BNF CHAPTER 1: GASTRO-INTESTINAL SYSTEM 1
ANTACIDS Maalox and Peptac are effective antacids that can be bought Over the Counter for self-limiting symptoms. Choice Product Cost Effective Options &Comments Co-Magaldrox 175mg//200mg/5ml Suspension Prescribe the brand Maalox Alginate Raft forming oral suspension or liquid Prescribe the brand Peptac (Compound Alginates) ANTISPASMODICS Choice Drug Cost Effective Options & Comments Mebeverine 135mg tablets Hyoscine Butylbromide tablets Colofac IBS is available OTC for self-limiting symptoms Buscopan Cramps is available OTC for self-limiting symptoms Note: Antispasmodics offer little benefit in irritable bowel syndrome and diverticular disease, where pain is a predominant symptom. 2
H 2 - RECEPTOR ANTAGONISTS Choice Drug Comments and Cost Effective Options Ranitidine Rantidine 75mg/5ml oral solution is a licensed cost effective option for patients with swallowing difficulties or a fitted PEF/NG tube. Dose should be optimised for liquid doses where applicable. Ranitidine 5mg/5ml oral suspension(unlicensed) is more cost effective than the 5mg/5ml solution Avoid prescribing Zantac Relief, Gavilast 75mg and Ranitidine 75mg which are available OTC for self-limiting symptoms. PROTON PUMP INHIBITORS Choice Drug Cost Effective Options & Comments Omeprazole caps or Lansoprazole caps Dispersible versions should be prescribed for patients with swallowing difficulties or those with a PEG or NG tube. Omeprazole 10mg/5ml and 20mg/5ml are unlicensed formulations Omeprazole 10mg (cap/tab) is available OTC for self-limiting conditions Pantoprazole tablets Note: For Barrett s esophagus and other disease complicated by stricture, recurrent ulceration or hemorrhage, full dose should be maintained. 3
ANTI-DIARRHOEAL DRUGS Choice Drug Cost Effective Options & Comments Loperamide 2mg capsules Codeine Phosphate 30mg or 60mg tablets Prescribe Loperamide 1mg/5ml oral solution S/F for patients with swallowing difficulties or those fitted with a PEG or NG tube Loperamide is available OTC as generic and Imodium formulations for self-limiting conditions Avoid prescribing Imodium melts as not a cost effective option. Codeine 25mg/5ml oral solution can be prescribed for patients with swallowing difficulties or those fitted with a PEG or NG tube. Drug therapy should be avoided in acute diarrhoea, particularly in the young and elderly. Consider Clostridium difficile Infection (CDI). Has the patient been in hospital recently? CDI affects the elderly, the debilitated and patients who have had antibiotic treatment. Antimotility drugs should not be prescribed in acute CDI, and a stool specimen should be considered. Ref: " CDI: How to deal with the problem" (HPA -DH - Jan-09) Fluid replacement is of the essence. AMINOGLYCOSATES Choice Drug Cost Effective Options and Comments There is no evidence to show that any one oral preparation of Mesalazine is more effective than another; however, the delivery characteristics of oral Mesalazine preparations may vary. Mesalazine MR 400mg Octasa MR 400mg tablets Patients with swallowing difficulties or fitted with a PEG or NG tube should be prescribed Asacol suppositories Other dose dependent options are Salofalk and Pentasa granules. 4
BULK-FORMING LAXATIVES Choice Drug Cost Effective options Ispaghula Husk Methylcellulose tablets One sachet is equivalent to 2 level 5ml spoonsful Isphaghula is available OTC as Fybogel and other generic forms for self-limiting symptoms Celevac is available OTC for self limiting symptoms OSMOTIC LAXATIVES Choice Product Cost Effective Options Macrogol oral compound powder Lactulose Solution Prescribe the brand Laxido (Paediatric & Adult ) Macrogol other branded generic brands are available OTC for self-limiting symptoms. Avoid prescribing the sachets Not recommended for use in inflammatory bowel disease Lactulose and other generic brands are available OTC for self-limiting symptoms 5
STIMULANT LAXATIVES Choice Product Cost Effective Options Bisacodyl Prescribe Generic.Available OTC for self limiting symptoms Senna 7.5mg.Available OTC for self-limiting symptoms Avoid prescribing Senna 15mg Prescribe Senna 7.5mg/5ml for patients with swallowing difficulties or fitted with a PEG or NG tube should be prescribed. RECTAL OPTIONS Choice Product Cost Effective Options & Comments Glycerol 4g suppositories Bisacodyl 5mg/10mg suppositories OR Docusate 120mg enema Third Sodium Citrate Relaxit Micro-Enema 6
