Section 1: Gastro-Intestinal System

Section Description

BNF 1.1.1

Antacids and simeticone

BNF 1.1.2

Compound alginates and proprietary indigestion preparations

BNF 1.2

Antispasmodics and other drugs altering gut motility

BNF 1.3

Antisecretory drugs and mucosal protectants

BNF 1.3.1

H2-receptor antagonists

BNF 1.3.3

Chelates and complexes

BNF 1.3.4

Prostaglandin analogues

BNF 1.3.5

Proton pump inhibitors (PPIs)

BNF 1.4.1

Adsorbents and bulk-forming drugs

BNF 1.4.2

Antimotility drugs

BNF 1.5

Chronic bowel disorders

BNF 1.6

Laxatives

BNF 1.6.1

Bulk-forming laxatives

BNF 1.6.2

Stimulant laxatives

BNF 1.6.3

Faecal softeners

BNF 1.6.4

Osmotic laxatives

BNF 1.6.5

Bowel cleansing solutions

BNF 1.6.6

Peripheral and opioid-receptor antagonists

BNF 1.6.7

5HT4-receptor antagonists

BNF 1.7.1

Soothing haemorrhoidal preparations

BNF 1.7.2

Compound haemorrhoidal preparations with corticosteroids

BNF 1.7.4

Management of anal fissures

BNF 1.8

Stoma care

BNF 1.9.1

Drugs affecting biliary composition and flow

BNF 1.9.2

Bile acid sequestrants

BNF 1.9.4

Pancreatin

BNF 1.1.1 Antacids and simeticone

Preparations

Type of antacid

Sodium content

Sugar free

Notes

(Updated July 2011)

Magnesium trisilicate mixture

Magnesium

6mmol in 10ml

Yes

 

Mucogel® suspension

Aluminium + magnesium

<1mmol in 10ml

Yes

Mucogel® and Maalox® are identical. Mucogel® suspension is less expensive and should be prescribed in preference to Maalox® suspension. Generic prescription = co-magaldrox

Infacol® liquid

Simeticone

<1mmol in 10ml

Yes

Licensed for infantile colic (gripes and wind pains) but evidence of benefit is uncertain.

Antacid and oxetacaine suspension       Restricted/ Specialist Prescribing Only. Unlicensed equivalent to Mucaine® (no longer available) for radiotherapy/ oncology patients with swallowing difficulties.
Sodium citrate 0.3M solution

 

 

 

Restricted/ Specialist Prescribing Only. RWT Delivery suite guidelines

BNF 1.1.2 Compound alginates and proprietary indigestion preparations

Preparations

Sodium content

Sugar free

Notes (updated May 2014)

Gaviscon® infant sachets

0.92mmol / dose

Yes

ONE dose sachet per 100ml feed is a typical dose.

Peptac® liquid

3.1mmol in 5ml

Yes

Aniseed and peppermint flavours
Peptac® is identical to Gaviscon® but is 20% less expensive.

BNF 1.2 Antispasmodics and other drugs altering gut motility

Antimuscarinics

Dicycloverine HCI

Previously dicyclomine HCI. Expensive product, reserve for patients unable to tolerate other treatments

Kolanticon® gel

Sugar-free

Hyoscine butylbromide

(Buscopan®) For short-term relief of muscle spasm

Other Antispasmodics

Alverine citrate

 

Mebeverine hydrochloride

 

Peppermint oil 0.2ml gastro-resistant capsules (Mintec®)

Peppermint oil 0.2ml gastro-resistant modified release capsules (Colpermin®) contain peanut oil and are more expensive

Motility stimulants
Metoclopramide and domperidone (BNF section 4.6) are used in some patients with non-ulcer dyspepsia.

BNF 1.3 Ulcer-healing drugs

Helicobacter pylori eradication regimens for adults - Hospital

Helicobacter pylori eradication regimens for adults - Primary care

Helicobacter pylori eradication regimens for children – please see BNF for children for dosage recommendations by age range.

BNF 1.3.1 H2-receptor antagonists

Ranitidine

Fewer drug interactions than cimetidine. Less expensive than famotidine and nizatidine.

BNF 1.3.3 Chelates and complexes

Sucralfate

Tablets may be dispersed in water.

BNF 1.3.4 Prostaglandin analogues

Misoprostol

Contra-indicated in women of child-bearing age
Not recommended for children

BNF 1.3.5 Proton pump inhibitors (PPIs)

NICE Clinical Guideline CG184 (Dyspepsia – management of dyspepsia in adults in primary care) indicates:

For further details see NICE CG184

Gastro-oesophageal reflux disease : recognition, diagnosis and management in children and young people - NICE NG1

Proton pump inhibitor

Full/standard dose

Low dose (on demand dose)

Double dose

Additional information

Doses for dyspepsia, GORD, peptic ulcer disease

Lansoprazole capsules are less expensive than tablets. Omeprazole capsules are less expensive than tablets.
Dispersible tablets should be reserved for use in patients with extreme swallowing difficulties.

