figure 1.) has been used to
assess the Quality and Strength of the Evidence in this Clinical Practice Guideline.
1


Figure 1. Quality of Evidence and Strength of Recommendation Grading Matrix

Introduction
The enteral route of medication administration is preferred over the intravenous route for improved safety,
increased patient comfort, and decreased cost.
2
The intravenous route of medication administration is
classified as an independent risk factor for having an adverse drug event (ADE) and is considered a high-
risk activity due to the potential for error resulting from the multiple necessary complex steps.
3-5
Studies
demonstrate that intravenous medication administration is associated with a 3% higher risk for ADE per
each medication administered.
4
The magnitude of harm resulting from these errors has also contributed
to its high-risk classification.
4,5
Furthermore, enteral administration may reduce the risk of intravenous
catheter related infections, medication incompatibilities, and thrombophlebitis.
2,6
Increased costs, length
of stay, and significantly higher mortality (versus other medication errors) have all been linked to
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6
intravenous administration of medications.
7,8
Intravenous administration of medications should be
minimized whenever possible by encouraging conversions to oral route whenever possible.
4
Enteral
medication is associated with decreased cost in comparison to intravenous medications and associated
lines, sets, and infusion pumps necessary for administration. Early interchange to oral medications has
been linked to shorter lengths of stay without clinical outcome compromise, independent of ADEs.
9,10


Criteria for inclusion of medications in the guideline were high oral bioavailability and good enteral
tolerance.
11
Medications were included in this guideline based upon clinical data confirming tolerability
and high oral bioavailability.
Recommendations
1. Parenteral to enteral
1.1. To initiate the parenteral to enteral interchange, which includes medications administered
orally or via feeding tubes, the medication must be listed in Table 1. In addition, patients
must meet all inclusion criteria and none of the exclusion criteria.
1.2. Inclusion Criteria (Class 1, Level C)
1.2.1. Patient must have a diet order and be tolerating either a clear liquid or more
advanced diet or must be tolerating enteral tube feedings.
9

1.2.2. For antibiotics, patient’s fever and white blood cell count must be down trending for
the past 24 hours.
11,12

1.3. Exclusion Criteria (Class 1, Level C)
1.3.1. Patient is unable to swallow, is strict NPO and without feeding tube, or refuses oral
medications.
9

1.3.2. Severe vomiting or diarrhea has been documented within the past 24 hours or
patient has an acute condition that affects gastrointestinal absorption (i.e.,
gastrointestinal obstruction or bleed, ileus, grade III or IV mucositis, gastrointestinal
transit time too short for absorption, malabsorption syndromes, partial/total removal
of the stomach, or short bowel syndrome.
1.3.3. Patient is hemodynamically unstable (sustained heart rate >100 beats/minute,
respiratory rate >24 breaths/minute, systolic blood pressure <90 mmHg or on high-
doses of vasopressors in presence of shock).
13

1.3.4. Patient requires continuous tube feedings that cannot be interrupted and patient
requires a medication known to bind to enteral nutrition formulas.
13

1.3.5. Patient with endocarditis, meningitis, brain abscess, orbital cellulitis, CNS infection,
osteomyelitis, or endophthalmitis that should be treated with intravenous antibiotic
therapy.
12


2. Enteral to parenteral
2.1. For a patient to be eligible for the enteral to parenteral interchange the medication must be
listed in Table 1 and the patient must meet one or more of the following clinical criteria.
2.2. Inclusion Criteria (Class 1, Level C)
2.2.1. Patient is unable to tolerate oral medications or has failed a swallow study and does
not have a feeding tube in place.
9

2.2.2. Patient has an acute condition that affects gastrointestinal absorption (i.e.,
gastrointestinal obstruction or bleed, severe diarrhea, ileus, severe vomiting or
grade III or IV mucositis).
13

2.2.3. Patient is nutritionally compromised and parenteral administration of medication is
clinically warranted to minimize the amount of time the enteral nutrition is interrupted
(e.g., phenytoin, fluoroquinolones, etc.).
13

2.2.4. Patient has had an NPO order for two days or more.
9

2.2.5. Patient requires continuous gastric suctioning.
13

2.3. Exclusion criteria
2.3.1. Acetaminophen, isavuconazole, posaconazole, and voriconazole cannot be
converted from enteral to parenteral formulation.

