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1. Gastro-Intestinal System

NICE CG184: Dyspepsia and gastro‑oesophageal reflux disease: Investigation and management of dyspepsia, symptoms suggestive of gastro‑oesophageal reflux disease, or both

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

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

CD&D APC Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

CD&D APC “Do Not Prescribe List” and “Grey List – drugs prescribed under limited circumstances” available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

CD&D Algorithm for the Management of Chronic Constipation available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

Co-magaldrox
BNF | BNFC | SPC

Sugar Free Suspension - 195/220

Brands include: Mucogel® & Maalox®

Sodium Citrate Solution
BNF | BNFC | SPC

0.3 Molar Solution - used in obstetrics for prophylaxis of acid aspiration

Infacol
BNF | BNFC | SPC
Colief
BNF | BNFC | SPC
Co-simalcite
BNF | BNFC | SPC

Sugar Free Suspension - 125/500

Brand: Altacite Plus®

 

Peptac
BNF | BNFC | SPC

Sugar Free Suspension

Use instead of Gaviscon

Gaviscon Infant
BNF | BNFC | SPC

Oral Powder

N.B. Each half of the dual-sachet is identified as ‘one dose'. To avoid errors prescribe as ‘dual-sachet' with directions in terms of ‘dose'.

Dicyloverine
BNF | BNFC | SPC

Tablets - 10mg

Syrup - 10mg/5ml

Hyoscine Butylbromide
BNF | BNFC | SPC

Tablets - 10mg

Injection - 20mg/ml

Hyoscine Butylbromide is first choice if injection needed (Hyoscine butylbromide tablets are poorly absorbed)

MHRA Drug Safety Update (Feb 2017): Hyoscine butylbromide (Buscopan) injection: risk of serious adverse effects in patients with underlying cardiac disease

Alverine Citrate
BNF | BNFC | SPC

Capsules - 60mg

Mebeverine
BNF | BNFC | SPC

Tablets - 135mg 

Sugar-free liquid - 50mg in 5ml

Peppermint Oil
BNF | BNFC | SPC

E/C Capsules - 0.2ml

Metoclopramide
BNF | BNFC | SPC

Tablets - 10mg

Oral Solution - 5mg/5ml

Injection - 10mg/2ml

*N.B. Unlicensed Indication*

Do not use in people under 20 years

MHRA Drug Safety Update (Aug 2013):  restricted dose and duration

Ranitidine
BNF | BNFC | SPC

Tablets - 150mg, 300mg 

Oral Solution - 75mg/5ml 

Cimetidine
BNF | BNFC | SPC

Tabs - 200mg, 400mg, 800mg

Oral Solution - 200mg/5ml

 

Sucralfate
BNF | BNFC | SPC

Tablets - 1g 

Suspension - 1g/5ml 

Misoprostol
BNF | BNFC | SPC

Tablets - 200microgram 

Proton pump inhibitors are usually preferred for the prevention of gastro-intestinal bleeding (better tolerated). Most hospital use of misoprostol is for the induction of labour or termination of pregnancy (unlicensed indications).

Lansoprazole
BNF | BNFC | SPC

Capsules - 15mg, 30mg 

Orodispersible Tablets - 15mg, 30mg 

N.B. The orodispersible tablets should only be used in patients who cannot swallow capsules or tablets and for NG/PEG/PEJ use.

Omeprazole
BNF | BNFC | SPC

Capsules - 20mg 

Orodispersible tablets (MUPS) - 10mg, 20mg & 40mg 

Dosage form restriction: do NOT use tablets. Avoid 40mg strength capsules (use 2x20mg). Omeprazole orodispersible (MUPs) tablets should only be used in patients who cannot swallow capsules or tablets AND where lansoprazole orodispersible tablets are unsuitable.

Omeprazole IV
BNF | BNFC | SPC

40mg IV Infusion
40mg Injection (powder for reconstitution)

Drug protocol: IV Omeprazole loading dose (CDDFT intranet access only)

Drug protocol: Omeprazole continuous infusion protocol for adult inpatients (CDDFT intranet access only)

 

First Choice Regimen = Lansoprazole 30mg (or omeprazole 20mg), clarithromycin 500mg & amoxicillin 1g all twice daily for 7 days


Note: metronidazole 400mg bd, clarithromycin 250mg bd & lansoprazole 1g bd should be used nstead of amoxicillin in patients who are allergic to penicillins.

Loperamide
BNF | BNFC | SPC

Capsules - 2mg 

Syrup - 1mg/5ml 

Loperamide capsules should be used in preference to tablets

Use of loperamide should be avoided in diarrhoea of infective origin until the infecting organism is known. Inappropriate use, particularly in Clostridium difficile diarrhoea, may result in development of toxic megacolon.