Lansoprazole

30mg once a day

15mg once a day

30mg twicea day

Omeprazole

20mg once a day

10mg once a day

40mg once a day

Pantoprazole

40mg once a day

20mg once a day

40mg twice a day

Doses for severe oesophagitis

Lansoprazole

30mg once a day

15mg once a day

30mg twice a day

Omeprazole

40mg once a day

20mg once a day

40mg twice a day

Pantoprazole

40mg once a day

20mg once a day

40mg twice a day

BNF 1.4.1 Adsorbents and bulk-forming drugs

Not recommended.

BNF 1.4.2 Antimotility drugs

Faecal incontinence: the management of faecal incontinence in adults – NICE CG49

Loperamide oral

Capsules cheaper than tablets

Do not prescribe loperamide or other antimotility agent if patient has received a course of antibiotics in the last 8 weeks - increased risk of C.diff infection.

Codeine phosphate oral

 

BNF 1.5 Chronic bowel disorders

Irritable bowel syndrome in adults: Diagnosis and management of irritable bowel syndrome in primary care - NICE CG61

BNF 1.5.1: AMINOSALICYLATES

Balsalazide

Only initiated by a specialist.

Mesalazine prescribed as branded product, Octasa®

Mesalazine to be prescribed as branded product in light of the concern expressed by Consultant Gastroenterologists regarding the inequivalence of generic products.

Sulfasalazine

Specify whether normal or enteric coated tablets are required.


BNF 1.5.2: CORTICOSTEROIDS

First Line

 

Hydrocortisone rectal foam

e.g. Colifoam®

Hydrocortisone oral

 

Prednisolone rectal preps

e.g. suppositories and enemas

Prednisolone oral

 

Second Line

 

Budesonide oral

 

 

BNF 1.5.3: Drugs affecting the immune response

Azathioprine oral

Prescribed and monitored within the guidance of a shared care agreement.

Methotrexate

Prescribed and monitored within the guidance of a shared care agreement.

Sulfasalazine oral

Prescribed and monitored within the guidance of a shared care agreement.

CYTOKINE INHIBITORS

 

Adalimumab (Humira®)

Restricted/ Specialist Prescribing Only

Crohn’s disease - NICE TA187

Ulcerative colitis - NICE TA329

Infliximab (Remicade®, Inflectra®, Remsima®)  

Restricted/ Specialist Prescribing Only

Crohn’s disease - NICE TA187

Ulcerative colitis - NICE TA163 and NICE TA329

Golimumab (Simponi®)

Restricted/ Specialist Prescribing Only

Ulcerative colitis - NICE TA329

Tofacitinib

Restricted/ Specialist Prescribing Only

Tof acitinib for treating moderately to severely active ulcerative colitis NICE TA457

Vedolizumab

Restricted/ Specialist Prescribing Only

Vedolizumab for treating moderately to severely active ulcerative colitis NICE TA342

Vedolizumab for treating moderately to severely active Crohn's disease after prior therapy NICE TA352

BNF 1.6 Laxatives

There is limited evidence comparing laxatives. The choice of agent should be made according to the nature of the constipation and patient preference. Some laxatives are more expensive than others. There is little to choose between the different agents. Patient acceptability and cost should influence the prescribing decision. [MeRec Bulletin Volume 10; Number 9, 1999]

Diagnosis and management of idiopathic childhood constipation in primary and secondary care NICE CG99

Laxative

Recommended doses

Macrogols

Polyethylene glycol 3350 + electrolytes

Disimpaction

Paediatric formula (Movicol Paediatric Plain®) U < 5 years

Under 1 year: ½ to 1 sachet daily**

1 – 5 years: 2 sachets on first day, then 4 sachets daily for 2 days, then 6 sachets daily for 2 days, then 8 sachets daily**

5 – 12 years: 4 sachets on first day, then increase in steps of 2 sachets daily to a maximum 12 sachets daily

Adult formula

12 – 18 years: 4 sachets on first day, increased in steps of 2 sachets daily.  Maximum 8 sachets daily**

Mix contents of sachets with water (see SPC for full prescribing information)

Maintenance

Under 1 year: ½ to 1 sachet daily** U < 2 years

1 – 6 years: 1 sachet daily: adjust dose to produce regular soft stools.  Maximum 4 sachets daily**

6 – 12 years: 2 sachets daily; adjust dose as above

12 – 18 years: 1 – 3 sachets daily usually for up to 2 weeks.  Maintenance: 1 – 2 sachets daily

Mix contents of sachets with water (see SPC for full prescribing information)

Stimulant laxative

Sodium picosulfate

Elixir (5mg/5ml) Dulcolax liquid®

1 month – 4 years: 2.5 – 10mg once a day**

4 – 18 years: 2.5 – 20mg once a day**

Perles® (1 capsule – 2.5mg) Dulcolax® U < 4 years

4 – 18 years: 2.5 – 20mg once a day**

 

Bisacodyl

Tablets (5mg) Dulcolax / generic:

4 – 18 years: 5 – 20mg once daily**

Suppository (10mg / paediatric 5mg) U < 4 years

2 – 18 years: 5 – 10mg once daily**

Senna

Syrup (7.5mg/5ml) U < 2 years

1 month – 4 years: 2.5 – 10ml once daily

4 – 18 years: 2.5 – 20ml once daily

Tablets (7.5mg)

6 – 18 years: 1 – 4 tablets once daily

Docusate sodium

Paediatric oral solution (12.5mg / 5ml)

6 months – 2 years: 12.5mg three times daily

2 – 12 years: 12.5 – 25mg 3 times daily

12 – 18 years: up to 500mg daily in divided doses

Osmotic laxative

Lactulose

1 month – 1 year: 2.5ml twice daily

1 – 5 years: 2.5 – 10ml twice daily**

5 – 18 years: 5 – 20ml twice daily

U – Unlicensed i.e. no UK marketing authorisation                       **Doses differ to BNF for children

 

BNF 1.6.1 Bulk-forming laxatives

ISPAGHULA

Fybogel®

These products are sugar and gluten-free

Isogel®

BNF 1.6.2 Stimulant laxatives

Bisacodyl

 

Docusate sodium

 

Glycerol suppositories

glycerine

Senna

 

Sodium picosulfate

 

DANTRON

ONLY licensed for the prophylaxis & treatment of analgesia-induced constipation, in terminally ill patients (of all ages). Danthron has limited indications because rodent studies indicate potential carcinogenic risk.

Co-danthramer 25/200 and other strengths

Co-danthrusate 50/60

BNF 1.6.3 Faecal softeners

Arachis Oil Enema

Restricted/ Specialist Prescribing Only

BNF 1.6.4 Osmotic laxatives

Lactulose

Lactulose should only be used in adults when less expensive laxatives have failed to produce an effect. It must be taken regularly for up to 3 days before an effect is seen. [MeReC Bulletin Volume 10; Number 9, 1999]. Product is sucrose-free.

Macrogols

Limited evidence suggests that Movicol® (polyethylene glycol + electrolytes) may offer slight advantages over lactulose. It is relatively expensive. Published studies comparing it with other agents are lacking. Its place in therapy is unclear.

Liquid Paraffin and Magnesium Hydroxide Oral Emulsion

Restricted / Specialist Prescribing Only: for short-term use by consultant gastroenterologists

 

Rectal Preparations

 

Phosphates

Cleen® Ready-to-use enema
Fletchers phosphate enema (standard)
Fletchers phosphate enema (long tube)

Sodium citrate

Relaxit® micro-enema

BNF 1.6.5 Bowel cleansing solutions

Oral Preparations

 

Picolax®

 

Fleet Phospho-soda®

 

Klean-Prep®

Initiation by the Paediatric team

Moviprep®

Restricted/ Specialist Prescribing Only

BNF 1.6.6 Peripheral opioid antagonists

Naloxegol

Naloxegol for treating opioid-induced constipation NICE TA345

BNF 1.6.7 5HT4-receptor antagonists

Linaclotide

For treating severe irritable bowel syndrome with constipation (IBS-C) in adults in line with NICE CG61 Addendum 2015

Lubiprostone

Lubiprostone for treating chronic idiopathic constipation NICE TA318

Prucalopride

2nd line - hospital Gastroentereology Consultants; primary care in line with MTRAC verdict and NICE TA211

BNF 1.7.1 Soothing haemorrhoidal preparations

Preparation

Contents

Preparation

Anusol®

Bismuth, Peru balsam & zinc oxide

Cream or suppositories

BNF 1.7.2 Compound haemorrhoidal preparations with corticosteroids

First Choice:

Xyloproct®

 

Alternatives:

Anusol HC®

 

Uniroid HC®

BNF 1.7.4 Management of anal fissures

Glyceryl trinitrate 0.4% rectal ointment

Diltiazem 2% cream (Anoheal®) use if intolerant to glyceryl trinitrate 0.4% rectal ointment

BNF 1.8 Stoma care

Please contact the stoma care nurses for advice on Royal Wolverhampton Trust extension 4084 or direct line 01902 694084.

BNF 1.9.1 Drugs affecting biliary composition and flow

Cholestasis in biliary atresia

Ursodeoxycholic acid – unlicensed use

Improvement in hepatic metabolism of essential fatty acids and bile flow, in children with cystic fibrosis

Ursodeoxycholic acid – unlicensed use

Cholestasis associated with TPN

Ursodeoxycholic acid – unlicensed use

Primary biliary cirrhosis

Ursodeoxycholic acid – only Ursofalk® brand licensed for this indication

Dissolution of radiolucent gallstones

Ursodeoxycholic acid

BNF 1.9.2 Bile acid sequestrants

Colestyramine (Cholestyramine)

Other drugs to be taken at least 1 hour before or 4-6 hours after colestyramine to reduce interference with absorption.

BNF 1.9.4 Pancreatin

Creon® preparations