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7
3. Enteral to enteral (oral to feeding tube and feeding tube to oral)
3.1. Medication orders with an enteral route of administration are eligible for this interchange.
An initial medication order must be documented in the medical record to initiate the
interchange. The pharmacist will modify the medication order based on the below inclusion
criteria and evaluation of assessment criteria.
3.2. Assessment Criteria (Class 1, Level C)
3.2.1. Evaluation of available alternative dosage forms including an assessment of
formulation appropriateness and modification of dosage and/or frequency of product
if therapeutically warranted.
3.2.2. Assessment of drug pharmacokinetic parameters including the site of drug action,
bioavailability, absorption characteristics and the effects of food on drug absorption.
3.2.3. Evaluation of the type of feeding tube and placement location within the
gastrointestinal tract.
3.2.4. Assessment and modification of dosage and/or frequency if therapeutically
warranted (i.e., phenytoin capsules to phenytoin suspension). A pharmacist is also
permitted to modify an extended release product to an immediate release product if
listed in Appendix A, Table 2 (i.e., divalproex sodium to valproic acid solution).
3.3. Oral to Feeding Tube Inclusion Criteria (Class 1, Level C)
3.3.1. To qualify for the oral to enteral interchange an enteral feeding tube there must be
documentation of appropriate placement and approval for use
3.3.2. Extended Release to Immediate Release Product Inclusion Criteria (Class 1, Level
C)
3.3.2.1. A patient is currently ordered an extended release product and no longer
able to take medications by mouth and qualifies for conversion to
administration by feeding tube.
3.3.2.2. Extended release product for conversion is listed in Appendix A, Table 2.
3.4. Feeding Tube to Oral Inclusion Criteria (Class 1, Level C)
3.4.1. To initiate a feeding tube to oral interchange the patient must have passed a
swallow study as documented in the EMR.
3.4.2. Immediate Release to Extended Release Product Inclusion Criteria (Class 1, Level
C)
3.4.2.1. A patient who had previously been converted to immediate release product
from extended release product who now qualifies for feeding tube to oral
inclusion criteria (3.2.1).
3.4.2.2. Extended release product for conversion is listed in Appendix A, Table 2.

4. Documentation
4.1. Medication orders meeting the above criteria for the change in the route of administration
are subject to interchange as soon as the patient meets the established criteria.
4.2. Once a patient meets the criteria, the pharmacist will discontinue the current medication
order and automatically convert the medication to the appropriate corresponding dosage
form by placing an order in the EMR.
4.3. The pharmacist will document all protocol directed route interchanges in the electronic
health record.
UW Health Implementation
Potential Benefits/Harms:
Benefits of guideline implementation include decreased length of stay, decreased cost of medication
therapy, increased patient comfort, and decreased risk associated with intravenous administration of
medications.
Qualifying Statements
As new data becomes available for safety and efficacy of route administration of medications
recommendations may change.


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8
Implementation Plan/Tools
1. Guideline will be housed on U-Connect in a dedicated folder for CPGs.
2. Links to this guideline will be updated and/or added in appropriate Health Link or equivalent tools.

