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1: Gastrointestinal System

Approved: 1 Nov 2010. Last amended: 6 Sep 2019.

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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

  • Asilone

    contains simeticone

  • 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

    • Specific Indication

  • Tripotassium Dicitratobismuthate

    Second line H.pylori eradication

    • 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

    GHNHSFT Inflammatory Bowel (IBD) Biologics Pathway

    Specific Indication

  • Adalimumab

  • Golimumab

    Ulcerative colitis. NICE TA329

  • Infliximab
  • Tofacitinib

    Ulcerative colitis NICE TA547

  • Ustekinumab

    Crohn’s disease. NICE TA456

  • Vedolizumab

    • 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

  • 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

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    Key

    Hospital / Specialist only

    Specialist initiation

    Treatment Guidelines

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