Codeine Phosphate
BNF | BNFC | SPC

Tablets - 15mg, 30mg & 60mg

Kaolin and Morphine
BNF | BNFC | SPC
Eluxadoline▼
BNF | BNFC | SPC

NTAG Sept 2016:  The Northern (NHS) Treatment Advisory Group does not recommend the use of eluxadoline for the treatment of diarrhoea dominant IBS.

Adsorbents such as Kaolin are not recommended for acute diarrhoea. Bulk-forming drugs such as methylcellulose and ispaghula (section 1.6.1) are useful in controlling faecal consistency in colostomy and ileostomy, and in controlling diarrhoea associated with diverticular disease.

Kaolin
BNF | BNFC | SPC

Not yet reviewed and as such should not be prescribed.

Mesalazine
BNF | BNFC | SPC

Asacol

Tablets - 400mg, 800mg

Enema - 1g 

Suppositories - 500mg 

Octasa

400mg e/c m/r tablets

Pentasa

Tablets - 500mg, 1g

Enema - 1g 

Suppositories - 1g 

1g m/r granules/ sachet

MR Granules / sachet are only to be used in patients with difficulty in swallowing

Mezavant XL

Tablets - 1.2g 

The delivery mechanisms of oral mesalazine may vary. These preparations should not be considered interchangeable.

Balsalazide
BNF | BNFC | SPC

Capsules - 750mg 

Sulfasalazine
BNF | BNFC | SPC

Tablets, EC Tablets - 500mg 

Suspension - 250mg/5ml 

Prednisolone
BNF | BNFC | SPC

Tablets - 1mg, 5mg 

Rectal Foam - 20mg 

Retention Enema - 20mg 

Suppositories - 5mg 

Budesonide
BNF | BNFC | SPC

CR Capsules - 3mg 

 

Hydrocortisone
BNF | BNFC | SPC

Foam - 10% 

Prednisolone 30mg
BNF | BNFC | SPC

Tablets

Shared guidance for azathioprine, mercaptopurine and methotrexate can be found here:

Area Prescribing Committee website

CDDFT Intranet Link

NTAG Nov 2014: The Northern (NHS) Treatment Advisory Group does not recommend the use of biologic drugs for treatment refractory moderate to severely active ulcerative colitis in younger patients to avoid colectomy.

Azathioprine
BNF | BNFC | SPC

50mg tablets

Mercaptopurine
BNF | BNFC | SPC

50mg tabletsu  - unlicensed indication

Methotrexate
BNF | BNFC | SPC

2.5mg tablets - unlicensed indication

Adalimumab
BNF | BNFC | SPC

40mg in 0.8ml vials, pre-filled pens & disposable devices

NICE guidance: NICE TA329

Golimumab
BNF | BNFC | SPC

50mg injection (prefilled pen & syringe)

NICE guidance: NICE TA329

Infliximab
BNF | BNFC | SPC

100mg vials for intravenous infusion (Remicade®, Inflectra®▼ & Remsima®▼)

Infliximab NICE guidance: NICE TA163, NICE TA140, NICE TA329

NTAG September 2015: The Northern (NHS) Treatment Advisory Group recommends the use of infliximab biosimilars as an option where the originator product (Remicade®) would normally be prescribed.

Vedolizumab▼
BNF | BNFC | SPC

300mg vial concentrate for IV infusion

NICE guidance: NICE TA342, NICE TA352

See algorithm for the management of chronic constipation

CDDFT intranet link

Ispaghula Husk
BNF | BNFC | SPC

Sachets

Methycellulose
BNF | BNFC | SPC

Tablets - 500mg

Senna
BNF | BNFC | SPC

Tablets - 7.5mg

Syrup - 7.5mg/5ml

Docusate Sodium
BNF | BNFC | SPC

Capsules - 100mg 

Oral Solution - 50mg/5ml, 12.5mg/5ml 

Micro-enema - 120mg in 10g 

Bisacodyl
BNF | BNFC | SPC

EC Tablets - 5mg 

Suppositories - 5mg, 10mg 

Glycerol
BNF | BNFC | SPC

Suppositories  - 1g, 2g, 4g  

Co-danthramer
BNF | BNFC | SPC

25/200 suspension, 25/200 capsules (25mg Dantron &
200mg Poloxamer ‘188’ per 5ml/capsule)
37.5/500 strong capsules (37.5mg Dantron & 500mg
Poloxamer ‘188’)
75/1,000 strong suspension (75mg Dantron & 1g
Poloxamer ‘188’ in 5ml)

N.B. Co-danthramer and Co-danthrusate are generally restricted to use in the treatment of constipation in terminally ill patients. A combination of Senna and Docusate is normally preferred.