Disclaimer
CPGs are described to assist clinicians by providing a framework for the evaluation and treatment of
patients. This Clinical Practice Guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood that
some patients will not fit the clinical condition contemplated by a guideline and that a guideline will rarely
establish the only appropriate approach to a problem.
References:
1. Jacobs AK, Kushner FG, Ettinger SM, et al. ACCF/AHA clinical practice guideline methodology summit report: a
report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice
Guidelines. J Am Coll Cardiol. 2013;61(2):213-265.
2. Cyriac JM, James E. Switch over from intravenous to oral therapy: A concise overview. J Pharmacol
Pharmacother. 2014;5(2):83-87.
3. Berdot S, Gillaizeau F, Caruba T, Prognon P, Durieux P, Sabatier B. Drug administration errors in hospital
inpatients: a systematic review. PLoS One. 2013;8(6):e68856.
4. Kane-Gill SL, Kirisci L, Verrico MM, Rothschild JM. Analysis of risk factors for adverse drug events in critically ill
patients*. Crit Care Med. 2012;40(3):823-828.
5. Westbrook JI, Rob MI, Woods A, Parry D. Errors in the administration of intravenous medications in hospital and
the role of correct procedures and nurse experience. BMJ Qual Saf. 2011;20(12):1027-1034.
6. Vijayakumar A, Sharon EV, Teena J, Nobil S, Nazeer I. A clinical study on drug-related problems associated with
intravenous drug administration. J Basic Clin Pharm. 2014;5(2):49-53.
7. Jewesson P. Cost-effectiveness and value of an IV switch. Pharmacoeconomics. 1994;5(Suppl 2):20-26.
8. Parker SE, Davey PG. Pharmacoeconomics of intravenous drug administration. Pharmacoeconomics.
1992;1(2):103-115.
9. Fischer MA, Solomon DH, Teich JM, Avorn J. Conversion from intravenous to oral medications: assessment of a
computerized intervention for hospitalized patients. Arch Intern Med. 2003;163(21):2585-2589.
10. Mertz D, Koller M, Haller P, et al. Outcomes of early switching from intravenous to oral antibiotics on medical
wards. J Antimicrob Chemother. 2009;64(1):188-199.
11. Kuper KM. Intravenous to Oral Therapy Conversion. In. Murdaugh, ed. Competance Assessment Tools for
Health-System Pharmacies. 4th ed. Bethesda, MD: American Society of Health-System Pharamcits, Inc.; 2008:
347-360.
12. Przybylski KG, Rybak MJ, Martin PR, et al. A pharmacist-initiated program of intravenous to oral antibiotic
conversion. Pharmacotherapy. 1997;17(2):271-276.
13. Ramirez JA. Antibiotic streamlining: development and justification of an antibiotic streamlining program. Pharm
Pract Manag Q. 1996;16(3):19-34.
14. Lexicomp Online® , Lexi-Drugs® , Hudson, Ohio: Lexi-Comp, Inc.; Accessed August 21, 2015.
15. Ho BP, Lau TT, Balen RM, Naumann TL, Jewesson PJ. The impact of a pharmacist-managed dosage form
conversion service on ciprofloxacin usage at a major Canadian teaching hospital: a pre- and post-intervention
study. BMC Health Serv Res. 2005;5:48.
16. Dickerson RN, Maish GO, 3rd, Minard G, Brown RO. Clinical relevancy of the levothyroxine-continuous enteral
nutrition interaction. Nutr Clin Pract. 2010;25(6):646-652.
17. Fish LH, Schwartz HL, Cavanaugh J, Steffes MW, Bantle JP, Oppenheimer JH. Replacement dose, metabolism,
and bioavailability of levothyroxine in the treatment of hypothyroidism. Role of triiodothyronine in pituitary
feedback in humans. N Engl J Med. 1987;316(13):764-770.
18. Pisegna JR. Switching between intravenous and oral pantoprazole. J Clin Gastroenterol. 2001;32(1):27-32.


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9
Appendix A
Table 1. Medications Approved for Parenteral and Enteral Route Interchange
*See Lexi-Comp or Micromedex “Do not crush” list for applicability of crushing tablets.

Parenteral Regimen
Parenteral
Dose/Frequency
Oral Regimen Oral Dose/Frequency Notes
Acetaminophen*
14

*Do not convert from enteral to
parenteral without provider order.
1000 mg IV
Acetaminophen
1000 mg orally
1 to 1 dosing
650 mg IV 650 mg orally
325 mg IV 325 mg orally
Azithromycin
14

250 mg IV
Azithromycin
250 mg orally daily
1 to 1 dosing
500 mg IV 500 mg orally daily
Ciprofloxacin
2,11,15

200 mg IV every12h
Ciprofloxacin Tablet
250 mg orally twice daily
For administration via feeding tube
see Dosing of Medications with
Tube Feeding Administration

Do not administer suspension via a
feeding tube
400 mg IV every 12h 500 mg orally twice daily
400 mg IV every 8h
OR 600mg IV every 12h
750 mg orally twice daily
Dexamethasone
11

2 mg IV
Dexamethasone
2 mg orally
1 to 1 dosing
4 mg IV 4 mg orally
6 mg IV 6 mg orally
10 mg IV 10 mg orally
Doxycycline
2
100 mg IV Doxycycline 100 mg orally 1 to 1 dosing
Fosphenytoin
11

18-20 mg IV PE*/kg
(loading)
Phenytoin
18-20 mg/kg in 2-3 divided
doses orally
(given 2-4 hours apart use
suspension or chew tabs)
Round to nearest 100 mg & 30 mg
capsule strength when converting
to capsules. Round to nearest 25
mg for chew tab and 50 mg for
suspension.
For administration via feeding tube
see Dosing of Medications with
Tube Feeding Administration, Drug-
Food Interaction Guideline
and Fosphenytoin and Phenytoin
Guideline

4-6 mg IV PE*/kg/day

*PE - phenytoin equivalent
chew tabs/suspension: 4-6
mg/kg/day in 2 divided
doses
capsules: 1-2 divided
doses orally (once daily if
dose < 400 mg)

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10

Parenteral Regimen Parenteral Dose/Frequency Oral Regimen Oral Dose/Frequency Notes
Fluconazole
11

100 mg IV
Fluconazole
100 mg orally
1 to 1 dosing 200 mg IV 200 mg orally
400 mg IV 400 mg orally
Isavuconazole*
14

