BNF Chapter 1: GASTRO-INTESTINAL SYSTEM

1. Gastro-Intestinal System | 2. Cardiovascular System | 3. Respiratory System | 4. Central Nervous System | 5. Antimicrobials | 6. Endocrine System | 7. Obstetrics, Gynaecology & Urology | 8. Malignant Disease & Immunosuppression | 9. Nutrition & Blood | 10. Musculoskelatal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics |  GP Centre Home

ANTACIDS Emergency Treatment of Poisoning – Elimination of GI Tract
CHARCOAL ACTIVATEDOral suspension 50gSeek advice from National Poisons Centre
http://www.toxbase.org/
YOU WILL NEED A USERNAME AND PASSWORD
CHRONIC BOWEL DISORDERS BNF CODE – 1  
1.3 – Inflammatory Bowel Disease
AMINOSALICYLATESNOTES
Delivery characteristics of oral mesalazine preparations may vary These preparations should NOT be considered interchangeable Prescribe by brand name

What are the differences between different brands of mesalazine tablets?

MESALAZINEOCTASA:  MR Tablets 400mg, 800mg

MEZAVANT XL: MR Tablets 1.2g

PENTASA: MR Tablets 500mg,   Suppositories 1g, Retention Enema 1g/100ml

SALOFALK: Tablets 250mg, 500mg,  1g  Granules 500mg, 1g, 1.5g, 3g

 APC Mesalazine 400mg MR tablets Policy Statement 2012

APC Salofalk for treatment of Ulcerative Colitis Policy Statement 2016

APC traffic light status: GREEN

OLSALAZINE SODIUM Capsules 250mg, Tablets 500mgAPC traffic light status: none
SULFASALAZINE Tablets EC 500mg

Suspension 250mg in 5ml

APC traffic light status: AMBER
CORTICOSTEROIDSNOTES
BUDESONIDE3 mg E/C MR Capsules (ENTOCORT)RESTRICTED for GASTROENTEROLOGY team only
Licensed for mild to moderate Crohns affecting ileum or ascending colon. ADULTS
9mg once daily in the morning for up to 8 weeks
Reduce dose for the last 2 weeks of treatmentAPC traffic light status: none
3 mg E/C Capsules (BUDENOFALK)RESTRICTED for GASTROENTEROLOGY team only
Licensed for mild to moderate Crohns affecting ileum or ascending colon. ADULTS
3mg three times daily for up to 8 weeks
Reduce dose for the last 2 weeks of treatment]APC traffic light status: none
Rectal foam 2mg/metered applicationRecommended by Surrey PCN as 1st line foam enema for UC

PC Budenofalk rectal foam for Ulcerative Colitis Policy Statement 2017

APC traffic light status: GREEN

HYDROCORTISONE ACETATE10% Foam enemaAPC traffic light status: GREEN
PREDNISOLONERectal Foam enema 20mgAPC traffic light status: BLACK
IMMUNOSUPPRESSANTS – Monoclonal antibodiesNOTES
Biologic drugs should always be prescribed by brand. The brand providing best value in the local health economy should be prescribed for all new patients. After obtaining informed consent, existing patients should be switched to the brand providing best value in the local health economy.Infliximab, Adalimumab, Vedolizumab and Golimumab are High Cost Drugs and Payment by Results excluded
PCN Crohn’s treatment flow diagram updated August 2017

APC statement: TNF alpha sequential use in UC

APC Ulcerative Colitis biologics pathway

ADALIMUMAB   40mg injectionPrescribing should be by an NHS specialist only, in line with NICE and/or local pathways. Funding is only available with the use of Blueteq initiation and continuation forms.

NICE TA 187 Infliximab and adalimumab for the treatment of Crohn’s disease

NICE TA 329 Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy

PCN Implementation of NICE TA 329 Policy Statement APC statement: Adalimumab dose escalation APC Policy Statement: Adalimumab biosimilar (Aug 2019)

APC traffic light status: RED

INFLIXIMAB 100mg vialPrescribing should be by an NHS specialist only, in line with NICE and/or local pathways. Funding is only available with the use of Blueteq initiation and continuation forms.

Currently Inflectra®provides the best value in the local health economy.

