Data extracted : 24/11/2017
 Formulary Section 1: Gastro-intestinal system
01.01 Dyspepsia and gastro-oesophageal reflux disease

  • Review medicines patient is currently taking for any that may be associated with dyspepsia side effects.

  • Patients with acid reflux should be advised to lose weight (if appropriate), avoid tight clothing around the waist and reduce alcohol, caffeine and tobacco consumption.

  • A step-wise approach to symptom management is recommended

  • Patients with mild symptoms and/or those without proven pathology can often be managed using an antacid, an alginate or an H2-blocker initially.
Link   Leicestershire Guidelines: PPI Prescribing
Link   NICE CG 184: Dyspepsia and gastro‑oesophageal reflux disease
01.01.01 Antacids
Antacids may reduce absorption of a number of other drugs and should not be taken at the same time. Drugs most likely to be affected are tetracyclines (not doxycycline), iron salts, bisphosphonates, isoniazid, digoxin, ciprofloxacin, itraconazole, ketoconazole, nitrofurantoin, norfloxacin, penicillamine, phenytoin, rifampicin and others. They may also damage enteric coatings - patients should be advised to separate administration.
Link   NICE CG 184: Dyspepsia and gastro‑oesophageal reflux disease
01.01.01 Aluminium and magnesium containing antacids
First Choice:
Co-magaldrox 195/220 (magnesium hydroxide with aluminium hydroxide mixture)  (Mucogel®)
Sugar free, low sodium content and suitable for the majority of patients including those with cardiac or hepatic failure. Use with caution in severe renal impairment as aluminium and magnesium may accumulate
01.01.02 Compound alginates and proprietary indigestion preparations
Restricted Drug  Gastrocote suspension  
Prison use only
01.01.02 Compound alginate preparations
  • Alginate preparations may be more effective for those not responding to simple antacids.

  • Take after meals to achieve a raft effect.

Link   NICE CG 184: Dyspepsia and gastro‑oesophageal reflux disease
First Choice:
Restricted Drug  Gaviscon Advance 
Used only in obstetrics and gynaecology at UHL
01.02 Antispasmodics and other drugs altering gut motility
It is worth rotating through all antispasmodics of IBS sufferers. If recommended choices are ineffective dicycloverine, alverine citrate or peppermint oil capsules may be tried.
First Choice:
Mebeverine Hydrochloride 
Provides relief of abdominal pain by relaxing smooth muscle in irritable bowel disease. Useful to treat colicky pain in diverticular disease.
Second Choice:
Hyoscine Butylbromide  (Buscopan®)
Evidence of efficacy in meta-analyses of trials but oral absorption is poor.
01.03 Helicobacter pylori infection
H Pylori eradication

  • Consider for all patients with duodenal or gastric ulcers that are not associated with aspirin or NSAID ingestion.

  • Eradication for those with dyspepsia should only be considered when lifestyle changes and initial medical management are unsuccessful.

  • Asymptomatic individuals should not be given H. pylori eradication therapy as they may subsequently develop symptoms.

  • Eradication treatment may be given during or after a course of ulcer-healing treatment.

  • Compliance with the regimen is most important, both to ensure maximum effectiveness and to minimise the risk of bacterial resistance (otherwise subsequent attempts at eradication may fail).

      Recommended regimen for H. pylori eradication

      • One-week triple-therapy regimens comprising a proton pump inhibitor with 2 antibacterial agents tend to be effective in over 90% of cases. There is some evidence of metronidazole resistance locally therefore the recommended combination is:
          Lansoprazole 30mg bd, clarithromycin 500mg bd, amoxicillin 1g bd OR (for those that are allergic to amoxicillin) a lansoprazole 30mg bd, clarithromycin 250mg bd, metronidazole 400mg bd regimen for 7 days. Do not re-test unless there is a strong clinical need.
        Link   Leicestershire Guidelines: PPI Prescribing
        01.03.01 H2-receptor antagonists

        • Ranitidine can prevent stress ulceration in seriously ill patients.

