CD&D Algorithm for the Management of Chronic Constipation available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/
CD&TV Guidance for Prescribing & Monitoring Post Bariatric Surgery
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
NICE NG129: Crohn’s disease: management
NICE NG130: Ulcerative colitis: management
NICE NG147: Diverticular disease: diagnosis and management
NICE NG172: COVID-19 rapid guideline: gastrointestinal and liver conditions treated with drugs affecting the immune response
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
CD&D Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/
NHS England Guidance on “Conditions for which over the counter items should not routinely be prescribed” available at: https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/
Prescribing of medicines available to purchase over the counter for self-care
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Sugar Free Suspension - 195/220
Brands include: Mucogel® & Maalox®
0.3 Molar Solution - used in obstetrics for prophylaxis of acid aspiration
Simeticone
Limited hospital only use in gastroenterology for use in endoscopy only
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
As colic eventually improves on its own, medical treatment isn’t usually recommended. There are some over-the counter treatments available that could be tried however; there is limited evidence for the effectiveness of these treatments.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
As colic eventually improves on its own, medical treatment isn’t usually recommended. There are some over-the counter treatments available that could be tried however; there is limited evidence for the effectiveness of these treatments.
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
oral solution 320microgram/ml (Sialanar)
Glycopyrronium bromide 320 microgram/ml has been approved for the treatment of severe sialorrhoea in children and adolescents with chronic neurological disorders. Only licensed glycopyrronium oral solution in chidlren. Tablets are not licensed in children and oral solution is more cost effective than using unlicensed tablets.
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
2g/50ml enema
Unlicensed
For radiation proctitis; bowel inflammation following radiotherapy
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.
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.
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)
Product stocked at STHFT can only be given as infusion
72 hour continuous infusion is an unlicensed indication. Only on advice of gastroenterology
40mg tablets
Only for use in grade 4 oesophagitis. After failure of full dose PPI
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.
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.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Capsules - 2mgOTC
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.
MHRA Drug Safety Alert (Sept 2017): Loperamide (Imodium): reports of serious cardiac adverse reactions with high doses of loperamide associated with abuse or misuse
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Not yet reviewed and as such should not be prescribed.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
There is currently insufficient clinical evidence to support prescribing of probiotics within the NHS for the treatment or prevention of diarrhoea of any cause. Both the Public Health England C.difficile guidance and NICE CG 84 recommend that probiotics cannot be recommended currently and that “Good quality randomised controlled trials should be conducted in the UK to evaluate the effectiveness and safety of a specific probiotic using clearly defined treatment regimens and outcome measures before they are routinely prescribed.
Octasa
400mg, 800mg, 1600mg 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
Salofalk
Tablets - 250mg, 500mg, 1g
Granules/sachet - 500mg, 1g, 1.5g, 3g - only to be used in patients with difficulty in swallowing
Suppositories - 500mg, 1g
Mezavant XL
Tablets - 1.2g
Asacol
Tablets - 400mg, 800mg - to be used for existing patients only
Enema - 1g
The delivery mechanisms of oral mesalazine may vary. These preparations should not be considered interchangeable.
9 mg, prolonged release tablets
Prescribe by brand name
Indicated in adults for induction of remission in patients with mild to moderate active ulcerative colitis (UC) where 5-ASA treatment is not sufficient.
(N.B. budenoside capsules are not licensed for this indication)
8 week course to be provided by secondary care.
CR Capsules - 3mg
Prescribe by brand name
Indications:
1mg orodispersible tablet
Prescribe by brand name
Treatment of eosinophilic oesophagitis in adults older than 18 years of age.
6 -12 week course to be provided by secondary care.
2mg per actuation white foam
Approved as 1st line corticosteroid rectal foam with prednisolone rectal foam as 2nd line.
Tablets - 1mg, 5mg
Rectal Foam - 20mg (Predfoam Rectal preparation not in use in STEES)
Retention Enema - 20mg
Suppositories - 5mg
Tablets
Not a cost-effective product
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Poor evidence base.
UKMI Q&A: Is there any evidence to support the use of enteric coated (EC)
over uncoated prednisolone tablets?
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Shared guidance for azathioprine, mercaptopurine and methotrexate can be found here:
Area Prescribing Committee website
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.
40mg in 0.8ml vials, pre-filled pens & disposable devices
NICE guidance: NICE TA187, NICE TA329
50mg tablets
CD&D Shared Care Guideline available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/transfer-of-prescribing-policies-shared-care-guidelines/
25mg, 50mg and 100mg capsules
Must be prescribed by brand name
CD&D Shared Care Guideline available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/transfer-of-prescribing-policies-shared-care-guidelines/
Initiation of IV ciclosporin must be on advice of Consultant Gastroenterologist
Not approved in accordance with the following NICE TAs:
100mg vials for intravenous infusion (Remicade®, Inflectra®▼ & Remsima®▼)
120 mg solution for injection in pre-filled syringe or pre-filled pen for subcutaneous injection (Remsima®▼)
Infliximab NICE guidance: NICE TA163, NICE TA140, NICE TA329, NICE TA187
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.
