BNF CHAPTER 1: GASTRO-INTESTINAL SYSTEM - NHS Southend CCG
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BNF CHAPTER 1:
GASTRO-INTESTINAL SYSTEM
1
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018ANTACIDS
Maalox and Peptac are effective antacids that can be bought Over the Counter for self-limiting symptoms.
Choice Product Cost Effective Options &Comments
First Co-Magaldrox 175mg//200mg/5ml Suspension Prescribe the brand Maalox
Alginate Raft – forming oral suspension or liquid
Second Prescribe the brand Peptac
(Compound Alginates)
ANTISPASMODICS
Choice Drug Cost Effective Options & Comments
Prescribe generic
First Mebeverine 135mg tablets
Colofac IBS is available OTC for self-limiting symptoms
Prescribe generic
Second Hyoscine Butylbromide tablets
Buscopan Cramps is available OTC for self-limiting symptoms
Note: Antispasmodics offer little benefit in irritable bowel syndrome and diverticular disease, where pain is a predominant symptom.
2
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018H2 - RECEPTOR ANTAGONISTS
Choice Drug Comments and Cost Effective Options
Prescribe generic
Rantidine 75mg/5ml oral solution is a licensed cost effective option for patients with swallowing
difficulties or a fitted PEF/NG tube.
First Ranitidine
Dose should be optimised for liquid doses where applicable.
Ranitidine 5mg/5ml oral suspension(Unlicensed) is more cost effective than the 5mg/5ml solution
Avoid prescribing Zantac Relief, Gavilast 75mg and Ranitidine 75mg which are available OTC for
self-limiting symptoms.
PROTON PUMP INHIBITORS
Choice Drug Cost Effective Options & Comments
Prescribe generic
Omeprazole caps
Dispersible versions should be prescribed for patients with swallowing difficulties or those with a
PEG or NG tube.
First or
Omeprazole 10mg/5ml and 20mg/5ml are unlicensed formulations
Lansoprazole caps
Omeprazole 10mg (cap/tab) is available OTC for self-limiting conditions
Second Pantoprazole tablets Prescribe generic
Note: For Barrett’s esophagus and other disease complicated by stricture, recurrent ulceration or hemorrhage, full dose should be maintained.
3
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018ANTI-DIARRHOEAL DRUGS
Choice Drug Cost Effective Options & Comments
Prescribe generic
Prescribe Loperamide 1mg/5ml oral solution S/F for patients with swallowing difficulties or
Loperamide 2mg those fitted with a PEG or NG tube
First
capsules
Loperamide is available OTC as generic and Imodium formulations for self-limiting conditions
Avoid prescribing Imodium melts as not a cost effective option.
Codeine Phosphate Codeine 25mg/5ml oral solution can be prescribed for patients with swallowing difficulties or
Second
30mg or 60mg tablets those fitted with a PEG or NG tube.
Drug therapy should be avoided in acute diarrhoea, particularly in the young and elderly.
Consider Clostridium difficile Infection (CDI). Has the patient been in hospital recently? CDI affects the elderly, the debilitated and patients who
have had antibiotic treatment. Antimotility drugs should not be prescribed in acute CDI, and a stool specimen should be considered. Ref: "
CDI: How to deal with the problem" (HPA -DH - Jan-09)
Fluid replacement is of the essence.
AMINOGLYCOSATES
Choice Drug Cost Effective Options and Comments
There is no evidence to show that any one oral preparation of Mesalazine is more effective
than another; however, the delivery characteristics of oral Mesalazine preparations may vary.
Octasa MR 400mg tablets
First Mesalazine MR 400mg
Patients with swallowing difficulties or fitted with a PEG or NG tube should be prescribed
Asacol suppositories
Other dose dependent options are Salofalk and Pentasa granules.
4
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018BULK-FORMING LAXATIVES
Choice Drug Cost Effective options
Prescribe generic
First Ispaghula Husk One sachet is equivalent to 2 level 5ml spoonsful
Isphaghula is available OTC as Fybogel and other generic forms for self-limiting symptoms
Prescribe generic
Second Methylcellulose tablets
Celevac is available OTC for self –limiting symptoms
OSMOTIC LAXATIVES
Choice Product Cost Effective Options
Prescribe the brand Laxido (Paediatric & Adult )
Macrogol oral
First
compound powder
Macrogol other branded generic brands are available OTC for self-limiting symptoms
Prescribe generic.
Avoid prescribing the sachets
Second Lactulose Solution
Not recommended for use in inflammatory bowel disease
Lactulose and other generic brands are available OTC for self-limiting symptoms
5
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018STIMULANT LAXATIVES
Choice Product Cost Effective Options
First Bisacodyl Prescribe Generic.Available OTC for self –limiting symptoms
Prescribe generic .Available OTC for self-limiting symptoms
Avoid prescribing Senna 15mg
Second Senna 7.5mg
Prescribe Senna 7.5mg/5ml for patients with swallowing difficulties or fitted with a PEG or NG
tube should be prescribed.
