Download Gastro-intestinal - Lancashire Teaching Hospitals

Lancashire Teaching Hospitals NHS Foundation Trust and Greater Preston
CCG and Chorley & South Ribble CCG
Chapter 1
Gastro-intestinal System
1.1 Dyspepsia and gastro-oesophageal reflux disease
1.1.1 Antacids and Simeticone
Indications: dyspepsia.
Magnesium trisilicate mixture – First Choice - GREEN
Co-magaldrox suspension (“Mucogel”) - Second Choice – LOW SODIUM
- GREEN
Altacite Plus/ Maalox Plus – Palliative Care use AMBER 0
Antacid containing Simeticone
Additional prescribing advice:
 Administer between meals and at bedtime, when symptoms occur;
additional doses may be taken up to once an hour.
 Antacids should preferably be given at least 1 hour before or after other
drugs, as they may interfere with absorption. Do not give at the same time
as enteric-coated tablets, as premature rupture of the coating may occur.
 Use antacids, which are low in sodium (co-magaldrox) in patients with
cardiac, renal or hepatic disease, and use with caution in renal failure as
accumulation of aluminium and magnesium may occur.
 Aluminium-containing antacids may cause constipation and those
containing magnesium may cause diarrhoea - antacids containing both
(co-magaldrox) are preferred.
 If reflux is predominant an alginate-containing antacid may be preferred however antacid content is relatively low and it should not be used for
general dyspepsia.
 Antacid & oxetacaine oral suspension – for radiotherapy patients. RED
1.1.2 Compound alginates and proprietary indigestion
preparations
Alginate in combination with an antacid increases the viscosity of stomach
contents and can protect the oesophageal mucosa and should be reserved for
use in patients with symptoms of acid reflux.
Peptac suspension – First choice - GREEN
Gastrocote Tablets – Second choice – GREEN
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Paediatric: Gaviscon Infant Sachets – for reflux - GREEN
1.2 Antispasmodics and other drugs altering gut motility
Indications: adjunct in gastro-intestinal disorders characterised by smooth
muscle spasm.


Mebeverine and peppermint oil may relieve pain in irritable bowel
syndrome and diverticular disease.
Hyoscine butylbromide injection is useful in reducing spasm in endoscopic
or radiological procedures – Hospital Use Only.
ANTISPASMODICS
Mebeverine – First choice - GREEN
Second choices:
Peppermint Oil - GREEN
N.B. Capsules should not be broken or chewed; irritation of mouth or
oesophagus may result
Alverine citrate AMBER 0
Hyoscine butylbromide AMBER 0
 Injection 20mg in 1ml
 Tablets 10mg - For symptomatic relief of gastro-intestinal or genito-urinary
disorders characterised by smooth muscle spasm and bowel colic only.
Glucagon – RED
Indications: motility inhibitor in examinations of the gastro-intestinal tract by
radiography or endoscopy.
1.3 Antisecretory Drugs and mucosal protectants
General Guidelines

Urgent specialist referral for endoscopic investigation1 is indicated for
patients of any age with dyspepsia when presenting with any of the
following: chronic gastrointestinal bleeding, progressive unintentional
weight loss, progressive difficulty swallowing, persistent vomiting, iron
deficiency anaemia, epigastric mass or suspicious barium meal.
The Guideline Development Group considered that ‘urgent’ meant being seen within
2 weeks.
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
Patients >55 years old with new symptoms not responding to simple
measures (lifestyle advice, antacids) require endoscopy before further
treatment to exclude cancer.
Lifestyle Advice
 Lose weight if overweight
 Avoid lying down after meals
 Avoid irritant food (spicy, fatty)
 Reduce alcohol consumption
 Eat smaller quantities at meals
 Avoid late-night eating
 Stop smoking
H.Pylori Eradication

Patients with peptic ulceration shown to have infection with H. pylori
should be treated with an eradication regime. There are many regimes
available, but currently the recommended regime based on eradication
rate achieved and patient tolerability is:Lansoprazole 30mg twice daily
(or Omeprazole 20mg twice daily)
+
Amoxicillin 1g twice daily
+
Clarithromycin 500mg twice daily
ALL FOR 1 WEEK
 NB. If allergic to penicillin:
Use Clarithromycin 250mg bd and Metronidazole 400mg bd.



