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Nottinghamshire Area Prescribing Committee
Joint Formulary
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 Formulary Chapter 1: Gastro-intestinal system - Full Chapter
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01.01  Expand sub section  Dyspepsia and gastro-oesophageal reflux disease
01.01.01  Expand sub section  Antacids and simeticone
01.01.01  Expand sub section  Aluminium and magnesium containing antacids
Co-magaldrox (Mucogel®)
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First Choice
Green

Suspension
Low Sodium

  • Link to SPC
  • OTC Patients should be advised to purchase over the counter

  • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
 
Magnesium Trisilicate Mixture BP
View adult BNF View childrens BNF
Formulary
Green

Suspension

  • Link to SPC
  • OTC Patients should be advised to purchase over the counter

  • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
 
   
01.01.01  Expand sub section  Antacid preparations containing simeticone
01.01.01  Expand sub section  Simeticine alone to top
Simeticone (infacol®)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

For gastroenterology use in endoscopy only.

In paediatrics due to a lack of evidence for use (reviewed and rejected)

 
Link  Infant colic - self-care patient information (Notts APC)
   
01.01.02  Expand sub section  Compound alginates and proprietary indigestion preparations
01.01.02  Expand sub section  Compound alginate preparations
Alginate raft-forming oral suspension (Peptac®)
View adult BNF View childrens BNF
First Choice
Green

Suspension

  • OTC Patients should be advised to purchase over the counter

  • If self-care not appropriate then recommended brand in primary care is Peptac®. See Preferred Prescribing List.
  • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
  • SPC can be accessed via the MHRA website here
 
Gaviscon Infant
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Formulary
Green
Oral powder
 
   
Gaviscon Advance
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Restricted Drug Restricted
Amber 2
Suspension and chewable tablets
  • Specialist recommendation for the treatment of laryngopharyngeal reflux (LPR) symptoms only.
     
  • Link  Link to reviews
       
    Sodium citrate 0.3M
    Restricted Drug Restricted
    Red
    Secondary Care use only. Unlicensed
  • Solution for acid aspiration 
  •    
    01.02  Expand sub section  Antispasmodics and other drugs altering gut motility
    01.02  Expand sub section  Antimuscarinics
    Glycopyrronium
    (oral - hypersalivation)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Available as Oral solution (1mg/5ml or 2mg/5ml). Tablets are non-formulary

    Oral solution, use EITHER:

    - Sialanar® 2mg/5ml (preferred version for paediatric patients.)
    Glycopyrronium bromide oral solution (£320 for 250ml, DT Apr19, with 2 month expiry once opened).
    *Note that Sialanar® description on packaging and on GP prescribing systems is 320micrograms/mL – this is the amount of glycopyrronium BASE per mL and is equivalent to 400micrograms/mL of the SALT, glycopyrronium bromide. See link below for dosing information for Sialanar®.

    OR

    - 1mg/5ml glycopyrronium bromide oral solution - Colonis Pharma Ltd (£91 for 150ml, DT Apr19, with 1 month expiry once opened)

    • Specialist recommendation for management of hypersalivation / upper airway secretions in paediatric patients. Oral solutions listed above are licensed for hypersalivation in children. 
    • Prescribe by brand name to prevent confusion between strengths.
    • Specialist recommendation for management of hypersalivation in adults with Parkinson’s Disease in line with NICE guidance NG71 (APC Mar19) – off licence indication.
    • Specify doses as glycopyrronium bromide (not glycopyrronium base)
    • Switching between strengths is not advised without face to face counselling with the patient / carer.
    • Tablets - not cost-effective. Current patients should be reviewed and switched to oral solution.
    • For information on use in palliative care or hyperhidrosis see other entries.
     
