1: Gastrointestinal System
Approved: 1 Nov 2010. Last amended: 3 Dec 2020.
1.1 Dyspepsia and gastro-oesophageal reflux disease
1.1.1 Antacids and simeticone
prophylaxis of acid aspiration
Antacid & oxetacaine suspension (Mucaine® equivalent)
Post variceal banding, mucositis/oesophagitis secondary to chemotherapy/radiotherapy, Unlicenced. Usual dose 5-10ml 3-4 times a day (15 minutes before meals and at bedtime). Unlicenced. Usual dose 5-10ml 3-4 times a day (15 minutes before meals and at bedtime)
1.1.2 Compound alginates and proprietary indigestion preparations
sugar-free, but contains 3mmol sodium per 5ml
contain 2mmol sodium per tablet
Gaviscon® infant powder
contains 0.92 mmol sodium per dose
1.2 Antispasmodics and other drugs altering gut motility
1.2.2 Other antispasmodics
Peppermint oil capsules
IBS associated with bloating
1.3 Antisecretory drugs and mucosal protectants
1.3.1 H2-receptor antagonists
1.3.2 Selective antimuscarinics
1.3.3 Chelates and complexes
1.3.4 Prostaglandin analogues
1.3.5 Proton pump inhibitors
Treatment should be reviewed regularly
Pantoprazole or Rabeprazole
Patients intolerant of omeprazole or lansoprazole
Lansoprazole orodispersible tablets
Patients who are NBM or patients with swallowing difficulties/feeding tubes
- Endoscopically proven unhealed oesophagitis and with oesophagitis associated complications.
- Complicated gastroesophageal reflux disease (GORD) e.g. stricture
- Patients requiring maintenance doses of PPI should continue on the lowest dose that controls symptoms.
1.4 Acute diarrhoea
See BNF for oral rehydration preparations
1.4.1 Adsorbents and bulk-forming drugs
1.4.2 Antimotility drugs
can cause sedation and there is a risk of dependence with long-term use
1.4.3 Other drugs used in diarrhoea
Specialist initiation only: for treating IBS with diarrhoea in patients who have failed on a combination of antimotility agents, antispasmodics, and antidepressants. Patients must be reviewed at 4 weeks and treatment should be discontinued if ineffective / not-tolerated. NICE TA471
1.5 Chronic bowel disorders
Inflammatory bowel disease
- The Consultant Gastroenterologist should recommend the most appropriate drug and formulation for the patient
- Aminosalicylates should be prescribed by brand name
Octasa® MR 400mg, 800mg
Salofalk® 500mg, 1.5g, 3g
alternative mesalazine preparations may be prescribed if the first-line/recommended choices are clinically unsuitable
may be preferred if concurrent rheumatoid arthritis
Budenofalk® (budesonide) 3mg capsule
Crohn's disease when prednisolone unsuitable
Clipper® (beclometasone MR)
Specialist prescribing only for the treatment of acute flares of mild to moderate UC in patients who have a severe intolerance to systemic corticosteroids
1.5.3 Drugs affecting the immune response
Shared Care Guideline (intranet)
220.127.116.11 Cytokine modulators
- Ulcerative colitis. NICE TA329
- Ulcerative colitis NICE TA547
Laxative guideline: G-Care
1.6.1 Bulk-forming laxatives
There are limited indications for this type of laxative.
Ispaghula husk (Fybogel®)
1.6.2 Stimulant laxatives
Mainly acts as a faecal softener
- Terminally ill patients only
- Stimulant laxatives should be considered with opioids because bulk-forming and osmotic laxatives can result in faecal overloading and obstruction.
- Long-term use of stimulant laxatives is not advised due to the potential for damaging the large bowel and the loss of muscle tone in colon.
Chronic constipation where standard therapies (e.g. senna, bisacodyl, docusate and macrogols) and glycerol suppositories have failed.
1.6.3 Faecal softeners
Arachis oil enema
Severely impacted patients – contains peanut oil - use is contraindicated in patients with peanut allergy.
1.6.4 Osmotic Laxatives
Relaxit® Micro-enema (sodium citrate)
Fleet® Ready-to-use enema (phosphates)
1.6.5 Bowel cleansing preparations
(more expensive than the others)
For flexible sigmoidoscopy second-line to phosphate enema (at endoscopist's discretion)
1.6.6 Peripheral opioid-receptor antagonists
Opioid-induced constipation, resistant to usual laxative therapy. NICE TA651
Opioid-induced constipation, resistant to usual laxative therapy. NICE TA345
Opioid-induced constipation, resistant to usual laxative therapy (and where naloxegol has failed or is unsuitable) in patients receiving palliative care. Restricted to Palliative Care Team.
1.6.7 Other drugs used in constipation
Third-line for IBS-C in patients who have failed on a combination of laxatives and antispasmodics (first-line) and antidepressants (second-line). Patients must be reviewed at 4 weeks and treatment should be discontinued if ineffective / not-tolerated.
- As per NICE TA211
- Chronic constipation that has failed to respond to at least 2 laxatives from different classes at the highest tolerated doses for at least 6 months and where invasive treatment is being considered.
- Efficacy of prucalopride to be reviewed after 4 weeks and drug discontinued if ineffective.
1.7 Local preparations for anal and rectal disorders
1.7.1 Soothing haemorrhoidal preparations
cream and suppositories
1.7.2 Compound haemorrhoidal preparations with corticosteroids
ointment and suppositories
ointment and suppositories
1.7.3 Rectal sclerosants
Oily Phenol Injection
1.7.4 Management of anal fissures
Glyceryl Trinitrate 0.4% (Rectogesic®)
Diltiazem 2% cream (Unlicensed)
Usually applied sparingly BD. Second-line in patients who do not respond to glyceryl trinitrate 0.4% ointment
1.8 Stoma care
1.9 Drugs affecting intestinal secretions
1.9.1 Drugs affecting biliary composition and flow
Primary biliary cholangitis as per NICE TA443