NICE TA 163 Infliximab for acute exacerbations of ulcerative colitis

NICE TA 187 Infliximab and adalimumab for the treatment of Crohn’s disease

NICE TA 329 Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy

Dose escalation is possible (5mg/kg every 6 weeks or 10mg/kg every 8 weeks) in patients with moderate to severe active UC for a 12 week course to recapture response. If the patient loses reqponse to statndard dosing within a short time period, funding can be applied for to return to escalated dose.

IBD Infliximab Protocol

PCN Implementation of NICE TA 329 Policy Statement APC Policy Statement: Infliximab biosimilar (August 2019)

APC traffic light status: RED

VEDOLIZUMAB300mg injection Prescribing should be by an NHS specialist only, in line with NICE and/or local pathways. Funding is only available with the use of Blueteq initiation and continuation forms.

NICE TA 342Vedolizumab for treating moderately to severely active ulcerative colitis

NICE TA 352 Vedolizumab for treating moderately to severely active Crohn’s disease after prior therapy

PCN Vedolizumab for Ulcerative Colitis Policy Statement 2015 PCN Vedolizumab for Crohn’s Disease Policy Statement 2015

APC traffic light status: RED

GOLIMUMAB50mg Pre-filled syringe Prescribing should be by an NHS specialist only, in line with NICE and/or local pathways. Funding is only available with the use of Blueteq initiation and continuation forms.

NICE TA 329 Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy

PCN Implementation of NICE TA 329 Policy Statement

APC traffic light status: RED

USTEKINUMABInjection 45mg/0.5ml, 90mg/1mlPrescribing should be by an NHS specialist only, in line with NICE and/or local pathways. Funding is only available with the use of Blueteq initiation and continuation forms.

NICE TA456 – Ustekinumab for moderately to severely active Crohn’s disease after previous treatment

NICE TA 633: Ustekinumab for treating moderately to severely active ulcerative colitis

Ustekinumab for treating Crohn’s Disease PCN Policy Statement APC Policy Statement: GR Ustekinumab dose escalation

APC traffic light status: RED

IMMUNOSUPPRESSANTS – OtherNOTES
AZATHIOPRINETablets 25mg, 50mg IBD APC traffic light status: AMBER

Azathioprine & 6MP in IBD shared care

CICLOSPORINCaps 25mg, 50mg, 100mg

Injection 50mg/ml

Unlicensed (in UC)

Trust Guideline (Severe UC) 2012

APC traffic light status: RED

6-MERCAPTOPURINETablets 50mg IBD APC traffic light status: AMBER

Azathioprine & 6MP in IBD shared care

JANUS KINASE INHIBITORSNOTES
TOFACITINIB5mg tabletsPrescribing should be by an NHS specialist only, in line with NICE and/or local pathways. Funding is only available with the use of Blueteq initiation and continuation forms.

NICE TA 547: Tofacitinib for moderately to severely active ulcerative colitis

APC traffic light status: RED

1.4 – Irritable Bowel Syndrome
ANTISPASMODICSNOTES
MEBEVERINETablets 135mg

Liquid 50mg in 5ml

APC traffic light status: GREEN
PEPPERMINT OILCapsulesAPC traffic light status: GREEN
LAXATIVES – Guanylate cyclase-C Receptor AgonistsNOTES
LINACLOTIDE290microgram capsulesNICE Evidence summary: Irritable bowel syndrome with constipation in adults: linaclotide

APC traffic light status: GREEN (RED on Crawley, Horsham and Mid Sussex CCGs formulary.)

ANTIDIARRHOEALSNOTES
 ELUXADOLINE 75mg tablet

100mg tablet

NICE TA471: Eluxadoline for treating irritable bowel syndrome with diarrhoea

PCN Policy Statement: Eluxadoline for IBS with diarrhoea

MHRA ALERT: Eluxadoline (Truberzi▼): risk of pancreatitis; do not use in patients who have undergone cholecystectomy or in those with biliary disorders. Click for further details.

