ELMMB logo
Facebook logo Twitter logo
Menu
1.0 Gastrointestinal

1.0 Gastrointestinal

1.1.1 Antacids and simeticone

Suitable for most antacid purposes. Magnesium containing antacids tend to be laxative whereas aluminium containing antacids may be constipating.

GREEN        Co-magaldrox 195/220 suspension (Mucogel®)  (low sodium, no potassium)    
RED            Sodium citrate mixture 880mg/10mL (Delivery Suite only)
RED            Infacol (Endoscopy use only)

1.1.2 Compound Alginates

For use in reflux disease and not simple dyspepsia. 

 GREEN      Gaviscon Advance® liquid  (2.3mmol sodium/5ml, 1mmol potassium/5mL)      
 GREEN      Gastrocote® tablets  (1mmol sodium/tablet, no potassium)       
 GREEN      Infant Gaviscon® oral sachets 
 
 Alternative alginate preparations for use in primary care
 GREEN      Gastrocote® liquid   (1.8mmol sodium/5mL, no potassium)       
 GREEN      Peptac® liquid  (3.1mmol sodium/5mL, no potassium)     

Useful as adjunctive treatment in non-ulcer dyspepsia, irritable bowel syndrome and diverticular disease, to reduce intestinal motility.

GREEN    Mebeverine capsules 200mg (Colofac®MR)
GREEN    Mebevrine tablets135mg (prescribe as Colofac®)  
GREEN    Alverine Citrate capsules 60mg   
GREEN    Hyoscine butylbromide
                 tablets 10mg,  injection 20mg/mL  
GREEN    Peppermint oil e/c capsules     
 
RED         Peppermint water


Metoclopramide and domperidone stimulate gastric emptying, small intestinal transit and enhance strength of oesophageal sphincter contraction. Avoid metoclopramide in children and those under 20 years of age because of the risk of dystonic reactions.

GREEN     Domperidone - see section 4.6

GREEN     Metoclopramide- see section 4.6

Eluxadoline is recommended as an option in treating irritable bowel syndrome with diarrhoea in adults as per NICE guidance TA471
 
RED       Eluxadoline tablets 75mg, 100mg (Truberzi®)

Helicobacter pylori eradication regimen (see MicroGuide for further information on eradication therapy)

First Line
GREEN      Lansoprazole 30mg 12 hourly
GREEN      Clarithromycin 500 mg 12 hourly
GREEN      Amoxicillin 1g 12 hourly

Total duration of therapy 7 days 

Alternative for patients with penicillin allergy
GREEN      Lansoprazole 30mg 12 hourly
GREEN      Metronidazole 400mg 12 hourly
GREEN      Clarithromycin 500mg 12 hourly 

Total duration of therapy 7 days

Second Line 
GREEN      Lansoprazole 30mg 12 hourly 
GREEN      Amoxicillin 1g 12 hourly 
GREEN      Clarithromycin 500mg orally BD or Metronidazole 400mg BD (whichever was not used first line)
Total duration of therapy 7 days

Patients who have had previous exposure to Clarithromycin and Metronidazole
GREEN      Lansoprazole 30mg 12 hourly 
GREEN      Amoxicillin 1g 12 hourly 
GREEN      Levofloxacin 250mg 12 hourly
Total duration of therapy 7 days
 
Second line alternative if allergic to penicillin
GREEN      Lansoprazole 30mg 12 hourly
GREEN      Metronidazole 400mg BD
GREEN      Levofloxacin 250mg 12 hourly

Total duration of therapy 7 days

1.3.1 H2 receptor antagonists

All heal gastric and duodenal ulcers by reducing gastric acid output by H2 receptor blockade, and relieve peptic oesophagitis.