        • PPIs are not recommended for routine use in patients with GI bleeds until after endoscopy
        Link   NICE CG 141: Acute upper GI bleeding
        Link   NICE CG 184: Dyspepsia and gastro‑oesophageal reflux disease
        Link   SIGN clinical guideline 105 - management of acute upper and lower gastrointestinal bleeding
        First Choice:
        Ranitidine (including soluble tablets) 
        Reduce dose in renal or hepatic impairment. Monitor INR with oral anticoagulants
        01.03.03 Chelates and complexes
        Restricted Drug  Pepto Bismol  
        For use only on the recommendation of a specialist as part of an eradication regimen for resistant H pylori
        Restricted Drug  Tripotassium Dicitratobismuthate  (De-Noltab)
        For use only on the recommendation of a specialist as part of an eradication regimen for resistant H pylori
        01.03.05 Proton pump inhibitors (PPIs)

        • For patients who are unable to use gelatine capsules pantoprazole tablets may be prescribed.

        • Treatment should be regularly reviewed and stepped down where possible according to symptom control.

        • For complicated disease (severe oesophagitis- Los Angeles grades C&D, strictures and Barrett’s oesophagus) maintain full dose.

        • Symptom control may be achieved by splitting the dose (unlicensed)

        • PPIs may work better if taken 30-60 minutes before meals

        • For patients with recurrent severe symptoms or those refractory to drug treatment, laparoscopic surgery may be appropriate.

        • Exclude serious underlying disease including malignancy in middle-aged or older patients with new or recently changed symptoms

        • Use of drugs that reduce gastric acid production may increase gastrointestinal infections, including Salmonella, Campylobacter and Clostridium difficile.

        • H pylori eradication should be undertaken in patients with duodenal ulcer, gastric ulcer and non ulcer dyspepsia, and be considered in GORD. 

        • The MHRA has advised that PPIs should only be co-prescribed with clopidogrel if considered essential.  Local guidance available below. 

        • Esomeprazole has a limited place in therapy.  It should be reserved for GORD patients who have not responded to an adequate dose for an adequate time of Lansoprazole (Alternative Omeprazole) or on specialist advice in specific severe conditions e.g. high output stoma patients. 
        Link   Leicestershire Guidelines: Clostridium Difficile Guidance for Primary Care
        Link   NICE CG 141: Acute upper GI bleeding
        Link   NICE CG 184: Dyspepsia and gastro‑oesophageal reflux disease
        Link   SIGN clinical guideline 105 - management of acute upper and lower gastronintestinal bleeding
        Link   UHL Guidelines: Clostridium Difficile Associated Diarrhoea: antimicrobial management
        First Choice:
        Lansoprazole is unlicensed in children
        Second Choice:
        Use if lansoprazole is not tolerated. Licensed for use in paediatrics. Capsules have a lower cost than tablets and should be considered first.
        Restricted Drug  Lansoprazole orodispersible  (Zoton Fastabs®)
        Reserve for patients unable to swallow capsules as cost is higher than capsules. Can also be dispersed in a small amount of water and administered via a naso-gastric tube or oral syringe where appropriate.
        Lansoprazole fastabs are the first line agent in children who require a PPI via an NG tube or have difficulty swallowing.
        Restricted Drug  Omeprazole IV 
        Used in specific indications where an oral PPI can’t be given (e.g. ulcer with no bleeding, prophylaxis, oesophagitis)
        Used in certain patients with bleeding peptic ulcers on specialist advice only.
        IV monographs available through ’Injectable Medicines Guide’ link on front page of INsite.
        01.04 Acute diarrhoea

        • Antidiarrhoeal drugs provide symptomatic relief.
          They should not be used for longer than a few days without investigation of the
          underlying disorder.
        • Do not give antibiotics for acute diarrhoea
          without evidence of an infecting organism. 
        • Many cases of acute diarrhoea are
          short lived and all that is needed is fluid replacement with frequent small
          volumes of any clear liquid. More severe dehydration can be treated with oral
          rehydration solution
          , which contains sodium; potassium and glucose. Parenteral
          rehydration is necessary in very severe cases. Patients with high output
          diarrhoea due to ileostomy etc should use a rehydration formula with a higher
          sodium content.
        • See also colestyramine when diarrhoea
          associated with bile acid malabsorption. 
        • Antidiarrhoeals should be used with
          caution in acute flare of inflammatory bowel disease as this may precipitate
          toxic megacolon.
        • Adsorbents such as kaolin are no longer
          recommended in acute diarrhoea. 

