Suspension

High sodium content

Use with caution in patients with renal impairment

Sugar free suspension

Mucogel is the most cost-effective brand

Low sodium content

Use with caution in patients with renal impairment as aluminium and magnesium accumulate

Suspension

Specialist Use Only

Drops

For use in infantile colic

Oral powder

10mg Tablet 

20mg/ml Injection

Nausea and vomiting

Not recommended for patients under 20 years of age due to risk of dystonic reactions

For restrictions for use in younger patients see MHRA guidance below

Prescribe as capsules E/C 0.2ml

Peppermint water is an unlicensed special and should only be prescribed (initiation and maintenance) by specialists, where no suitable alternative exists

For specialist use only

The MHRA has issued new advice for domperidone which states that it is no longer licensed for the relief of nausea and vomiting in children under the age of 12 years or those weighing less than 35kg (16th December 2019).

See MHRA Dug Safety Update

Domperidone is no longer recommended for managing heartburn,bloating and stomach discomfort

It should only be used for relief of nausea and vomiting at low doses for short periods (generally upto 1 week)

MHRA advice on domperidone

In line with NICE / PHE guidance

In line with NICE / PHE guidance 

Check availability of test in local laboratory

For specialist use only

For use in patients with swallowing difficulties or via nasogastric tubes only

The European Medicines Agency (EMA) Human Medicines Committee (CHMP) has recommended the suspension of all ranitidine medicines due to the presence of low levels of the impurity N-nitrosodimethylamine (NDMA). (30 April 2020)

For specialist initiation only

For specialist initiation only

Orodispersible tablets 15mg, 30mg
Orodispersible tablets cost twice as much as capsules

For use in patients with swallowing difficulties or who are on enteral tube feeding

££ - Orodispersible tablets are significantly more expensive than capsules

For use in swallowing difficulties or via nasogastric tubes when beads in the capsules are too large and lansoprazole orodispersible are not acceptable (e.g. children with fine NG tubes)

Hospital use only

Follow OptimiseRx advice for most cost-effective prescribing option

For fluid and electrolye replacement following diarrhoea

Click here for St Mark's recipe

UNLICENSED

Specialist use only

Avoid long term use due to possible dependence

Capsules are more cost effective than tablets

Loperamide melts (orodispersible) tablets are reserved for high risk stoma output patients  and patients with swallowing difficulty only

Not to be used if C.diff is suspected

Caution in patients with a history of recent or repeated antibiotic use as increased risk of C.diff infection in this group

Specialist use only in line with NICE TA

In line with NICE

Hospital use only

Mesalazines  should be prescribed by brand.

Please refer to Optimise Rx messages for the preferred brand to be prescribed.
 
Brands include – Pentasa®, Asacol®, Asacol MR®, Salofalk® (granules/enema), Mezavant XL®, Octasa®

Sandwell 

 Amber Recommended -Sandwell only

Walsall

 Green -Walsall only

Wolverhampton 

  Amber Specialist Initiation continued in Primary Care -Wolverhampton only

 Dudley 

 Amber SC-Dudley only

ESCA Balsalazide (Dudley only)

Plain tablets are more cost effective than enteric coated tablets

Walsall

 Green -Walsall only

Sandwell 

 Amber Recommended -Sandwell only

Wolverhampton

 Amber SC-Wolverhampton only

ESCA Sulfasalazine-Wolverhampton only

Dudley 

 Amber SC-Dudley only

ESCA Sulfasalazine (Dudley only)

Tablets 5mg, EC2.5mg, 5mg, Soluble 25mg

Plain tablets are first line option

EC tablets are more expensive than plain tablets without any substantial evidence that they confer any GI benefits

25mg tablets are more expensive per mg than 5mg tablets

Soluble tablets are significantly more expensive than normal tablets which can be crushed and dispersed (unlicensed)

For short term use in acute exacerbation or "flare-ups" of relevant conditions

• Rectal foam Enema
• Gastro-resistant Capsules
• Granules

• Enema
• CR/MR Capsules

In line with NICE

For specialist initiation

Foam enema 125mg /metered application

Walsall

 Amber Initiation Walsall only 

Wolverhampton

 Amber Shared Care Wolverhampton only

ESCA Azathioprine (Wolverhampton only)