GREEN      Ranitidine
                   tablets 150mg, 300mg , dispersible tablets 150mg    
                   syrup 75mg/5mL (paediatric use only)        
 
RED           Ranitidine injection 25mg/mL IV infusion 50mg in 50mL 


1.3.3 Chelates and Complexes

RED          Sucralfate
                  tablets 1g, suspension 1g/5mL                             


1.3.5 Proton pump inhibitors

GREEN      Omeprazole
                   capsules 10mg, 20mg    
GREEN      Lansoprazole 
                   capsules 15mg, 30mg    
                   orodispersible tablets 15mg, 30mg (for tubes, swallowing difficulties)        
AMBER      Omeprazole dispersible tablets 10mg  (for use in paediatrics only)
 
RED           Omeprazole intravenous infusion 40mg

BLACK     Omeprazole liquid * Not recommended for prescribing in primary or secondary care
                  Prescribers should use;
                     * Paediatrics - Omeprazole gastro-resistant dispersible tablets (link to leaflet)
                     * Adults with swallowing difficulties - Lansoprazole orodispersible tablets
 


Esomeprazole
 

Esomeprazole should only be initiated by a consultant gastroenterologist in patients with treatment resistant severe GORD confirmed by endoscopy, who have failed to respond to the use of high doses of generic omeprazole and/or generic lansoprazole.

Esomeprazole should not be initiated by prescribers within primary care, nor should it be used in the treatment of dyspepsia or in H.pylori eradication regimes or for any other indication.

After 8 weeks therapy with esomeprazole patients should be reviewed and stepped down to a generic PPI where possible. 

AMBER    Esomeprazole capsules 20mg

First line treatment in acute diarrhoea and gastro-enteritis is prevention or treatment of fluid and electrolyte depletion. For details of oral rehydration preparations see section 9.2.1.2.  In babies and infants it is unusual for this fluid to be required for more than about two feeds.

1.4.2 Antimotility drugs

GREEN      Loperamide 
                  capsules 2mg 
                  syrup 1mg/5mL
 
GREEN      Codeine phosphate
                   tablets 15mg, 30mg, 60mg
                   syrup 25mg/5mL

These drugs for chronic bowel disorders are recommended for initiation only on specialist advice.

1.5.1 Aminosalicylates

Mesalazine

Mesalazine is an aminosalicylate that is used routinely to induce and maintain remission in chronic inflammatory bowel disease – ulcerative colitis (UC) and Crohn’s disease.  Mesalazine is commonly given as a modified release (MR) preparation to target delivery of the drug to the diseased area of the bowel to provide topical anti-inflammatory therapy. 

Available formulations have differences in licensed indications, tablet strengths, pharmaceutical, pharmacological and pharmacokinetic properties. As the delivery characteristics of the different mesalazine preparations may vary: mesalazine preparations must be prescribed by brand name.

Octasa® is the first line choice across the ELMMB healthcare economy, and where possible 800mg strength tablets should be prescribed and supplied. Patients currently taking generic mesalazine or Asacol® can be switched to Octasa®. Switching to Octasa® in patients currently taking other brands of mesalazine can be considered, but response needs to be monitored as brands are not directly interchangeable.

AMBER     Octasa®  MR e/c 400mg & 800mg tablets (Mesalazine)  - (specify brand when prescribing)                  

In circumstances when a switch to Octasa® is not clinically appropriate, Asacol® or Mezavant® may be continued.
New patients are not to be initiated on Asacol® or Mezavant®.
 
AMBER      Asacol® MR 400mg e/c tablets (Mesalazine) - (specify brand when prescribing) 
AMBER      Mezavant®  XL 1200mg tablets (once daily) (Mesalazine) - (specify brand when prescribing)     
 
Pentasa® is available for administration via large bore enteral feeding tubes or in swallowing difficulty. The 500mg 
tablet will dissolve in water, leaving small beads (0.7mm-1mm diameter) that can be swallowed or administered whole
(beads must not be crushed).
 
AMBER     Pentasa®  e/c 500mg tablets (Mesalazine) -  (specify brand when prescribing)  
 
Rectal mesalazine preparations
Asacol® foam enemas are licensed for mild to moderate acute exacerbations of ulcerative colitis affecting the distal
colon, and Asacol® suppositories are also licensed for maintenance of remission of distal ulcerative colitis.
 