*Do not convert from enteral to
parenteral without provider order.
372 mg
(isavuconazole 200 mg)
every 8 h
Isavuconazole
372 mg
(isavuconazole 200 mg)
every 8 h
1 to 1 dosing
Lacosamide
14

50 mg IV
Lacosamide
50 mg orally
1 to 1 dosing
100 mg IV 100 mg orally
150 mg IV 150 mg orally
200 mg IV 200 mg orally
Levetiracetam
11
500-1500 mg IV Levetiracetam 500-1500 mg orally 1 to 1 dosing
Levofloxacin
14
500-750 mg IV once daily Levofloxacin 500-750 mg PO once daily
For administration via feeding tube
see Dosing of Medications with
Tube Feeding Administration and
Drug-Food Interaction Guideline

Levothyroxine
11,16,17

15 mcg/day IV
Levothyroxine
25 mcg orally daily
Parenteral dose should be approx.
80% of oral dose
16,17


For administration via feeding tube
see Dosing of Medications with
Tube Feeding Administration

35 mcg/day IV 50 mcg orally daily
50 mcg/day IV 75 mcg orally daily
75 mcg/day IV 100 mcg orally daily
85 mcg/day IV 125 mcg orally daily
100 mcg/day IV 150 mcg orally daily
125 mcg/day IV 175 mcg orally daily
150 mcg/day IV 200 mcg orally daily
Linezolid
11
600 mg IV Linezolid 600 mg orally 1 to 1 dosing
Metoclopramide
14
10 mg IV Metoclopramide 10 mg orally 1 to 1 dosing
Metronidazole
14
500 mg IV Metronidazole 500 mg orally 1 to 1 dosing
Methylprednisolone
14
4 mg IV Prednisone 5 mg orally
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11
Parenteral Regimen Parenteral Dose/Frequency Oral Regimen Oral Dose/Frequency Notes
Moxifloxacin
2
400 mg IV Moxifloxacin 400 mg orally
1 to 1 dosing
For administration via feeding tube
see Dosing of Medications with
Tube Feeding Administration

Mycophenolate mofetil
(CellCept)
Heart transplant patients
500 mg IV every 12h
Mycophenolate sodium
(Myfortic)
360 mg every 12h

1000 mg IV every 12h 720 mg every 12h
1500 mg IV q12h 1080 mg every 12h
Mycophenolate mofetil
(CellCept)
Kidney, liver, pancreas
transplant patients
250 mg IV every 12 h
Mycophenolate mofetil
generic
250 mg twice daily
When converting 1000 mg from IV
to enteral, base enteral dose on
home regimen or UW Health
transplant regimens.
500 mg IV every 12h 500 mg twice daily
750 mg IV every 12h 750 mg twice daily
1000mg IV every 12h 1000 mg 2-3 times daily
Mycophenolate mofetil
(CellCept)
Kidney, liver, pancreas
transplant patients
250 mg IV every 12 h
Mycophenolic acid

180 mg twice daily
When converting 1000 mg from IV
to enteral, base enteral dose on
home regimen or UW Health
transplant regimens.
500 mg IV every 12h 360 mg twice daily
750 mg IV every 12h 540 mg twice daily
1000 mg IV every 12h 720 mg 2-3 times daily
Pantoprazole
11,18
40 m IV Pantoprazole 40 mg orally 1 to 1 dosing
Phenobarbital
1-3 mg/kg/day IV (2 divided
doses)
Phenobarbital
1-3 mg/kg/day orally (1-2
divided doses)

Only maintenance dosage qualifies
for interchange.

Phenytoin
2,11

18-20 mg IV PE*/kg (loading)
Phenytoin
18-20 mg/kg in 2-3 divided
doses orally
Round to nearest 100 mg & 30 mg
capsule strength when converting
to capsules. Round to nearest 25
mg for chew tab and 50 mg for
suspension.
For administration via feeding tube
see For administration via feeding
tube see Dosing of Medications
with Tube Feeding Administration,
Drug-Food Interaction Guideline
and Fosphenytoin and Phenytoin
Guideline
4 – 6 mg/kg IV/day
chew tabs/suspension: 4-6
mg/kg/day in divided doses
capsules: 1-2 divided doses
orally (once daily if dose <
400 mg)
Posaconazole*
14

*Do not convert from enteral to
parenteral without provider
order.
300 mg IV daily Posaconazole
300 mg PO daily delayed-
release tablet
1 to 1 dosing