Co-danthrusate
BNF | BNFC | SPC

50/60 capsules (50mg Dantron & 60mg Docusate sodium)

N.B. Co-danthramer and Co-danthrusate are generally restricted to use in the treatment of constipation in terminally ill patients. A combination of Senna and Docusate is normally preferred.

Arachis Oil
BNF | BNFC | SPC

Single Dose Enemas - 130ml 

Liquid Paraffin Oral Emulsion
BNF | BNFC | SPC
Liquid Paraffin with magnesium hydroxide
BNF | BNFC | SPC
Lactulose
BNF | BNFC | SPC

Solution

Hepatic encephalopathy and Paediatrics only. Initiated by a consultant

Macrogols
BNF | BNFC | SPC

Laxido®

Movicol® (including Movicol Half  and Movicol Paediatric Plain)                       

 

Phosphate Enema
BNF | BNFC | SPC

Enemas (sodium acid phosphate 12.8g + sodium phosphate
10.24g in 128ml)

Sodium Citrate Micro-enemas
BNF | BNFC | SPC

5ml micro-enemas (sodium citrate 450mg together with a
surfactant, glycerol & sorbitol)

Naloxegol▼
BNF | BNFC | SPC

Film Coated Tablets - 12.5mg &  25mg 

Naloxegol: to be used on the advice of a specialist only in line with NICE TA345.  Naloxegol is recommended, within its marketing authorisation, as an option for treating opioid induced constipation in adults whose constipation has not adequately responded to laxatives. An inadequate response is defined as opioid‑induced constipation symptoms of at least moderate severity in at least 1 of the 4 stool symptom domains (that is, incomplete bowel movement, hard stools, straining or false alarms) while taking at least 1 laxative class for at least 4 days during the prior 2 weeks.

 

Prucalopride
BNF | BNFC | SPC

Tablets - 1mg, 2mg 

Prucalopride: approved for use in the symptomatic treatment of chronic constipation in women whom laxatives fail to provide adequate relief. For use in accordance with NICE TA211.

See algorithm for the management of chronic constipation

CDDFT intranet link

 

Lubiprostone▼
BNF | BNFC | SPC

Capsules - 24microgram 

Lubiprostone: to be used in line with NICE TA318.  It should be recommended by a specialist with experience of treating chronic idiopathic constipation (e.g. consultant gastroenterologist or through a specialist constipation clinic).  Prescribing should be done by the GP following recommendation and GP should assess symptoms after 2 weeks and stop if not effective.

 

Linaclotide▼
BNF | BNFC | SPC

290 microgram capsules

Linaclotide: approved for use in IBS with constipation within licensed indications. It should be recommended by a consultant gastroenterologist or through a specialist constipation clinic. Prescribing should be done by the GP following recommendation and GP should assess symptoms after 4 weeks and stop if not effective.

Picolax
BNF | BNFC | SPC
Moviprep
BNF | BNFC | SPC

For use as a laxative bowel preparation prior to clinical procedures such as colonoscopy. To be used instead of Klean Prep.

Klean Prep
BNF | BNFC | SPC
Fleet Phospho-Soda
BNF | BNFC | SPC
Xyloproct
BNF | BNFC | SPC

Ointment  

Ointment containing lidocaine 5%, hydrocortisone acetate 0.275%, aluminium acetate 3.5% & zinc oxide 18% Recommended for short-term use only

Anusol HC
BNF | BNFC | SPC

Ointment

Suppositories

Glyceryl Trinitrate
BNF | BNFC | SPC

Ointment - 0.4%  

NICE evidence summary for unlicensed / off-label medicines:

ESUOM7 Chronic anal fissure: 0.2% topical glyceryl trinitrate ointment

Diltiazem cream
BNF | BNFC | SPC

Cream - 2% u

Initiation by specialist only (2nd line)

NICE evidence summary for unlicensed / off-label medicines:

ESUOM3: Chronic anal fissure: 2% topical diltiazem hydrochloride

Ursodeoxycholic acid
BNF | BNFC | SPC

150mg tablets; 250mg tablets; 500mg tablets
250mg in 5ml sugar-free suspension

Obeticholic Acid▼
BNF | BNFC | SPC

5 mg and 10mg film-coated tablets

For treating primary biliary cholangitis as per NICE TA443

Colestyramine
BNF | BNFC | SPC

4g sachets
4g sugar-free sachets

Creon
BNF | BNFC | SPC

5,000, 10,000 & 25,000 & 40,000 capsules
(10,000, 25,000 and 40,000 units lipase activity)