AMBER     Asacol®  foam enema 1gram/metered application (Mesalazine)   
                  (specify brand when prescribing)
AMBER     Salofalk®  suppositories 500mg, 1g (Mesalazine) 
                  (specify brand when prescribing)
 
Pentasa® liquid enemas are licensed for the treatment of ulcerative colitis affecting the distal colon and rectum
 
AMBER     Pentasa®  liquid retention enema 1gram/100mL (Mesalazine) - (specify brand when prescribing) 
 
Ipocol® is not a recommended brand of mesalazine for new patients as it is not interchangeable with Asacol® due to 
differences in its site of delivery, even though it is the same strength of mesalazine.  
 
AMBER     Balsalazide capsules 750mg
AMBER     Sulfasalazine tablets 500mg (not recommended for new patients)


1.5.2 Corticosteroids

Treatment of acute attacks of ulcerative colitis and Crohn's disease:
GREEN       Prednisolone 
                    tablets 5mg
                    retention enema 20mg
                    suppositories 5mg
GREEN        Hydrocortisone 10% rectal foam (Colifoam®)
 
Budesonide oral capsules 
(as an option as per NICE clinical guideline for Crohn's disease, if  conventional corticoseteroid is not  tolerated) 
Given that the Budenofalk brand of budesonide offers more flexible dosing than alternative products and is more
cost effective Consultants support using only the Budenofalk brand of budesonide.  All other brands are considered
non-formulary.
 
AMBER       Budenofalk capsules 3mg
 
For the Induction of remission of mild-to-moderate active ulcerative colitis where 5-ASA (aminosalicylate) treatment is
not sufficient then Budesonide multimatrix MMX 9mg prolonged release tablets (Cortiment®) are an option under 
specialist care.
 
RED            Budesonide multimatrix MMX 9mg prolonged release tablets (Cortiment®)


1.5.3 Drugs affecting the immune response


Ciclosporin is occasionally used in the management of severe inflammatory bowel disease (unlicensed). It requires 
regular monitoring and should only be prescribed under the direction of a specialist. Azathioprine is used in the
maintenance of remission of acute ulcerative colitis and Chron's disease, and also requires regular monitoring
(unlicensed).
 
Maintenance and symptomatic treatment of ulcerative colitis and Crohn's disease:
AMBER      Azathioprine tablets 25mg, 50mg (unlicensed for use in IBD) 
AMBER      Ciclosporin capsules 10mg, 25mg, 50mg, 100mg (Neoral®) – (unlicensed for use in IBD) 
                       (specify brand when prescribing)
RED            Ciclosporin 50mg/ml  concentrate for iv infusion– (unlicensed for use in IBD)
 
Cytokine modulators
NICE guidance for Ulcerative Colitis updated Feb 2015 (TA329) 
 
Infliximab ( Remicade®, Inflectra® or Remsima®), adalimumab (Humira®) and golimumab (Simponi®) are 
recommended as possible treatments for adults with moderate to severe ulcerative colitis if conventional therapy 
hasn’t worked or isn’t suitable.
 
Infliximab is also recommended as a possible treatment for children or young people aged 6–17 years with severe 
ulcerative colitis, if conventional therapy hasn’t worked or isn’t suitable.

infliximab is a treatment option for acute exacerbation of severely active ulcerative colitis where the patient meets the
NICE criteria to start a biologic (TA163) 
RED       Infliximab ( Remicade®,Inflectra®,Remsima®.) Prescribe by brand 
RED       Adalimumab  (Humira®) 
RED       Golimumab (Simponi®)
 
NICE guidance for treating moderately to severely active ulcerative colitis (TAG342
Vedolizumab is recommended as a possible treatment for adults with moderate to severe ulcerative colitis
RED      Vedolizumab  (Entyvio®) 
             Concentrate for intravenous infusion 300mg vial
 
NICE guidance for treating for moderately to severely active Crohn's disease after prior therapy (TA352)
RED     Vedolizumab (Entyvio®)
            Concentrate for intravenous infusion 300mg vial
 
NICE guidance for treating for moderately to severely active Crohn's disease after previous therapy (NICE TA456) 
RED       Ustekinumab (Stelara®)                                                                                                                  CCG Commissioned 
               Solution for injection, solution for injection pre-filled syringes 45mg/0.5ml 
               solution for injection pre-filled syringes 90mg/1ml
 