        Link   NICE CG 49: Faecal incontinence
        Link   UHL Guidelines: Clostridium Difficile Associated Diarrhoea: antimicrobial management
        First Choice:
        Loperamide Hydrochloride 
        Less likely to cause central side effects than codeine and appears to be the most effective drug for controlling diarrhoea in ileostomy and colostomy patients. Should not be used in conditions where inhibition of peristalsis should be avoided, where abdominal distension develops, or in acute diarrhoeal conditions such as ulcerative colitis or antibiotic-associated colitis. The syrup contains saccharin so usually avoided when using loperamide in short bowel / ileostomy patients to control output as can worsen the diarrhoea.
        Second Choice:
        Codeine Phosphate 
        Avoid long term use due to possible tolerance/ dependence. Do not use in conditions where inhibition of peristalsis should be avoided, where abdominal distension develops, or in acute diarrhoeal conditions such as ulcerative colitis or antibiotic-associated colitis.
        Caution: Abuse potential in prisons.
        Restricted Drug  Loperamide regular, high dose 
        Regular high dose loperamide is used for patients with chronic functional diarrhoea and in high output stoma patients. This is unlicensed use and restricted to initiation by hospital specialists in the field.
        01.05 Chronic bowel disorders
        Link   NICE CG166: Ulcerative Colitis
        Link   SCA: 6-Mercaptopurine, Aminosalicylates, Azathioprine and Methotrexate
        Restricted Drug  Glucodrate® 
        Initiation by the UHL Intestinal Failure Team only. For patients with complications due to high output stoma and unable to tolerate St Mark’s solution.
        01.05 Irritable bowel syndrome

        • Irritable bowel disease may present with predominantly diarrhoea or constipation, or a mix of these symptoms with abdominal pain. The mainstay of treatment is to increase dietary fibre and fluid intake and/or use a bulking agent such as ispaghula husk

        • Consider offering antispasmodic agents like mebeverine which provides relief of abdominal pain by relaxing intestinal smooth muscle.

        • Antidiarrhoeal drugs such as loperamide may be appropriate if diarrhoea and pain are the main problems.

        • Consider offering laxatives for constipation but discourage use of lactulose.

        • Psychotropic drugs such as antidepressants should only be used when  specifically indicated.  For example if pain is a major feature 50-100mg of amitriptyline, imipramine or nortriptyline (in descending order of sedative effect, which is the main limiting factor) may be given.  Evidence of benefit is otherwise relatively poor and psychosocial counselling may be more effective in some cases.
        Link   NICE CG 61: Irritable Bowel Syndrome
        01.05 Inflammatory bowel disease

        • Includes ulcerative colitis and Crohn’s disease.

        • Aminosalicylates and corticosteroids form the basis of drug treatment..

        • Some patients with Crohn’s or ulcerative colitis may require continuous treatment with azathioprine to maintain remission (specialist initiation only).

        • Methotrexate is prescribed for Crohn’s disease.  The BNF recommends that only one strength of methotrexate tablet (usually 2.5 mg) is prescribed and dispensed.

        Link   NICE CG152: Crohn’s disease
        01.05 Antibiotic-associated colitis
        Link   Leicestershire Guidelines: Clostridium Difficile
        Link   UHL Guidelines: Clostridium Difficile Associated Diarrhoea: antimicrobial management
        01.05 Diverticular disease

        • Symptoms may be relieved by a high fibre diet with supplemental bran or bulk-forming agents such as ispaghula husk.

        • Mebeverine is useful to treat colicky pain.

        • Antidiarrhoeal drugs, which reduce gut motility and stimulant laxatives should be avoided
        01.05 Aminosalicylates

        • Patients should be advised to report any unexplained bleeding, bruising, sore throat, fever or malaise that occurs during treatment. Stop drug immediately and perform blood count if suspicion of a blood dyscrasia

        • Prescribe by brand. Different brands should not be regarded as inter-changeable because of variations in formulation. Pentasa tablets contain coated granules that may release the drug at an earlier stage during transit through the GI tract than Octasa tablets which are coated with an acrylic-based resin.

        • Octasa and Asacol have a similar release profile and are virtually identical. Octasa has a lower cost and is the preferred choice in new patients where either of these preparations is being considered. Patients currently prescribed Asacol can be considered for switching to Octasa. Advise patient to report any changes in symptoms.