H. Pylori eradication is not always successful. If symptoms recur, seek
specialist advice.
It is not necessary to routinely confirm successful eradication in patients
who are no longer symptomatic. However, if confirmation is thought
necessary for certain patients who are at high risk in which further
ulceration may be life threatening - seek specialist advice.
Patients with non-ulcer dyspepsia but who have H. pylori infection there is little evidence that eradication will produce relief of dyspepsia, but
the patient may still reasonably want to have the infection eliminated.
Duodenal ulcer (refer to NICE guidance for treatment algorithm)
-
http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline
Erosive duodenitis should be treated as for duodenal ulcer.
Gastric ulcer (refer to NICE guidance for treatment algorithm)
- http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline
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
All patients with a GASTRIC ULCER should be referred for repeat
endoscopy after completion of treatment to ensure complete
epithelialisation.
H.Pylori - Negative Peptic Ulcer (refer to NICE guidance for treatment
algorithm)
- http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline

All patients with gastric ulcer need to be sent for a repeat endoscopy.
Prevention Of Gastro-Intestinal Complications In Those Taking NSAIDs







Prophylaxis with low dose PPI should be considered in patients who are in
at least one of the following high risk groups, if they are taking regular
NSAID therapy:
Age 65 years
Previous history of peptic ulcer when taking NSAID
Previous history of gastro-intestinal bleeding
Taking other medicines that could increase the risk of gastro-intestinal side
effects
Patients on systemic corticosteroid therapy
Co-morbidity
Treatment Of Peptic Ulceration Occuring During NSAID Therapy
(refer to NICE guidance for treatment algorithm)
-
http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline
Gastro-Oesophageal Reflux Disease (GORD)
(refer to NICE guidance for treatment algorithm)
-
http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline
Non-Ulcer (Functional) Dyspepsia- dyspepsia with no identifiable cause on
investigation.
(refer to NICE guidance for treatment algorithm)
- http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline

Treatment is aimed at symptom relief.
Step 1 -
Consider alternative diagnosis e.g. gallstones, irritable bowel
syndrome
Step 2 Lifestyle modification + antacid/alginate (Reserve for patients
with symptoms of reflux.)
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Step 3 -
change to lowest effective dose of PPI.
Non-Erosive Duodenitis

Treat as for non-ulcer dyspepsia.
1.3.1 H2-RECEPTOR ANTAGONISTS
Ranitidine - GREEN
1.3.3 CHELATES AND COMPLEXES
Sucralfate – Consultant Initiation AMBER 0
Indications: Stress ulcer prophylaxis in critically ill patients and difficult
dyspepsia/bile reflux patients.
1.3.5 PROTON PUMP INHIBITORS