NTAG June 2020: The Northern (NHS) Treatment Advisory Group recommends Remsima SC® be available as additional treatment option during the COVID-19 pandemic for both licensed and off-label uses as part individual hospital Trust management strategies to reduce hospital day case admissions, and keep immunosuppressed people out of hospital during the COVID-19 pandemic. Remsima SC® could be considered as an option where the patient would otherwise get the intravenous Remsima® formulation of Infliximab. This recommendation is subject to any off-label use of Remsima SC® being considered and approved via individual hospital trust governance processes (including clinical governance) for the use of unlicensed/off-label drugs. It was also agreed that this recommendation would be reviewed after 12 months.
Must be prescribed by Brand.
50mg tabletsu - unlicensed indication
CD&D Shared Care Guideline available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/transfer-of-prescribing-policies-shared-care-guidelines/
Tees Shared Care Guideline: Shared care for Severe acute Crohn’s disease, maintenance of remission of Crohn’s disease or ulcerative colitis Gastroenterology Shared Care Guideline
2.5mg tablets - unlicensed indication
CD&D Shared Care Guideline available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/transfer-of-prescribing-policies-shared-care-guidelines/
MHRA Drug Safety Update (Sept 2020): Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
MHRA Drug Safety Update (Sept 2020): Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
MHRA Drug Safety Update (Sept 2020): Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
5mg tablets
Commissioner CCGs - adults
Approved for use in accordance with the following NICE TAs:
MHRA Drug Safety Update (May 2019): Tofacitinib (Xeljanz▼): restriction of 10 mg twice-daily dose in patients at high risk of pulmonary embolism while safety review is ongoing
MHRA Drug Safety Update (Mar 2020): Tofacitinib (Xeljanz▼): new measures to minimise risk of venous thromboembolism and of serious and fatal infections
45 mg solution for injection
90 mg solution for injection
45 mg solution for injection in pre-filled syringe
90 mg solution for injection in pre-filled syringe
Approved for use in accordance with the following NICE TAs:
300mg vial concentrate for IV infusion
108 mg solution for subcutaneous injection
NICE guidance: NICE TA342, NICE TA352
See algorithm for the management of chronic constipation
Capsules - 100mg
Oral Solution - 50mg/5ml, 12.5mg/5ml
Micro-enema - 120mg in 10g
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.
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.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
SolutionOTC
Hepatic encephalopathy and Paediatrics only. Initiated by a consultant
Laxido®
Movicol® (including Movicol Half and Movicol Paediatric Plain)
Enemas (sodium acid phosphate 12.8g + sodium phosphate
10.24g in 128ml)
For use as a laxative bowel preparation prior to clinical procedures such as colonoscopy. To be used instead of Klean Prep.
Dose 1 (mango flavour):
Macrogol (polyethylene glycol) 3350 100g plus electrolytes.
Dose 2 (fruit punch flavour):
Sachet A—macrogol (polyethylene glycol) 3350 40g plus electrolytes;
Sachet B—ascorbic acid 7.54g, sod. ascorbate 48.11g.
For bowel cleansing in adults (>18years of age) prior to any procedure requiring a clean bowel, bowel clesansing prior to Colonoscopy and also for CT Virtual Colonoscopy in those patients who cannot tolerate Moviprep.
For consultant prescribing only.
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.
200 micrograms film-coated tablets
Approved for use in accordance with the following NICE TAs:
Naldemedine is recommended, within its marketing authorisation, as an option for treating opioid-induced constipation in adults who have had laxative treatment.
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
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.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Proctofoam HC Rectal Foam
Hydrocortisone acetate 1.0% w/w Pramocaine hydrochloride 1.0% w/w
Proctosedyl Ointment 30g -Cinchocaine Hydrochloride (Micro) BP 0.5 %ww, Hydrocortisone (Micro) EP 0.5 %ww
Cinchocaine 0.5% / Prednisolone 0.19% ointment - 30g
Cinchocaine 1mg / Prednisolone hexanoate 1.3mg suppositories
Ointment - 0.4%
NICE evidence summary for unlicensed / off-label medicines:
ESUOM7 Chronic anal fissure: 0.2% topical glyceryl trinitrate ointment
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
Only to be used if Glyceryl trinitrate ointment fails
Use the most cost-effective product currently out of cream and ointment.
Ointment - 2% u
Initiation by specialist only (2nd line)
NICE evidence summary for unlicensed / off-label medicines:
ESUOM3: Chronic anal fissure: 2% topical diltiazem hydrochloride
Only to be used if Glyceryl trinitrate ointment fails
Use the most cost-effective product currently out of cream and ointment.
150mg tablets; 250mg tablets; 500mg tablets
250mg in 5ml sugar-free suspension
5 mg and 10mg film-coated tablets
For treating primary biliary cholangitis as per NICE TA443
MHRA Drug Safety Update (April 2018): Obeticholic acid (Ocaliva▼): risk of serious liver injury in patients with pre-existing moderate or severe hepatic impairment; reminder to adjust dosing according to liver function monitoring