        • Pentasa and Salofalk are released in the small bowel and are therefore suitable for Crohn’s as well as ulcerative colitis. Asacol and Octasa are released in the terminal ileum though it may not be released in active colitis due to reduced stool pH.

        • Lactose content of preparations is important in some patients, Pentasa preparations are lactose free.

        • Lactulose may prevent release of mesalazine from Asacol or Octasa by lowering pH in the colon.

        • The BNF advises that renal function should be monitored before starting an aminosalicylate, at 3 months of treatment and then annually (more frequently in renal impairment). 

        • Other treatment options for specialist initiation only include ciclosporin, azathiaprine, 6 mercaptopurine (if intolerant to azathiaprine)and methotrexate (for Crohn’s).
        First Choice:
        Use in maintenance to reduce relapse once the acute attack is controlled. Maintenance is more effective at higher doses (at discretion of specialist).
        May be used in mild attacks of acute colitis. Can also be of some value in Crohn’s ileo-colitis or small bowel Crohn’s disease. Avoid in renal impairment even if mild. Mesren MR brand has now been discontinued and replaced by Octasa. This brand is the recommended choice. Both 400mg and 800mg tablets are available. Salofalk granules are an alternative choice.
        Mesalazine rectal is the route of choice in proctitis / proctosigmoiditis in relapse
        (Rectal mesalazine is Simple Amber and does not require a SCA)
        Second Choice:
        Sulfasalazine EC 
        For acute treatment of extensive or severe ulcerative colitis. Introduce gradually to avoid nausea and vomiting. Small doses given more often may be beneficial. Warn male patients of the possibility of reversible infertility. Monitor blood counts during prolonged use (initially monthly then 3-monthly) Monitor liver function monthly for the first 3 months, monitor renal function at regular intervals. Urine and some soft contact lenses may be stained orange.
        Restricted Drug  Balsalazide 
        Second line in patients not responding to Octasa, particularly with left sided colitis. Specialist initiation only
        01.05 Corticosteroids
        • Treat mild cases of ulcerative colitis with rectal corticosteroids e.g. suppositories for proctitis, foam where the sigmoid colon and rectum are involved or enema for left- sided disease. Patient preference should be considered when selecting the preparation

        • Long term use of rectal preparations can give systemic effects.

        • Oral therapy not recommended for maintenance therapy due to risk of serious adverse effects at the doses required. Women in particular are prone to osteoporosis; adequate calcium intake should be encouraged.

        • Maximum length of steroid therapy is 12 weeks in ulcerative colitis.

        • An elemental peptide or polymeric diet can be used in active Crohn’s though recurrence is common once the diet is stopped.

        • Corticosteroids should not be used where there is untreated local infection, obstruction, perforation, fistula or peritonitis.
        First Choice:
        Use for acute treatment of severe ulcerative colitis either alone or in combination with mesalazine if not controlled by mesalazine or sulphasalazine. Treatment of choice for inducing remission in active Crohn’s.
        The potential advantage of soluble or enteric coated preparations to reduce the risk of gastric ulcers is speculative. They are considerably more costly.
        Prednisolone EC tablets are not routinely stocked at UHL.
        Prednisolone soluble can be up to 200 times more costly than plain tablets depending on the setting. Plain tablets can be crushed and dispersed (unlicensed).
        First Choice:
        Budesonide foam enema  (Budenofalk®)
        Budesonide rectal foam. To be used as an alternative to prednisolone enemas. Please note, predisolone enemas are currently significantly more expensive than budesonide
        Second Choice:
        Hydrocortisone Acetate 10%  (Colifoam®)
        Hydrocortisone foam enema. Does not have the same reach into the colon as budesonide
        Second Choice:
        Hydrocortisone injection 
        Restricted Drug  Budesonide 
        May be used in Crohn’s ileitis on specialist advice only. (95% first pass metabolism so less systemic steroid side effects but potent effects on the bowel) Also licensed for autoimmune hepatitis.
        Budenofalk is the recommended preparation.
        Restricted Drug  Prednisolone Foam Enemas  (Predfoam®)
        Please note, significantly more expensive than budesonide foam enemas. Should be used by, or on advice from GI specialist only
        01.05 Cytokine inhibitors
        Restricted Drug  Infliximab (Inflectra®)  (Gastroenterology)
        Specialist use only for patients with severe active Crohn’s disease in line with NICE TA 187.
        Supported in line with NICE TA163 for acute exacerbations of ulcerative colitis