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12
Parenteral Regimen Parenteral Dose/Frequency Oral Regimen Oral Dose/Frequency Notes
Potassium Chloride 10 mEq - 40 mEq IV Potassium Chloride 10 mEq - 40 mEq orally
1 to 1 dosing
Convert to oral route only if patient
is asymptomatic and K ≥3.2 mmol/L
Doses ≥ 40 mEq should be given in
increments of 20mEq at 2 hour
intervals
See: Guideline for Use of Oral and
Enteral Electrolytes in Adults

Ranitidine
11
50 mg IV every 8h Ranitidine 150 mg orally twice daily
Rifampin 600 mg IV Rifampin 600 mg orally 1 to 1 dosing
Sulfamethoxazole-trimethoprim
320/1600 mg
Sulfamethoxazole-
trimethoprim
320/1600 mg
1 to 1 dosing
160/800 mg 160/800 mg
Valproic Acid
10-15mg/kg/day IV (divided
every 6 hr)
Divalproex
Valproic Acid solution
Immediate release 3-4x
orally daily; delayed
release 2-3 x orally daily;
10-15mg/kg/day
Round dose to nearest tablet
strength
Voriconazole*
2

*Do not convert from enteral to
parenteral without provider
order.
4 mg/kg IV every 12h
or
200-400 mg IV every 12
Voriconazole
4 mg/kg PO every 12h
(susp) or
200-400 PO every 12h
For administration via feeding tube
see Dosing of Medications with
Tube Feeding Administration
Round to the nearest tablet
strength using tablets


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



13
Table 2. Formulary Extended Release Medications Oral to Feeding Tube Interchange
See also non-formulary medications approved for formulary interchange

ER – extended release, IR – immediate release
ER Formulation Dose/Frequency IR Formulation Dose/Frequency Notes
Bupropion ER 150 – 400 mg/day Bupropion 50 -100 mg 3-4 times daily
1:1 daily dose conversion with
increased frequency
Carbamazepine ER
200 mg/day
Carbamazepine
200 mg/day in divided doses
Same total daily dosage divided
two to four times daily
400 mg/day 400 mg/day in divided doses
600 mg/day 600 mg/day in divided doses
800 mg/day 800 mg/day in divided doses
Carbidopa 25 /levodopa 100 ER

25/100 – 200/800 mg twice
daily
Carbidopa/levodopa 25/100
40/160 – 320/1280 mg/day in
divided doses
Convert dose based on levodopa
equivalents. Give 80% of the total
daily levodopa ER dose as
immediate release levodopa.
Divide calculated total daily dose
into 3 or four times daily dosing.
Round doses to the nearest 50
mg.
Diltiazem HCL ER 24hr
120 mg/day
Diltiazem
30 mg four times daily

180 mg/day 45 mg four times daily
240 mg/day 60 mg four times daily
300 mg/day 75 mg four times daily
Divalproex Sodium ER
500 mg/day
Valproic Acid Solution
500 mg/day in divided doses
Same total daily dosage divided
three times daily
1000mg/day 1000mg/day in divided doses
Isosorbide Mononitrate ER 30 mg/day Isosorbide Mononitrate 10 mg TID
Patient must have at least 12hr
nitrate free period
Metoprolol Succinate ER
25 mg/day
Metoprolol Tartrate
12.5 mg twice daily
Same total daily dosage
50 mg/day 25mg twice daily
100 mg/day 50 mg twice daily
200 mg/day 100 mg twice daily
Morphine Sulfate ER
90 mg/day
Morphine Sulfate
15 mg every 4 hr
Only listed doses may be
converted; all other doses require
physician order
180 mg/day 30 mg every 4 hr
270 mg/day 45 mg every 4 hr
Oxycodone ER
30 mg/day
Oxycodone
5 mg every 4 hr
Only listed doses may be
converted; all other doses require
prescriber order
60 mg/day 10 mg every 4 hr
90 mg/day 15 mg every 4 hr
Potassium Chloride ER
10 mEq
Potassium Chloride Solution
10 mEq
1:1 conversion at same frequency
20 mEq 20 mEq
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



14
ER Formulation Dose/Frequency IR Formulation Dose/Frequency Notes
Propranolol SR
60 mg/day
Propranolol
20 mg three times daily

80 mg/day 20 mg four times daily
120 mg/day 30-40 mg 3-4 times daily
160 mg/day 40 mg four times daily
Venlafaxine ER 75 – 225 mg/day Venlafaxine 37.5 – 75 mg 2-3 times daily 1:1 dose conversion
Verapamil HCL ER
120 mg/day
Verapamil
40 mg three times daily
180 mg/day 60 mg three times daily
240 mg/day 80 mg three times daily

Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org