 Sandwell 

 Amber Shared Care Sandwell only

For use in Inflammatory Bowel Disease (IBD) as per effective shared care agreement

ESCA Azathioprine (Sandwell only)

 Dudley 

  Amber Shared Care Dudley only

ESCA Azathioprine (Dudley only)

Treatment of ulcerative colitis - for specialist use only

MHRA specify the ciclosporin must be prescribed and dispensed by brand as bioavailabilty differences exist between brands

Maintenance of remission of acute ulcerative colitis and Crohn’s disease in adults – unlicensed but in line with national guidelines

For use in Inflammatory Bowel Disease (IBD) 

Walsall

 Amber Initiation- Walsall only 

Wolverhampton

 Amber Shared Care- Wolverhampton only

ESCA Mercaptopurine-Wolverhampton only

Sandwell 

 Amber Shared Care- Sandwell only

ESCA Mecaptopurine (Sandwell only)

 Dudley 

  Amber Shared Care Dudley only

 ESCA Mecaptopurine (Dudley only)

Tablets 2.5mg (2.5mg tablets preferred as per NPSA alert)

Cytotoxic - do not crush and disperse in water

For use in active Crohn's disease

For specialist initiation only

Wolverhampton
 Amber Shared Care Wolverhampton only

 ESCA :Methotrexate (Wolverhampton only): 

Walsall

 Amber Initiation Walsall only 

Sandwell 

  Amber Shared Care Sandwell only

 ESCA:Methotrexate in active Crohn's disease (Sandwell only)

 Dudley 

  Amber Shared Care Dudley only

ESCA:Methotrexate (Dudley only)

In line with NICE

Tofacitinib for moderately to severe active ulcerative colitis - providers are NHS hospital trusts

For specialist use only in line with NICE guidance

£££££

For specialist use only in line with NICE guidance

Commissioned in paediatrics by NHSE

£££££

Specialist use only in line with NICE  guidance below

Follow Optimise Rx recommendation on which brand to choose

Adequate fluid intake is important to prevent obstruction (6-8 cups per day) and should not be taken immediatley before bed

Unsuitable for frail patients who are likely to drink less than daily required volume of fluid

Fluid thickens on standing so should be taken as soon as possible after mixing

Time to effect is approximately 48-72 hours

Tablets 7.5mg, Syrup 7.5mg/5ml

Syrup is currently more cost effective than tablets

Time to effect approximately 8 to 12 hours

Capsules 100mg, Liquid 50mg/5ml

Solution is utterly unpalatable- only fit for use down tubes

Probably acts as a softening laxative as well as a stimulant

Time to effect is approximately 24 to 48 hours

5mg E/C tablets

10mg Suppository

Capsules 25/200, 75/1000

Co-danthramer strong preferred as per palliative care formulary guidance

Capsules 50/60

Micro-enema

Microlette®, Relaxit® and Micralax®

Follow Optimise Rx recommendation on the most cost effective brand to prescribe

Prescribe as Laxido

Fletchers phosphate enema®

Fleet ready to use enema®

For use in hospital prior to bowel procedures

For treating opioid-induced constipation in line with NICE

£££££

For treating opioid-induced constipation in line with NICE

For moderate to severe IBS-Constipation

For patients who have not responded adequately to or cannot tolerate all other suitable treatment options BUT BEFORE other agents with higher costs

Supported by a RICaD (in development)

 For use in men and women for chronic constipation

 Supported by a RICaD (in development)

Anusol® - other brands also available

Contains the same ingredients as Proctosedyl® but is much more cost effective

£££££

Unlicensed - for use only in patients intolerant of or unresponsive to GTN ointment

Store in the fridge

One tube will last a month if used as 2cm apllication TWICE DAILY

Topical diltiazem 2% may be used twice daily [unlicensed indication] in patients with chronic anal fissures unresponsive or intolerant to topical nitrates and before considering surgery

Supported by a RICaD (in development)

Supported by a RICaD (In development)

NHSE commissioned

In line with NICE

In line with NICE, supported by RICaD (In development) 

For specialist initiation only

For Specialist initiation

Counsel patient on need for adequate hydration

Prescribe by Brand only

Use brand and strength recommended by specialist