        Prescribe by brand. Inflectra is the recommended choice for new patients

        CCG commissioned

        Date decisions added to Formulary:
        Ulcerative Colitis - May 15
        Restricted Drug  Adalimumab  (Gastroenterology)
        Specialist use only in line with NICE TAs below
        CCG commissioned

        Date decision added to Formulary:
        Ulcerative Colitis - May 15
        Restricted Drug  Golimumab  
        Specialist use only in line with NICE TAs below
        CCG commissioned

        Date decision added to Formulary:
        Ulcerative Colitis - May 15
        Restricted Drug  Ustekinumab  (Gastroenterology)
        Specialist use only in line with NICE TA below
        CCG commissioned

        Date decision added to Formulary:
        Crohns Disease - October 17
        Restricted Drug  Vedolizumab  
        Specialist gastroenterology use only in line with NICE TA 342 and NICE TA 352

        Date of entry of decision to formulary:
        Crohn’s - November 2015
        Ulcerative colitis - September 2015
        01.06 Laxatives

        Before prescribing laxatives

        • Treat any underlying condition

        • Review use of drugs which may be contributing to constipation e.g. anticholinergics, opiates, tricyclic antidepressants, phenothiazines and aluminium antacids

        • Undertake a full assessment of the patient including history of bowel habit, current bowel action and include rectal examination if appropriate.

        • Mobilise the patient.  Patients who have been in hospital may have got out of their usual routine due to immobility or embarrassment in asking to go to the toilet.  Ensuring they are taken and are able to sit in the optimum position on the toilet may be enough to regain this.

        • Encourage a diet rich in fibre with adequate fluid intake (seek advice from a dietician if necessary).  If dietary fibre cannot be increased sufficiently a bulk forming laxative is appropriate.  These are not appropriate for acute relief as they may take several days to work but are a good option for long term control.

        • For acute constipation a stimulant laxative is appropriate unless the stool is hard.  This should be reviewed after 3 days.

        • Enemas and suppositories are useful when a rapid effect is required e.g. for faecal impaction or bowel clearance before surgery.

        • For all patients with ’soft’ stools a stimulant and /or fibre is appropriate. A combination of ispaghula and senna provides a rational choice for resistant constipation if adequate fluid intake.

        • Patients with hard stools benefit from faecal softeners or osmotic laxatives.  If there is a tendency to perianal pain, as in fissures, then faecal softeners are appropriate. 

        • All laxatives are contra-indicated in intestinal obstruction.

        • Drastic purgation should be avoided during pregnancy

        1. Abdominal (non-rectal) GI operations e.g. sigmoid-colectomy, appendicectomy. Delay in re-establishing bowel action is usually due to resolving paralytic ileus. Occasionally such a delay may indicate problems with an intestinal anastomosis. After 3-4 days try glycerol suppositories. Do not give oral laxatives or enemas without senior advice.

        2. Rectal operations e.g. anterior resection. Do not give oral or rectal laxatives without direct senior advice.

        3. Anal operations e.g. haemorrhoidectomy, anal fissure repair. Start lactulose, 10mL twice daily before surgery and continue afterwards if necessary. Other laxatives (Senna, Movicol) may be added by day 2-3 and if no bowel action has occurred by four days, give a micro-enema (avoid suppositories, as they tend to cause pain). If the bowels remain stubborn seek senior advice.

        4. Non-GI abdominal operations e.g. cholecystectomy. As for ’1’. If glycerol suppositories fail try simple laxatives cautiously e.g. lactulose (10mL twice daily) unless abdominal pain is severe. After 6 days try a Micro-enema. If all this fails seek senior advice.
        Link   UHL Guidelines: Laxative Algorithm
        01.06.01 Bulk-forming laxatives
        A combination of ispaghula and senna provides a rational choice for resistant constipation
        Link   UHL Guidelines: Laxative Algorithm
        First Choice:
        Ispaghula Husk  (Fybogel®)
        Suitable for long term use. May not have an immediate effect. Adequate fluid intake must be maintained. Mixing ispaghula husk with refrigerated water delays the onset of gelling and may aid administration
        01.06.02 Stimulant laxatives
        • Stimulant laxatives increase intestinal motility and often cause abdominal cramp
        • Avoid in intestinal obstruction but may be used in patients with an atonic colon or full rectum.
        • Senna and bisacodyl are both suitable for occasional or intermittent use
        • A combination of ispaghula and senna provides a rational choice for resistant constipation

        Link   UHL Guidelines: Laxative Algorithm
        First Choice:
        Second Choice:
        Has a more purgative action than senna. Available in suppository form for rectal use
        Second Choice:
        Suppositories if rectal use required
        Restricted Drug  Co-danthramer 
        A combination of a stimulant laxative (danthron) and a softening agent (poloxamer 188) which acts within 6-12 hours. It should only be used in terminally ill patients because it is potentially carcinogenic.