NICE guidance for Crohn's disease (TAG187)  
 
   >   Adalimumab, within its licensed indications, is recommended as a treatment option for adults with severe 
        active non-fistulising Crohn's disease as induction treatment followed by maintenance treatment.
        Maintenance treatment with adalimumab should continue until treatment failure (which includes the need
        for surgery), or until 12 months after the start of treatment, whichever is the shorter. The patient's disease
        should then be reassessed. Maintenance should only then be continued if there is clear evidence of ongoing
        disease, as determined by clinical symptoms and investigation, including endoscopy if necessary.  People whose 
        disease relapses after maintenace treatment is stopped should have the option to resume treatment for a
        further 12 months. They should then be reassessed to determine whether ongoing treatment is still 
        clinically appropriate. 
   >   Infliximab is a treatment option for severe Crohn's disease when there is clear evidence of primary intolerance 
        to adalimumab, or if Crohn's disease is fistulising, or if the patient is either a child or adolescent.
  
Please see the full guidance for further information.

RED           Adalimumab pre-filled pen/syringe 40mg


Dietary advice is important. Before prescribing laxatives it is also important to be sure the patient is constipated
and that it is not secondary to an underlying undiagnosed complaint. Use only if really necessary - not for long 
term use.
 

1.6.1 Bulk-forming laxatives

May be required when fibre cannot be increased in the diet. Of value in those with small hard stools, need an 
adequate fluid intake and may take a few days for full effect to develop.
GREEN      Ispaghula husk granules 3.5g/sachet 
GREEN      Methylcellulose tablets 500mg    
AMBER     Normacol Plus® (post gastrointestinal surgery)   
 

1.6.2 Stimulant laxatives

Increase intestinal motility, often cause abdominal cramp, should not be used in intestinal obstruction.
GREEN      Bisacodyl 
                   tablets e/c 5mg   
                   suppositories 5mg, 10mg
GREEN      Senna 
                   tablets 7.5mg  
                   syrup 7.5mg/5mL     
GREEN      Sodium picosulfate
                   elixir 5mg/5mL    
GREEN      Docusate sodium
                   capsules 100mg  
                   syrup 12.5mg/5mL, 50mg/5mL  
 
Co-danthramer and co-danthrusate are licensed for use in palliative care only
GREEN      Co-danthramer (dantron /poloxamer ‘188’) 
                   suspension 25/200 per 5mL,       
                   strong suspension 75/1000 per 5mL  
GREEN      Co-danthrusate (dantron /docusate sodium) 
                   capsules 50/60    
 
Rectal stimulant
GREEN      Glycerol suppositories 1g, 2g, 4g
 

1.6.3 Faecal softeners

Lubricate and soften impacted faeces and promote a bowel movement.
GREEN      Arachis oil enema
 

1.6.4 Osmotic laxatives

Retain fluid in the bowel and change the pattern of water distribution in the faeces. They commonly cause bloating,
flatulence and cramping and are unpalatable for some patients. They must be taken regularly for up to three days 
before an effect is seen, making them unsuitable for rapid relief of constipation or for ‘as required’ dosing.
 
First Line
GREEN      Lactulose solution 3.35g/5mL   
 
Second line 
Oral route: 
GREEN      Laxido® for adults
GREEN      Laxido® for adults 
                   Movicol paediatric® sachets  
 
Rectal route: 

GREEN      Phosphate enema
GREEN      Relaxit® or Micralax® micro enema 

1.6.5 Bowel cleansing solutions

Bowel cleansing solutions are for use only before colonic surgery, colonoscopy, or radiological examination to ensure the bowel is free of solid contents. They are not treatments for constipation.
RED           Citramag® sachets
RED           Klean-Prep® sachets
RED           Picolax® sachets 
RED           Moviprep® sachets


1.6.7 5HT4 receptor agonists and guanylate cyclase-C receptor agonists

Prucalopride (Resolor®) for the treatment of chronic constipation in women (NICE TA211)
 
        1.   Prucalopride is recommended as an option for the treatment of chronic constipation only in women for
              whom treatment with at least two laxatives from different classes, at the highest tolerated
              recommended doses for at least 6 months, has failed to provide adequate relief and in whom invasive
              treatment for constipation is being considered.
        2.   If treatment with prucalopride is not effective after 4 weeks, the woman should be re-examined and the 

              benefit of continuing treatment reconsidered.

