1 Chap GI 2013
1 Chap GI 2013
1 Chap GI 2013
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
ANTISPASMODICS
Mebeverine First choice Second choices: Peppermint Oil N.B. Capsules should not be broken or chewed; irritation of mouth or oesophagus may result Alverine citrate Hospital Only Use: Hyoscine butylbromide - Hospital Only 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 Hospital Only Indications: motility inhibitor in examinations of the gastro-intestinal tract by radiography or endoscopy.
MOTILITY STIMULANTS
Indications: Adjunct in management of oesophageal reflux; management of gastroparesis. Metoclopramide - First choice Domperidone second choice Additional prescribing advice: Domperidone and metoclopramide stimulate gastric emptying and small intestinal transit, and enhance the strength of oesophageal sphincter contraction. Metoclopramide is drug of first choice. Domperidone may be used in younger patients (< 20 years old) who are at higher risk of dystonic
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG reactions, or in patients with a history of dystonic reaction with metoclopramide; domperidone may induce dystonic reaction rarely. http://www.mhra.gov.uk/Safetyinformation/DrugSafetyUpdate/CON300404 Erythromycin can also be used in a low dose (250mg bd/tds) for gastric motility unlicensed - Hospital only.
Lifestyle Advice Lose weight if overweight Avoid lying down after meals Avoid irritant food (spicy, fatty) Reduce alcohol consumption 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. Eat smaller quantities at meals Avoid late-night eating Stop smoking
The Guideline Development Group considered that urgent meant being seen within 2 weeks.
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG 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.
Gastric ulcer (refer to NICE guidance for treatment algorithm) - http://www.nice.org.uk/nicemedia/pdf/CG017fullguideline 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)
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG - 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.) Step 3 change to lowest effective dose of PPI. Non-Erosive Duodenitis Treat as for non-ulcer dyspepsia.
Tripotassium DicitratoBismuthate (De-Noltab) Consultant Use Only Indications: Helicobacter pylori eradication in conjunction with antibiotic therapy N.B. A proton-pump inhibitor + clarithromycin + metronidazole is the preferred choice for H. pylori eradication; bismuth-containing regimens should only be used if this is unsuitable Tablets 120mg
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
Lansoprazole Fastabs for swallowing difficulties Only NB. Fastabs can be dispersed in a small amount of water and administered by oral syringe or nasogastric tube. Omeprazole Mups Paediatrics Only Injection 40mg Hospital only 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 initiated only Second line after treatment failure with another PPI
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG 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).
1.5.1 Aminosalicylates
Mesalazine 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 Crohns disease and ulcerative colitis. 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 only Sulphasalazine (Sulfasalazine) Indications: induction and maintenance of remission in ulcerative colitis; active Crohns disease.
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
1.5.2 Corticosteroids
Prednisolone For these indications use Plain tablets - NOT E.C. Indications: Orally - treatment of severe Crohns disease and ulcerative colitis Rectally - treatment of proctitis, distal Crohns 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 only Hydrocortisone (Colifoam)
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
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.
Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
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Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
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Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
Indications: Moderate to severe irritable bowel syndrome with constipation Linaclotide Review treatment if no response after 4 weeks
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Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
1.7 Local
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Lancashire Teaching Hospitals NHS Foundation Trust with Greater Preston and Chorley &South Ribble CCG
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 only 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.
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