APC traffic light status: RED

2 CONSTIPATION & BOWEL CLEANSING
2.1 Bowel Cleansing
NPSA Alert for Bowel cleansingBetween 2002 and 2012 patient safety alerts were issued by the National Patient Safety Agency (NPSA) – the NPSA website was archived in 2012.  Please use material with caution.  NPSA Alerts were only updated to reflect changes in current safety knowledge or clinical care until the point their ‘action complete’ date was reached.  Some of these ‘action complete’ dates for NSPA Alerts, Safety Notices and Rapid Response Reports are now over fifteen years in the past, and no NPSA publications have been updated since the closure of the NPSA in 2012.

Reducing risk of harm from oral bowel cleansing preparations

 Prescribing guidance for treatment of constipation in adults in primary care
CITRAMAGOral PowderAPC traffic light status: none
MOVIPREPOral Powder2 sachets when reconstituted with water to 2 litres provides solution for bowel cleansing

APC traffic light status: none

FLEET PHOSPHO-SODAOral solutionAvoids cramping & stimulant effects

APC traffic light status: none

KLEAN-PREPOral PowderRESTRICTED use for Paediatric Team

APC traffic light status: none

PICOLAXOral PowderAPC traffic light status: none
2.2 CONSTIPATION
BULK FORMING LAXATIVES NOTES
ISPAGHULA HUSK3.5g Granule sachetsAPC traffic light status: GREEN
STERCULIA620mg/g 7g sachetsTreatment of diarrhoea & constipation in patients undergoing pelvic radiotherapy

APC traffic light status: GREEN

CHORIDE-CHANNEL AGONISTSNOTES
LUBIPROSTONECapsules, 24 micrograms NICE Guidance (TA318) Lubiprostone for treating chronic idiopathic constipation

PCN Lubiprostone for the treatment of Chronic Idiopathic Constipation SURREY CCGs Constipation in adults – Prescribing guidance for primary care

APC traffic light status: GREEN

OSMOTIC LAXATIVESNOTES
LACTULOSE SolutionAPC traffic light status: GREEN
MACROGOL (polyethylene glycol) Oral Compound SachetsAPC traffic light status: GREEN
MACROGOL PAEDIATRIC Oral Compound SachetsAPC traffic light status: none
MAGNESIUM HYDROXIDE BP MixtureAPC traffic light status: GREEN
PHOSPHATE Enema (long tube), (standard tube)General ward in-pt use

APC traffic light status: GREEN

SODIUM CITRATE RELAXIT ® Micro-enemaGeneral ward in-pt use

APC traffic light status: GREEN

SODIUM CITRATE 0.3M oral solutionAPC traffic light status: none
SELECTIVE 5HT-4 RECEPTOR AGONISTSNOTES
PRUCALOPRIDE 1mg, 2mg tabletsNICE TA211: Prucalopride for the treatment of chronic constipation in women

Constipation in women

APC traffic light status: GREEN

FAECAL SOFTENERSNOTES
ARACHIS OIL EnemaWARNING: Contra-indicated in patients with nut allergies. Use Phosphate Enema.

APC traffic light status: none

DOCUSATE SODIUM Capsules 100mg

Syrup 50mg in 5ml

 Also stimulant laxative

APC traffic light status: GREEN

LIQUID PARAFFIN & MAGNESIUM HYDROXIDE B.P. EmulsionRESTRICTED use. Obstetrics & Gynaecology Only

APC traffic light status: none

STIMULANT LAXATIVES NOTES
BISACODYL Tablets 5mg

Suppositories 5mg (paediatric), 10mg

APC traffic light status: GREEN
CO-DANTHRAMERCapsules 25/200,

Suspension 25/200 in 5ml, 75/1000 in 5ml

RESTRICTED use. The CSM Advise the indication for dantron containing products are restricted to treat constipation in terminally ill patients.

