Through its core work to review recorded patient safety events, the National Patient Safety Team identified a report of feeding tube blockage following administration of hydrocortisone granules.

The incident report described administration of soluble hydrocortisone granules, via a patient’s jejunal tube causing blockage; the tube had to be removed and reinserted.

Alkindi^® is a brand of hydrocortisone, presented as ‘granules in capsules for opening’. It is used in children when the body is not making enough cortisol due to the adrenal gland not working. The manufacturer’s information outlines that the granules are not suitable for giving through a nasogastric feeding tube as they may block the tube.

We communicated with the British National Formulary who revised information in the BNF and BNFC to specify that non-soluble granules of hydrocortisone should not be given via any feeding tube, as this may cause blockage.  We also liaised with the British Society for Paediatric Endocrinology and Diabetes who agreed to highlight these concerns to its members who care for children with adrenal insufficiency.

Publication reference: PRN01208