RECTAL OPTIONS
Choice Product Cost Effective Options & Comments
First Glycerol 4g suppositories Prescribe generic
Bisacodyl 5mg/10mg suppositories
Second OR Prescribe generic
Docusate 120mg enema
Third Sodium Citrate Relaxit Micro-Enema
6
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018Choice Product Cost Effective Options & Comments
Prescribe generic
For consideration, if at least two laxatives from different classes have been tried at the highest
tolerated recommended doses for at least 6 months, and failed to relieve symptoms, where
invasive treatment (such as suppositories, enemas, rectal irrigation and/or manual
Lubiprostone 24mg
disimpaction) is being considered.
NICE TA 318
Should only be prescribed in line with NICE guidelines
If treatment is not effective after 2 weeks, the person should be re-examined and the benefit
of continuing treatment reconsidered.
Other drugs Prescribe generic
Linaclotide for the symptomatic treatment of moderate-to-severe irritable bowel syndrome with
constipation (IBS-C) in adults
Only for opioid induced constipation where response to other laxatives is inadequate.
An inadequate response is defined as opioid-induced constipation symptoms of at least
Naloxegol NICE TA345
moderate severity in at least 1 of the 4 stool symptom domains (that is, incomplete bowel
(2105)
movement, hard stools, straining or false alarms) while taking at least 1 laxative class for at
least 4 days during the prior 2 weeks.
HOSPITAL ONLY
Should only be prescribed in line with NICE guidelines
Licensed for constipation in terminally ill patients.
Co-Danthramer
Available as suspension
7
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018PREPARATIONS FOR ACUTE HAEMORRHOIDS
Choice Product Cost Effective Options & Comments
Zinc oxide 10.75% + bismuth oxide 2.14% + balsam peru Prescribe as Anusol cream.
First
1.8% Available over the counter.
Prescribe as Anusol HC cream.
Hydrocortisone 0.5% + zinc oxide 12.35% + Peru balsam
1.85% + benzyl benzoate 1.2% + Bismuth oxide 0.875% Available over the counter as Anusol Plus
Second Ointment
Uniroid HC Ointment
Hydrocortisone / Cinchocaine 5mg /5mg
Uniroid HC Suppositories
BNF 1.7.4 MANAGEMENT OF CHRONIC ANAL FISSURES (Present for > 6 weeks)
Choice Product Cost Effective Options
Glyceryl trinitrate 0.4%
First Prescribe generic
Rectal ointment
Diltiazem Ointment is the most cost effective option as it
Second Diltiazem 2% ointment (unlicensed)
currently costs less than 50% compared to the cream
Rectogesic is the only licensed product currently available in the UK
Diltiazem ointment acts as a smooth muscle relaxant. The Association of Coloproctology of Great Britain and Ireland states a preference
for topical diltiazem over GTN as it has similar efficacy to Glyceryl Trinitrate but a lower incidence of side effects. It is not recommended
for long term use. Typical duration of use 6-8 weeks.
8
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018NAUSEA AND VOMITTING
Choice Product Cost Effective Options
First
Caution: can cause extrapyramidal side effects. Increased risk of drug-induced
Prochloperazine tablets
parkinsonism in the elderly particularly after prolonged use
Domperidone caution: risk of cardiac side effects. Use restricted to nausea and
vomiting only. The maximum treatment duration should not usually exceed one
Second Domperidone or Metoclopramide week. - MHRA 2014
Metoclopramide caution: Risk of neurological adverse effects. Treatment with
metoclopramide should not be prescribed for longer than 5 days. MHRA 2013
TRANS ANAL IRRIGATION APPLIANCES:
NICE recently approved the use of Trans –anal irrigation kits for bowel dysfunction and should be offered as part of a supportive bowel
care programme.
Trans Anal Irrigation Products currently available on prescription.
Table below is based on daily irrigation
PS: IryPump S cones are re-usable and last up to 3 months with every day use
9
NHS Castle Point and Rochford CCG
NHS Southend CCG
September 2018Product Cost of Features How often Cost of How often Other Cost Cost Cost Total
Name System is this Catheters is this consumables Y1 Y2 Y3 Estimated
replaced? based on replaced? e.g. bags tubes Costs
daily usage (Misc)
IryPump S £498.76 Electric 3 -4years £61.19 Every 3 Water bags tubes £744 £245 £245 £1,234.00
Set months
Peristeen £76.90 Manual 3 months £270.00 monthly Water bags tubes £3547 £3547 £3547 £10,641.00
Qufora £99.00 Manual monthly 15 extra req. monthly Water bags tubes £2568 £2568 £2568 £7,704.00
+15 £115
catheters
Qufora £101.66 Manual + monthly 15 extra req. Monthly Water bags tubes £1928 £1928 £1928 £5,784.00
15 cones cones £59
Navina £300.92 Electric+ 18-24 £260 for 30 Monthly Water bags tubes £3420 £3120 £3420 £10,260.00
Smart 2 cones months cones
Aquaflush £35.00 Manual monthly £118 for 30 monthly Water bags tubes £1836 £1836 £1836 £5,508.00
cones
Formulary Chapter 1 Gastro-intestinal system
Date ratified by D&T Committee April 2013
Next Review Date April 2015
1st Amendment September 2018
NICE TAG recommendations
Reference to self-limiting conditions and OTC options
Date ratified by D&T Committee October 2018
Next Review Date October2020
10
NHS Castle Point and Rochford CCG
NHS Southend CCG
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