All prescriptions for proton pump inhibitors should state the
intended duration of treatment to avoid indefinite and unnecessary
treatment. Discharge letters should also state intended duration of
treatment.
Lansoprazole -GREEN
 Fastabs – for swallowing difficulties Only - green
NB. Fastabs can be dispersed in a small amount of water and administered
by oral syringe or nasogastric tube.
Omeprazole - GREEN
 Mups – Paediatrics Only - green
 Injection 40mg – Hospital only RED
 Major peptic ulcer bleeding (following endoscopic treatment) initial
intravenous infusion of omeprazole 80mg over 40-60 minutes then by
continuous IV infusion, omeprazole 8mg/hour for 72 hours.
 See FAQ – intranet – pharmacy, medicines information
Esomeprazole - Consultant Initiation AMBER 0
 Second line after treatment failure with another PPI
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1.4 Acute diarrhoea.
1.4.2 Antimotility drugs
Indications: adjunct to fluid and electrolyte replacement in acute diarrhoea;
adjunct to other therapy in chronic diarrhoea.
Loperamide – First choice -GREEN
Codeine phosphate – Second choice - GREEN
Co-phenotrope – Consultant Initiation AMBER 0
 For short bowel syndrome and high output stoma patients.
Additional prescribing advice:
 Mild infective diarrhoea lasting < 24 hours should not be treated with
antimotility drugs. Oral rehydration preparations may be given, especially to
frail and elderly patients.
 In other cases, investigate cause (history of travel, antibiotics, other drugs,
inflammatory bowel disease; stool microscopy and culture). If there are no
contra-indications, antimotility drugs may be used to control symptoms.
 Refer to Antibiotic Guidelines for treatment of enteric infection and
antibiotic-associated Clostridium difficile infection.
 For high output ileostomy and short bowel syndromes control of water and
electrolyte losses requires special attention - seek expert help.
 Do not use anti-motility drugs where impairment of peristalsis should be
avoided e.g. hepatic encephalopathy and severe colitis (risk of dilatation).
1.5 Chronic Bowel Disorders
INFLAMMATORY BOWEL DISEASE
 ALL PATIENTS SHOULD BE ASSESSED BY A CONSULTANT WITH
AN INTEREST IN GASTROENTEROLOGY (if diagnosis unclear).
1.5.1 Aminosalicylates
Mesalazine – amber 0
Indications: treatment of mild to moderate inflammatory bowel disease and
maintenance of remission.
Additional prescribing advice:
 Preparations are suitable for various sites of disease.
 Octasa or Asacol releases mesalazine in the distal ileum and proximal
colon and is therefore best suited to ileo-colonic Crohn’s disease and
ulcerative colitis.
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 Pentasa is licensed for ulcerative colitis
 Different formulations of mesalazine have different release characteristics
and should not be regarded as interchangeable; the proprietary name
should be specified.
 If Mesalazine tablets are prescribed – Octasa brand will be dispensed. For
Asacol this will need to be prescribed by brand.
 Mesalazine enema, foam enemas and suppositories may be used for distal
colitis or rectal disease resistant to prednisolone enema or suppositories
either instead of or in addition to topical prednisolone.
 Patients should be told to report any unexplained bleeding, bruising,
purpura, sore throat, fever or malaise that occurs during treatment. A blood
count should be performed and the drug stopped immediately if there is
suspicion of a blood dyscrasia.
 Avoid in renal impairment (nephrotoxic).
Balsalazide – Consultant initiation AMBER 0
Sulphasalazine (Sulfasalazine) AMBER 2
Indications: induction and maintenance of remission in ulcerative colitis;
active Crohn’s disease.
1.5.2 Corticosteroids
Prednisolone – For these indications use Plain tablets - NOT E.C. GREEN
Indications: Orally - treatment of severe Crohn’s disease and ulcerative
colitis
Rectally - treatment of proctitis, distal Crohn’s disease and
ulcerative colitis; adjunct to systemic steroids in severe distal disease.
NB. enteric-coated form not suitable for use in inflammatory bowel conditions
characterised by diarrhoea or a rapid transit time as it could cause symptoms
to recur.
Budesonide (CR) – Consultant initiation AMBER 0
Hydrocortisone (Colifoam) – AMBER 0
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1.5.3 Drugs affecting the immune response
Should only be used under expert supervision.
Azathioprine - AMBER 2
Ciclosporin – unlicensed indication - AMBER 2
Mercaptopurine – unlicensed indication - AMBER 2
Methotrexate – unlicensed indication - AMBER 2
Infliximab - NICE TA187, NICE TA163 – RED, NICE TA 329 RED
Adalimumab – NICE TA187 – RED, NICE TA329 RED
Golimumab NICETA329 - RED
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1.6 Laxatives
GUIDELINES ON TREATMENT OF CONSTIPATION
ACUTE CONSTIPATION
Identify and treat cause:
 Mechanical obstruction (if suspected organise X-ray and surgical referral)
 Underlying disease
 Dehydration
 Immobility
 Drug therapy (if possible, avoid or reduce dose)
 Pregnancy
 Low fibre intake
CHRONIC CONSTIPATION
Assessment:
 Treat any underlying cause - underlying disease, dehydration, immobility or
drug therapy (if possible, avoid or reduce dose).
 Increase Dietary fibre intake
 Add bulk forming agent
 Add faecal softener
 Add stimulant laxative
 Movicol (Specialist advice)
PREGNANCY
 Fybogel, lactulose and glycerin suppositories may be used.
ELDERLY
 Bulking agents are unsuitable for frail or immobile elderly patients. A
stimulant laxative (e.g. senna) with or without a faecal softener (e.g.
docusate) is most appropriate
PATIENTS TAKING OPIOID ANALGESICS
 Patients prescribed regular opiates for any longer than a few days may
become constipated e.g. post-operatively. This can be minimised by
attention to diet, mobility and fluid intake, but patients prescribed regular
opiates for longer than a few days should be prescribed regular laxatives
for the duration of opiate treatment if constipation occurs, providing there
are no contra-indications (e.g. intestinal obstruction). This is mandatory in
terminally ill patients as soon as they are prescribed continuous, regular
opiate therapy (see Palliative Care Guidelines).
PALLIATIVE CARE
 See Palliative Care Guidelines.
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1.6.1 Bulk-forming laxatives
Indications: Chronic constipation where dietary measures are insufficient;
management of patients with colostomy, ileostomy, haemorrhoids, anal
fissure, chronic diarrhoea associated with diverticular disease, irritable bowel
disease and ulcerative colitis.
Ispaghula - GREEN
N.B. Preparations that swell on contact with water should be swallowed
carefully and should not to be taken immediately before going to bed.
Additional prescribing advice:
 Adequate fluid intake must be maintained to avoid intestinal obstruction
 Avoid use in intestinal obstruction, colonic atony and faecal impaction as
they may compound the condition; use with caution in the elderly. Avoid in
patients who have difficulty swallowing.
 Use with caution in patients with opiate-induced constipation (risk of
obstruction).
 May take several days for full effect (patients should be told this) and are
therefore more suitable in patients with normal gut motility and
uncomplicated constipation.
1.6.2 Stimulant laxatives
Indications: Acute constipation
Senna - GREEN
Bisacodyl - GREEN
N.B Acts in 20-60 minutes
Docusate (Dioctyl sodium sulphosuccinate) - GREEN
N.B. Acts within 1-2 days.
Glycerol suppositories (Glycerin) - GREEN
Danthron (Dantron) – Palliative Care Only - GREEN
N.B. Rodent studies have indicated a potential carcinogenic risk with
danthron. It should only be used for opiate-induced constipation in terminally
ill patients.
 Co-Danthrusate
Additional prescribing advice:
 Avoid in intestinal obstruction
 Avoid prolonged use, except in elderly and terminally ill patients
 Acts in 8-12 hours when given orally
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1.6.3 Faecal softeners
Indications: to soften impacted faeces
Arachis oil Enema - GREEN
1.6.4 Osmotic laxatives
Lactulose – First Choice - GREEN
Indications: Chronic constipation, hepatic encephalopathy.
N.B. Acts in 48 hours; not suitable for acute constipation
Constipation – 10ml bd
Hepatic encephalopathy
Lactulose - 30-50ml 3 times daily, subsequently adjusted to produce 2-3 soft
stools daily.
Rifaximin NICE TA 337 – Consultant initiation – AMBER 0
Use only when lactulose NOT working
Macrogols (movicol) – Second Choice - GREEN
Indications: Chronic constipation.
Acute Constipation:
Phosphates (rectal) Enema - GREEN
Sodium citrate (rectal) micro-enema - GREEN
1.6.5 Bowel cleansing preparations
Indications: Bowel preparation before elective colonic surgery, colonoscopy
or radiological examination.
 Oral Powder - Klean-prep, Moviprep, Picolax - GREEN
 See Hospital Guidelines
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1.6.7 Other Drugs Used in Constipation
Indications: chronic constipation in women when other laxatives fail to
provide an adequate response.
Prucalopride AMBER 0
Approved in line with NICE guidance TA211. After 4 weeks the patient is reassessed and only continued if there was clear benefit. Prescribing will pass
to primary care after evidence of benefit to the patient.
Lubiprostone AMBER 0
Approved in line with NICE guidance TA318. If treatment with lubiprostone is
not effective after 2 weeks, the person should be re-examined and the benefit
of continuing treatment reconsidered. Prescribing will pass to primary care
after evidence of benefit to the patient.
Indications: Moderate to severe irritable bowel syndrome with constipation
Linaclotide AMBER 0
Review treatment if no response after 4 weeks