Choice Product Cost Effective Options & Comments Lubiprostone 24mg NICE TA 318 For consideration, if at least two laxatives from different classes have been tried at the highest tolerated recommended doses for at least 6 months, and failed to relieve symptoms, where invasive treatment (such as suppositories, enemas, rectal irrigation and/or manual disimpaction) is being considered. Should only be prescribed in line with NICE guidelines Other drugs Linaclotide Naloxegol NICE TA345 (2105) HOSPITAL ONLY Co-Danthramer If treatment is not effective after 2 weeks, the person should be re-examined and the benefit of continuing treatment reconsidered. for the symptomatic treatment of moderate-to-severe irritable bowel syndrome with constipation (IBS-C) in adults Only for opioid induced constipation where response to other laxatives is inadequate. 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. Should only be prescribed in line with NICE guidelines Licensed for constipation in terminally ill patients. Available as suspension 7
PREPARATIONS FOR ACUTE HAEMORRHOIDS Choice Product Cost Effective Options & Comments Zinc oxide 10.75% + bismuth oxide 2.14% + balsam peru 1.8% Hydrocortisone 0.5% + zinc oxide 12.35% + Peru balsam 1.85% + benzyl benzoate 1.2% + Bismuth oxide 0.875% Hydrocortisone / Cinchocaine 5mg /5mg Prescribe as Anusol cream. Available over the counter. Prescribe as Anusol HC cream. Available over the counter as Anusol Plus Ointment Uniroid HC Ointment Uniroid HC Suppositories BNF 1.7.4 MANAGEMENT OF CHRONIC ANAL FISSURES (Present for > 6 weeks) Choice Product Cost Effective Options Glyceryl trinitrate 0.4% Rectal ointment Diltiazem 2% ointment (unlicensed) Diltiazem Ointment is the most cost effective option as it currently costs less than 50% compared to the cream Rectogesic is the only licensed product currently available in the UK Diltiazem ointment acts as a smooth muscle relaxant. The Association of Coloproctology of Great Britain and Ireland states a preference for topical diltiazem over GTN as it has similar efficacy to Glyceryl Trinitrate but a lower incidence of side effects. It is not recommended for long term use. Typical duration of use 6-8 weeks. 8
NAUSEA AND VOMITTING Choice Product Cost Effective Options Prochloperazine tablets Caution: can cause extrapyramidal side effects. Increased risk of drug-induced parkinsonism in the elderly particularly after prolonged use Domperidone or Metoclopramide Domperidone caution: risk of cardiac side effects. Use restricted to nausea and vomiting only. The maximum treatment duration should not usually exceed one week. - MHRA 2014 Metoclopramide caution: Risk of neurological adverse effects. Treatment with metoclopramide should not be prescribed for longer than 5 days. MHRA 2013 TRANS ANAL IRRIGATION APPLIANCES: NICE recently approved the use of Trans anal irrigation kits for bowel dysfunction and should be offered as part of a supportive bowel care programme. Trans Anal Irrigation Products currently available on prescription. Table below is based on daily irrigation PS: IryPump S cones are re-usable and last up to 3 months with every day use 9
Product Name Cost of System Features How often is this replaced? Cost of Catheters based on daily usage How often is this replaced? Other consumables e.g. bags tubes (Misc) Cost Y1 Cost Y2 Cost Y3 Total Estimated Costs IryPump S 498.76 Electric 3-4years 61.19 Every 3 Water bags tubes 744 245 245 1,234.00 Set months Peristeen 76.90 Manual 3 months 270.00 monthly Water bags tubes 3547 3547 3547 10,641.00 Qufora 99.00 Manual +15 catheters Qufora 101.66 Manual + 15 cones Navina 300.92 Electric+ monthly 15 extra req. 115 monthly 15 extra req. cones 59 18-24 260 for 30 Smart 2 cones months cones Aquaflush 35.00 Manual monthly 118 for 30 cones monthly Water bags tubes 2568 2568 2568 7,704.00 Monthly Water bags tubes 1928 1928 1928 5,784.00 Monthly Water bags tubes 3420 3120 3420 10,260.00 monthly Water bags tubes 1836 1836 1836 5,508.00 Formulary Chapter 1 Gastro-intestinal system Date ratified by D&T Committee April 2013 Next Review Date April 2015 1 st Amendment NICE TAG recommendations Reference to self-limiting conditions and OTC options Date ratified by D&T Committee October 2018 Next Review Date October2020 10