1: Gastrointestinal System
Approved: 1 Nov 2010. Last amended: 3 Dec 2020.
On this page
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Dyspepsia and gastro-oesophageal reflux disease
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Antispasmodics and other drugs altering gut motility
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Antisecretory drugs and mucosal protectants
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Acute diarrhoea
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Chronic bowel disorders
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Laxatives
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Local preparations for anal and rectal disorders
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Stoma care
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Drugs affecting intestinal secretions
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Miscellaneous
1.1 Dyspepsia and gastro-oesophageal reflux disease
1.1.1 Antacids and simeticone
Recommended
Magnesium trisilicate
mixture
Specific Indication
Sodium citrate
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
Recommended
Peptac® liquid
sugar-free, but contains 3mmol sodium per 5ml
Gaviscon® tablets
contain 2mmol sodium per tablet
Gaviscon® infant powder
contains 0.92 mmol sodium per dose
1.2 Antispasmodics and other drugs altering gut motility
1.2.1 Antimuscarinics
Recommended
Hyoscine butylbromide
1.2.2 Other antispasmodics
Recommended
Mebeverine 135mg
tablets
Specific Indication
Peppermint oil capsules
IBS associated with bloating
1.3 Antisecretory drugs and mucosal protectants
Helicobacter pylori (H. pylori) eradication click here
1.3.1 H2-receptor antagonists
Recommended
Ranitidine
1.3.2 Selective antimuscarinics
none
1.3.3 Chelates and complexes
Recommended
Sucralfate
1.3.4 Prostaglandin analogues
Not recommended.
1.3.5 Proton pump inhibitors
Treatment should be reviewed regularly
GHNHSFT Treatment Guideline: Oral PPIs
GHNHSFT Treatment Guideline: Intravenous PPIs
GHNHSFT Treatment Guideline: Clopidogrel / PPI interaction
Recommended
Omeprazole
capsules
Alternative
Lansoprazole
capsules
Specific Indication
Pantoprazole or Rabeprazole
Patients intolerant of omeprazole or lansoprazole
Lansoprazole orodispersible tablets
Patients who are NBM or patients with swallowing difficulties/feeding tubes
Esomeprazole
- 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
none
1.4.2 Antimotility drugs
Recommended
Loperamide
Alternative
Codeine
can cause sedation and there is a risk of dependence with long-term use
1.4.3 Other drugs used in diarrhoea
Specific Indication
Eluxadoline
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
1.5.1 Aminosalicylates
- The Consultant Gastroenterologist should recommend the most appropriate drug and formulation for the patient
- Aminosalicylates should be prescribed by brand name
Recommended
Mesalazine (oral)
Octasa® MR 400mg, 800mg
tablets
Salofalk® 500mg, 1.5g, 3g
granules
Mesalazine (rectal)
Salofalk® 1g
suppositories
Salofalk® 2g
enemas
Alternative
Balsalazide
Mesalazine
alternative mesalazine preparations may be prescribed if the first-line/recommended choices are clinically unsuitable
Olsalazine
Sulfasalazine
may be preferred if concurrent rheumatoid arthritis
1.5.2 Corticosteroids
1.5.2.1 Oral
Recommended
Prednisolone 5mg
tablet
Specific Indication
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
1.5.2.2 Rectal
Prednisolone 5mg
suppository
Prednisolone
liquid enema
Budenofalk® (budesonide)
foam enema
1.5.2.3 Parenteral
Hydrocortisone
1.5.3 Drugs affecting the immune response
Azathioprine
Ciclosporin
Mercaptopurine
Shared Care Guideline (intranet)
Methotrexate
1.5.3.1 Cytokine modulators
Specific Indication
Adalimumab
- Crohn's disease. NICE TA187
- Ulcerative colitis. NICE TA329
Golimumab
- Ulcerative colitis. NICE TA329
Infliximab
- Crohn’s disease. NICE TA187
- Ulcerative colitis. NICE TA163, NICE TA329
Tofacitinib
- Ulcerative colitis NICE TA547
Ustekinumab
- Crohn’s disease. NICE TA456
- Ulcerative colitis. NICE TA633
Vedolizumab
- Ulcerative colitis. NICE TA342
- Crohn's disease. NICE TA352
1.6 Laxatives
GHNHSFT Local Guideline: Laxatives
Laxative guideline: G-Care
1.6.1 Bulk-forming laxatives
There are limited indications for this type of laxative.
Recommended
Ispaghula husk (Fybogel®)
Alternative
Sterculia (Normacol®)
1.6.2 Stimulant laxatives
Recommended
Bisacodyl
Senna
Alternative
Docusate sodium
Mainly acts as a faecal softener
Glycerol (glycerin)
suppostitories
Specific Indication
Co-danthramer
- 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.
Lecicarbon® suppositories
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
Recommended
Magnesium sulphate
(Epsom Salts)
Alternative
Macrogols
(Laxido®)
Specific Indication
Lactulose
Hepatic encephalopathy
Relaxit® Micro-enema (sodium citrate)
Fleet® Ready-to-use enema (phosphates)
1.6.5 Bowel cleansing preparations
Recommended
Citramag®
Fleet Phospho-soda®
Citrafleet®/Picolax®
Alternative
Klean-Prep®
(more expensive than the others)
Lecicarbon® suppositories
For flexible sigmoidoscopy second-line to phosphate enema (at endoscopist's discretion)
1.6.6 Peripheral opioid-receptor antagonists
Specific Indication
Naldemedine
Opioid-induced constipation, resistant to usual laxative therapy. NICE TA651
Naloxegol
Opioid-induced constipation, resistant to usual laxative therapy. NICE TA345
Methylnaltrexone
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
Specific Indication
Linaclotide
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.
Prucalopride
- 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
Anusol®
cream and suppositories
1.7.2 Compound haemorrhoidal preparations with corticosteroids
Recommended
Scheriproct®
ointment and suppositories
Alternative
Anusol® HC
ointment and suppositories
1.7.3 Rectal sclerosants
Oily Phenol Injection
1.7.4 Management of anal fissures
Recommended
Glyceryl Trinitrate 0.4% (Rectogesic®)
ointment
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
Refer to guidance in BNF click here
1.9 Drugs affecting intestinal secretions
1.9.1 Drugs affecting biliary composition and flow
Recommended
Ursodeoxycholic acid
Specific Indication
Obeticholic acid
Primary biliary cholangitis as per NICE TA443
1.9.2 Bile acid sequestrants
Colestyramine (Questran® and Questran Light®)
1.9.3 Pancreatin
Recommended
Creon®
Alternative
Pancrex®
1.10 Miscellaneous
Rifaximin (Targaxan®)
Gastroenterology / Hepatology Consultant initiation only as per Shared Care Guideline. Hepatic encephalopathy (not associated with gastrointestinal bleeding, medication, or neurological injury) that has not responded to optimal lactulose therapy: NICE TA337
On this page
-
Dyspepsia and gastro-oesophageal reflux disease
-
Antispasmodics and other drugs altering gut motility
-
Antisecretory drugs and mucosal protectants
-
Acute diarrhoea
-
Chronic bowel disorders
-
Laxatives
-
Local preparations for anal and rectal disorders
-
Stoma care
-
Drugs affecting intestinal secretions
-
Miscellaneous