APC traffic light status: GREEN

GLYCERIN Suppositories 4gAPC traffic light status: GREEN
SENNA Tablets 7.5mg

SF Solution 7.5mg in 5ml

APC traffic light status: GREEN
SODIUM PICOSULFATE Capsules 2.5mg

Elixir 5mg in 5ml

APC traffic light status: GREEN
OPIOID RECEPTOR ANTAGONISTSNOTES
NALOXEGOLTablets, 25mgNICE TA 345: Naloxegol for treating opioid‑induced constipation

PCN Naloxegol for opioid-induced constipation Policy Statement 2015

APC traffic light status: GREEN

3 DIARRHOEA
ANTIDIARRHOEAL DRUGS – AntipropulsivesNOTES
CODEINE PHOSPHATE Tablets 30mg

Solution 25mg in 5ml

APC traffic light status: GREEN
CO-PHENOTROPEDiphenoxylate 2.5mg + Atropine 25micrograms TabletsRESTRICTED for occasional use, consultant request only and also reserved for St.Mark’s Centre treatment for IBS

APC traffic light status: GREEN

LOPERAMIDE Capsules 2mg

Syrup 1mg in 5ml

APC traffic light status: GREEN
 4 DISORDERS OF GASTRIC ACID & ULCERATION 
4.1 Dyspepsia
ALGINATESNOTES
GAVISCON AdvanceTablets

Suspension

APC traffic light status: GREEN
ALUMINIUM AND MAGNESIUM CONTAINING ANTACIDSNOTES
ALUMINIUM HYDROXIDECapsules 475mgNo sodium, can be constipating

APC traffic light status: none

CO-MAGALDROX (MUCOGEL)Suspension (Magnesium Hydroxide 195mg + Aluminium Hydroxide 220mg in 5ml)Sugar Free, Low sodium
neutral effect on bowel (neither constipating or laxative)APC traffic light status: GREEN
MAGNESIUM TRISILICATE Oral suspensionNa+ = 6mmol per 10ml

APC traffic light status: GREEN

ANTACID AND OXETACAINEOral suspensionUnlicensed

Restricted to St Luke’s radiotherapy patients

APC traffic light status: none

4.2 Gastric & Duodenal Ulceration
CHELATES AND COMPLEXESNOTES
SUCRALFATETablets 1g

Suspension 1g in 5ml

Benign gastric & duodenal ulcer
Chronic gastritis
Prophylaxis stress ulcerationAPC traffic light status: RED
H2 – RECEPTOR ANTAGONISTSNOTES
Medicines Q&A – Clostridium difficile infection – are acid suppressant medicines a risk factor?

Clostridium difficile infection – is use of proton pump inhibitors a risk factor?

RANITIDINETablets 150mg

Syrup 75mg in 5ml

Injection 50mg in 2ml

APC Ranitidine Recall Advice V6

APC traffic light status: GREEN

PROSTAGLANDIN ANALOGUESNOTES
MISOPROSTOL Tablets 200microgramsBenign gastric & duodenal ulcer
NSAID associated ulcer (treatment & prophylaxis)APC traffic light status: none
PROTON PUMP INHIBITORSNOTES
NICE GuidanceNICE Guidance Dyspepsia CG17
“Golden Rules” of PPI Prescribing (SASH)Golden Rules of PPI prescribing (SASH)
Medicines Q&A – Is there an interaction between warfarin and proton pump inhibitors?

Is there an interaction between warfarin and proton pump inhibitors?

Medicines Q&A – Do proton pump inhibitors reduce the clinical efficacy of clopidogrel?

Do proton pump inhibitors reduce the clinical efficacy of clopidogrel?

Medicines Q&A – Clostridium difficile infection – are acid suppressant medicines a risk factor?

Clostridium difficile infection – is use of proton pump inhibitors a risk factor?

Medicines Q&A – IS there an interaction between bisphosphates and proton pump inhibitors?

Is there an interaction between bisphosphonates and proton pump inhibitors?

LANSOPRAZOLE Capsules 15mg, 30mg

Orodispersible 15mg, 30mg

APC traffic light status: GREEN
OMEPRAZOLE Capsules 10mg, 20mg, 40mgAPC traffic light status: GREEN
 Dispersible tablets (MUPS) 40mgRESTRICTED  for Paediatric use

APC traffic light status: GREEN

 Intravenous infusion 40mgNilByMouth  or coffee ground vomit are NOT indications for IV PPI administration
 
RESTRICTED for the following situations
 
1)Post therapeutic endoscopy for proven peptic haemorrhage
2)Recommendation of GI Consultant