Drug treatment of constipation in children
General principles
 Attention to diet & fluid intake may avoid the need for drugs.
 Whatever drug regime is employed diet & fluids are still the most important
factor in determining long term outcome.
 The general approach to drug treatment is:
Step 1: Soften retained faeces with softener
Step 2: Add in stimulant to evacuate softened faeces
Step 3: Maintain bowel habit with a combination of softener & stimulant
 Wherever possible, a licensed medicine should be prescribed. However the
informed use of unlicensed medicines or of licensed medicines for
unlicensed applications is necessary in paediatric practice.
 The approach should always be flexible to suit the individual child/family
and these guidelines are not rigid.
 Laxatives generally have a low incidence of side effects and with careful
supervision doses can be increased above those given in the BNF.
 There is no convincing evidence of laxative dependence or diminution of
effect with continuing use.
 Various laxatives in multiple combinations may be used - there is little
evidence-based data to support any one laxative combination over the
others.
 Support & frequent and prolonged follow up is essential in the treatment of
constipation in childhood & it is important that the family realises that long
term drug treatment is very often needed.
 25% patients off laxatives within 6m of starting Rx
 50% patients off laxatives within 1yr of starting Rx
 75% patients off laxatives within 2yr of starting Rx
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Disimpaction:
First choice: Movicol paediatric plain - GREEN
Add a stimulant laxative: Senna, Docusate sodium, Bisacodyl or Sodium
picosulfate
Substitute a stimulant laxative or add an Osmotic laxative: Lactulose
Additional Prescribing Advice
 Lactulose takes 48hrs for full effect. Teeth should be brushed afterwards.
 Senna may cause gripes. Onset of action 8-12 hours, initial dose should be
low and the recommended dose only to be exceeded on specialist advice.
 Movicol can be used as single daily doses regularly in severe chronic
constipation. It may also be used as an alternative to enema/manual
removal for faecal impaction.
1.7 Local
preparations for anal and rectal disorders.
1.7.2 Compound haemorrhoidal preparations with
corticosteroids
Indications: local relief of haemorrhoids.
“Anusol” - GREEN
Scheriproct - GREEN
 cinchocaine 5mg and hydrocortisone 5mg
Scheriproct is suitable for occasional short-term use after exclusion of
infection.
NB. Radiotherapy patients may use for 14 days.
“Anusol HC” - GREEN
 Suppositories (with hydrocortisone acetate 10mg)
NB. Alternative for patients not benefiting from Scheriproct.
Radiotherapy patients may use for 14 days.
1.7.3 Rectal sclerosants
Indications: haemorrhoids
Oily Phenol injection - RED
 Oily Phenol injection 5% 5ml
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1.7.4 Management of Anal Fissures
First choice:
Glyceryl Trinitrate ointment 0.4% (Rectogesic) – AMBER 0
Second choice:
Unlicensed - Diltiazem Cream 2% - RED
1.8 Stoma care.
Contact stoma care nurse – Kim Moxham (Extension and bleep 2371)
Caution when prescribing enteric coated and slow release preparations,
laxatives, antidiarrhoeals, antibiotics, antacids, diuretics, digoxin, analgesics,
iron preparations and oral contraceptives.
1.9 Drugs affecting intestinal secretions
1.9.1 Drugs affecting biliary composition and flow
Indications: gall stone disease in patients in whom laparoscopic or
endoscopic treatment is unsuitable, primary biliary cirrhosis.
Ursodeoxycholic acid – Consultant initiation AMBER 0
Additional prescribing advice:
 Gallstone dissolution therapy should only be initiated on expert advice.
 Therapy is effective only for cholesterol gallstones and treatment may be
required for two years or more.
1.9.2 Bile acid sequestrants
Indications: pruritis in liver disease.
Colestyramine (“Questran light”) – Consultant initiation AMBER 0
 Other drugs should be taken at least 1 hour before or 4 - 6 hours after
colestyramine to reduce possible interference with absorption.
 Sachets 4g (sugar free)
Dosage: To relieve pruritis 1-2 sachets daily are usually sufficient.
N.B. Administration as a single daily dose makes giving other tablets at a
different time easier; however patient tolerance may mean administration in
divided doses is preferable.
Menthol 1% in aqueous cream AMBER 0
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1.9.4 Pancreatin
Indications: replacement in cystic fibrosis and following pancreatectomy,
total gastrectomy or chronic pancreatitis.
Pancreatin AMBER 0
 Capsules “Creon” 10,000 and 25,000
N.B. capsules may be swallowed whole, or the contents may be mixed
with fluid or soft food and swallowed immediately without chewing
 Granules “Pancrex”
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