        01.06.03 Faecal softeners
        Arachis Oil Enemas may be used as a lubricating laxative for patients with hard, compacted faeces when other measures have failed (see algorithm below).  They should not be used if the patient has a peanut or soya allergy.
        Link   UHL Guidelines: Laxative Algorithm
        01.06.04 Osmotic laxatives

        • Use only where bulking agents and stimulants are unsuitable

        • Macrogols such as Laxido (formerly Movicol) are preferred over lactulose by local specialists when prescribing for elderly or neurological patients with chronic constipation.  

          Prescribing points for hepatic encephalopathy

        1. Encephalopathy is thought to be caused by passage of toxic metabolites directly into the brain. Precipitating factors e.g. infection; bleeding and excessive diuresis should be identified and managed appropriately.

        2. Patients with severe liver disease are more sensitive to the central depressant effects of hypnotics, tranquillisers and opiate analgesics

        3. Neomycin is as effective as lactulose but is more likely to cause adverse effects with chronic use. Use for 5 days only. It can be used in addition to lactulose if necessary but may have an antagonistic effect. Combination therapy should be stopped if the patient’s condition deteriorates or if their stools cease to be acidic.

        4. Metronidazole is sometimes used and this may be preferred where Clostridium Difficile has been or is present. There is controlled clinical trial evidence to support use; generally for no more that 1-2 weeks.

        5. An H2 receptor antagonist should be given to prevent stress ulceration in fulminating hepatic coma.
        Link   UHL Guidelines: Acute Liver Failure
        First Choice:
        Phosphate enema 
        Rectal Use. UHL stock Fleet phosphate enemas (replacing phosphate enemas, standard tube) due to lower cost.
        Second Choice:
        ’Micolette’ or ’Relaxit’
        Restricted Drug  Lactulose 
        Use as a laxative only where bulking agents and stimulants are unsuitable. Adequate fluid intake It may take 48 hours or more to act. Prescribe as a regular dose, not “when required”. Less suitable for frail elderly patients. Associated with higher rate of faecal incontinence in this group
        Drug of choice for hepatic encephalopathy. See UHL Guidelines on Acute Liver failure above
        Restricted Drug  Macrogol Oral Powder, Compound 
        Cost of brand varies according to setting.
        Primary Care: Laxido is currently the first line brand in primary care for adults. Use Laxido paediatric in children. Brand prescribing is preferred in primary care as lower cost than generic.
        Secondary care: Movicol is currently the brand of choice.
        Macrogol oral powder compound is more costly than lactulose at usual starting doses so review regularly, chronic use may only require one sachet on alternate days.
        01.06.05 Bowel cleansing solutions

        Before colonic surgery

        1. Standard approach
        a. Fit, active patients - (starting as an outpatient) clear fluids for 48 hours with Sodium Picosulphate one sachet 24 hours before procedure and one sachet 6 hours before procedure. ’Klean-Prep’ is an alternative and should be used for diabetic patients with inflammatory bowel disease, but patients may find the large volume difficult to swallow.
        b. Less fit &/or elderly patients - admit 24-48 hours beforehand. Proceed as in ’a’ above. Set up an intravenous infusion the night before operation to correct any dehydration. Other approaches are also used.
        c. the accelerated approach where a colonoscopy/diet sheet is followed for 24 to 48hours.
        d. Enhanced recovery where a low residue diet is given for 48hours then a phosphate enema is given on admission.

        2. Before colonoscopy
        Ensure that both doctor and patient follow the written instructions provided by the Endoscopy Unit. Dietary restrictions are just as important as laxatives.

        3. Before sigmoidoscopy
        Dietary restrictions are just as important as direct bowel preparation. Some units employ an aperient regimen; others use a phosphate enema on arrival.