        3.   Prucalopride should only be prescribed by a clinician with experience of treating chronic constipation,
              who has carefully reviewed the woman’s previous courses of laxative treatments specified in point 1.
 
AMBER     Prucalopride  tablets f/c 1mg, 2mg 
 
Linaclotide (Constella®) treatment of moderate to severe irritable bowel syndrome with constipation in adults 
who have not responded to conventional treatment. Linaclotide can be considered as an option (specialist initiation 
only) for the treatment of persistent constipation in adults with IBS who have not responded to conventional treatment
based on suggested treatment pathway:
 
       1.   Follow irritable bowel syndrome in adults NICE CG61 (2008) and manage constipation with a range of
             osmotic and stimulant laxatives with the long-term use of soluble fibre
       2.   Where antispasmodics and laxatives are ineffective for pain relief, NICE suggests the use of tricyclic
             antidepressants (unlicensed use)
       3.   Assess patient at 4 weeks (in secondary care) and if no improvement discontinue use
       4.   If continued beyond 4 weeks, re-assess at 6 months for contniued benefit
 
 AMBER     Linaclotide capsules 290 micrograms
       

Lubiprostone (Amitiza®) is recommended as an option for treating chronic idiopathic constipation, that is, for adults in whom treatment with at least 2 laxatives from different classes, at the highest tolerated recommended doses for at least 6 months, has failed to provide adequate relief and for whom invasive treatment for constipation is being considered. 

If treatment with lubiprostone is not effective after 2 weeks, the person should be re-examined and the benefit of continuing treatment reconsidered.  Treatment should only be prescribed by a clinician with experience of treating chronic idiopathic constipation. As per NICE TAG 318 guidance.

AMBER            Lubiprostone  (Amitiza®) capsules 24mcg

Naloxegol (Moventig®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. NICE TAG345.
 
GREEN       Naloxegol (Moventig®) tablets 12.5mg, 25mg




1.7.1 Soothing haemorrhoidal preparations

GREEN       Anusol® cream & suppositories
 

1.7.2 Compound haemorrhoidal preparations with corticosteroids 

GREEN       Anusol® HC ointment (do not use for longer than 7 days) 
 

1.7.3 Rectal sclerosants

RED           Oily phenol injection 5%
 

1.7.4. Management of anal fissures

The management of anal fissure requires stool softening by increasing dietary fibre or by the use of a bulk-forming 
laxative. Short term use of local anaesthetic preparations may help. If these measures are inadequate the patient 
should be referred for specialist treatment in hospital – here the local use of glyceryl trinitrate or diltiazem may be 
appropriate.
 
AMBER     Diltiazem (Anoheal®) cream 2%
AMBER     Glyceryl trinitrate (Rectogesic®) ointment 0.4%

1.9.1 Drugs affecting biliary composition and flow

Mainly used for unlicensed use in itching related to gall bladder problems

AMBER     Ursodeoxycholic acid
                  tablets 150mg, capsules 250mg
                  suspension 250mg in 5mL
RED           Obeticholic acid▼                                                                                            NHS England Commissioned 
                  film coated tablets 5mg, 10mg
                  Patients should be reviewed 12 months after initiation to review effectiveness and treatment should only continue                      if there is evidence of clinical benefit - as per NICE TA443
 

1.9.2 Bile acid sequestrants

GREEN       Colestyramine sachets 4g (Questran Light®)

1.9.4 Pancreatin

GREEN       Creon® 10,000 capsules (protease 600/lipase 10,000/amylase 8000)
GREEN       Creon® 25,000 capsules (protease 1,000/lipase 25,000/amylase 18,000)
 
RED           Pancrex V Powder®  administration via enteral feeding tubes to reduce malabsorption in patients on enteral  
                  feeds. Gastroenterology use ONLY