APC traffic light status: RED

ESOMPERAZOLE Tablets 20mg, 40mgRESTRICTED use for
1) GASTROENTEROLOGY CONSULTANTS  in patients who have tried other PPIs up to at least a dose of 40mg omeprazole daily.APC traffic light status: BLACK
4.4 Helicobacter pylori diagnosis
UREA (13C) BREATH TESTAPC traffic light status: none
6 GASTRO-INTESTINAL SMOOTH MUSCLE SPASM 
ANTIMUSCARINICSNOTES
HYOSCINE BUTYLBROMIDETablets 10mg

Injection

Drug Safety Update Feb 2017 – Injection: Risk of serious adverse effects in patients with underlying cardiac disease

APC traffic light status: GREEN

ANTISPASMODICS NOTES
MEBEVERINETablets 135mg

Liquid 50mg in 5ml

APC traffic light status: GREEN
7 LIVER DISORDERS & RELATED CONDITIONS 
7.1 Biliary Disorders
BILE ACID SEQUESTRANTSNOTES
CHOLESTYRAMINE Sachet 4gAPC traffic light status: none
BILE ACIDSNOTES
URSODEOXYCHOLIC ACID Tablets 150mg, Capsules 250mg

Suspension 250mg in 5ml

APC traffic light status: BLUE
FARNESOID X RECEPTOR AGONISTNOTES
OBETICHOLIC ACIDTablets 5mg, 10mg  NICE TA 443 Obeticholic Acid for treating Primary Billary Cholingitis

Funding through NHS England / specialised commissioning
NHSE intent to treat letter v1.2

MHRA/CHM advice: Obeticholic acid (Ocaliva®): risk of serious liver injury in patients with pre-existing moderate or severe hepatic impairment; reminder to adjust dosing according to liver function monitoring (April 2018)

 

Billiary cirrhosis APC traffic light status: RED

7.2 Oesophageal Varicies
TERLIPRESSIN1mg injectionAPC traffic light status: none
8 Obesity
ORLISTATCapsules, 120mgUKMi Interaction between Orlistat & Thyroxine

Obesity: Guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children [CG43]

APC traffic light status: GREEN

9 RECTAL & ANAL DISORDERS 
9.1 Anal Fissures
Glyceryl Trinitrate (GTN) 0.4% Ointment 30g1st line for anal fissure

APC traffic light status: GREEN

Diltiazem 2% Cream 30gRESTRICTED use for GI Surgical Team

UNLICENSED product

2nd line for patients with adverse event or intolerance to 1st line GTN ointment

APC traffic light status: GREEN

2% Cream 30gRESTRICTED use for GI Surgical Team

UNLICENSED product

2nd line if anal fissure has not managed to heal after treatment with 1st line GTN.

No information sheet

APC traffic light status: BLUE

9.2 Haemorrhoids
CorticosteroidsNOTES
ANUSOL HC Ointment, SuppositoriesAPC traffic light status: GREEN
CINCHOCAINE WITH HYDROCORTISONE (PROCTOSEDYL) Ointment, SuppositoriesAPC traffic light status: none
Non – Corticosteroids NOTES
ANUSOL Cream, Ointment, SuppositoriesAPC traffic light status: GREEN
RECTAL SCLEROSANTSNOTES
No available licensed product
10 REDUCED EXOCRINE SECRETIONS 
PANCREATIC ENZYMESNOTES
PANCREATIN Creon®  Capsules 10000 units, 25000 unts

Pancrex V Capsules, Pancrex V Forte Tablets

 CSM warning: Evidence associating high strength pancreatin preparations with the development of large bowel strictures (fibrosing colonopathy) in children with cystic fibrosis aged between 2yr-13yr

APC traffic light status: none

ADDITIONAL TOPICS
 Oral  Rehydration
St Marks Electrolyte mix

What is St Mark’s Electrolyte Mix (solution)?

 Nausea & Vomitting – SEE CHAPTER 4 (Nervous System) – 4.5 NAUSEA & LABYRINTH DISORDERS

 

 

1. Gastro-Intestinal System | 2. Cardiovascular System | 3. Respiratory System | 4. Central Nervous System | 5. Antimicrobials | 6. Endocrine System | 7. Obstetrics, Gynaecology & Urology | 8. Malignant Disease & Immunosuppression | 9. Nutrition & Blood | 10. Musculoskelatal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics |  GP Centre Home