        The NPSA has issued an alert highlighting the risk of harm from inappropriate use of bowel cleansing solutions

        Link   NPSA Safety Alert: Bowel cleansing solutions
        Sodium Picosulfate 
        01.06.06 Peripheral opiod-receptor antagonist
        Restricted Drug  Methylnaltrexone Bromide  
        For use only the recommendation of the palliative care team.
        Use only in line with NICE guidance

        Date of entry of decision to formulary: October 2015
        01.06.07 5HT4 receptor agonists
        Restricted Drug  Prucalopride 
        For use in line with NICE TA 211 and LMSG Chronic Constipation guidance only.

        Audit requirement

        Restricted Drug  Lubiprostone  
        For use in line with NICE TA 318 and LMSG Chronic Constipation guidance only.

        Date decision added to Formulary: September 2014
        Restricted Drug  Linaclotide  
        Supported for use in line with IBS algorithm only.
        Specialist initiation by gastroenterology or functional bowel clinic at UHL
        01.07 Local preparations for anal and rectal disorders
        • Treating or prevention of constipation is likely to be beneficial
        • Contact allergic dermatitis is a relatively common problem in pruritus ani. The ingredients of common OTC products like Lanacane and Anusol may be responsible. The worst offenders are non-lignocaine anaesthetics and aminoglycosides.

        • A short burst (14 days) with potent topical steroids may be worthwhile where there is significant eczematisation.

        • Most patients arriving at hospital will have tried several ointments and creams which have not worked. Institute strict anal hygiene using cotton wool and lint / gauze with water to dab (not rub) clean instead of toilet paper. The area should be dabbed dry with soft cotton kept only for that purpose.

        First Choice:
        Anusol is safe and inexpensive and may help to relieve the symptoms associated with haemorrhoids such as pruritus and soreness
        Restricted Drug  Hydrocortisone cream 
        Ointment can be used to relieve inflammation. Do not use in the presence of untreated local infection. Avoid prolonged use.
        Restricted Drug  Prednisolone suppositories 
        Suitable for proctitis
        01.07.04 Management of anal fissures
        First Choice:
        Glyceryl trinitrate ointment 0.4%.  (Rectogesic®)
        Systemic absorption occurs and a minority of patients have to stop treatment due to headaches
        Restricted Drug  Diltiazem Cream 
        For use in patients with anal fissures who do not respond to or cannot tolerate topical glyceryl trinitrate. The cream is available on a named patient basis. This is an unlicensed product but is included in the BNF so is suitable for GPs to prescribe.
        01.09.01 Drugs affecting biliary composition and flow

        Restricted Drug  Obeticholic acid 
        For specialist hepatology use only in line with NICE TA443 to treat primary biliary cholangitis.
        Blueteq prior approval required before initiation

        Date of entry to formulary July 17
        01.09.02 Bile acid sequestrants
        Restricted Drug  Colestyramine 
        May help when diarrhoea is associated with bile acid malabsorption, for example due to ileal disease or resection. May reduce absorption of warfarin, digoxin and other drugs. Give these one hour before or 4 hours after colestyramine
        Restricted Drug  Colesevelam 
        For bile acid malabsorption (off label use) second line choice for patients who cannot tolerate colestyramine. Specialist gastroenterology initiation only.
        01.09.04 Pancreatin
        • Preparations are intended to replace absent or reduced pancreatic enzyme secretion

        • Dose requirements show considerable inter- individual variation. The dose should be adjusted according to stool frequency and consistency

        • Do not take at the same time of day as antacids

        • The capsules should preferably be swallowed whole without chewing

        • Ensure adequate hydration

        • The Committee on Safety of Medicines (CSM) has noted a possible association between some preparations containing high amounts of lipase and strictures of the large bowel in cystic fibrosis patients (not with ’Creon’ preparations). Patients taking pancreatin preparations should be reviewed if they develop new abdominal symptoms (or change in existing symptoms), to exclude colonopathy. The total dose of lipase for patients with cystic fibrosis should not exceed 10,000 units/kg/day.
        Link   CSM Advice: Higher-strength preparations
        Link   See also treatment of oesophageal varices
        First Choice:
        Pancreatin  (Creon® 10000)
        Derived from porcine origins. Some patients may object to use of it on religious grounds