    Link  Education materials to reduce risk of  anticholinergic effects
    Link  Link to reviews
    Link  NICE evidence summary: Glycopyrronium for hypersalivation
    Link  Price comparison of hypersalivation treatments
    Link  Sialanar (glycopyrronium bromide 2mg/5ml) dosing guide
    Link  UKMI Q&A: Hypersalivation – can glycopyrronium be used to treat it?
    Link  UKMI Q&A: Hypersalivation - what drug treatment options are available?
       
    Hyoscine Butylbromide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Injection

    • Tablets disperse in water if needed for tube administration (tastes terrible). They take a long time to disperse (30 min) but much quicker if crushed first. See here for general advice on dispersing tablets. Other alternatives may be a liquid (expensive unlicensed special) or consider hyoscine patches or s/c injections.
    • Be aware of potential for abuse. Reports of hyoscine butylbromide being crushed and smoked in prisons (smoking releases scopolamine, a know hallucinogen).
    • Injection cautioned in cardiac disease MHRA Guidance
     
    Link  Cost comparison of oral & topical treatments for hypersalivation
    Link  COVID19: Is there a shortage of EOL anticipatory medicines? (Notts CCG)
    Link  COVID19: NICE (NG163) Managing symptoms (incl EOL) in the community
    Link  COVID19: Notts CCG - Managing Symptoms of Covid-19 (End of Life) in Community and Non-acute Hospital Settings
    Link  End of life guideline available on Nottinghamshire APC site
    Link  End of life prescribing information
    Link  MHRA Drug Safety Update (Feb 2017)
    Link  Standard anticipatory medicines for end of life care
       
    Propantheline
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Green Traffic Light  For use in hyperhidrosis - the only licensed oral treatment. 
       
    01.02  Expand sub section  Other antispasmodics to top
    Mebeverine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, 135mg tablets only.

    • Tablets can be crushed and dispersed in water if needed (not licensed). Bitter taste will need masking. See here for general advice on dispersing tablets.
    • Note that a licensed oral suspension is available but is extremely expensive (>£600 for 28 days, DT May18).
     
       
    Peppermint Oil (Mintec®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Capsule 
       
    Peppermint water
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Solution (unlicensed) 
       
    01.03  Expand sub section  Antisecretory drugs and mucosal protectants
    01.03.01  Expand sub section  H2-receptor antagonists
    Ranitidine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Injection only

    • Mar 2020: Supply problems, follow guidance below for alternatives.
    • May 2020: IV - little availability and expensive stock (£10/dose)
    • SFH. Limited stability data for syringe drivers. Add to diluted contents LAST.
     
    Link  Dec 2019: Ranitidine supply disruption - Notts primary care guidance (CCG)
    Link  Dec 2019: Supply disruption alert - Ranitidine all oral formulations (DHSC)
    Link  Medicine Supply Notification Ranitidine all formulations UPDATE May 2020.pdf
       
    Cimetidine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Grey

    Tablet, oral solution

    • Jan 2020: Major supply problems (due to the knock on effect of ranitidine supplies being withdrawn).
    • May be prescribed during the rantidine supply disruption only if a PPI is not suitable and there is no ranitidine available.
    • Beware of interactions (interacts with multiple medicines)
     
       
    Famotidine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Grey

    Tablet

    • Jan 2020: Major supply problems (due to the knock on effect of ranitidine supplies being withdrawn).
    • May be prescribed during the rantidine supply disruption only if a PPI is not suitable and there is no ranitidine available.
    • Significantly more expensive than others in this class.
     
       
    Nizatidine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Capsule

    • Jan 2020: Major supply problems (due to the knock on effect of ranitidine supplies being withdrawn).
    • May be prescribed during the rantidine supply disruption only if a PPI is not suitable and there is no ranitidine available.
     
       
    01.03.02  Expand sub section  Selective antimuscarinics
    01.03.03  Expand sub section  Chelates and complexes
    Bismuth subsalicylate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 3
    Tablets 262.5mg
  • Liquid is non-formulary, black listed in drug tariff
  • Approved for use in line with antimicrobial guidelines for eradication of helicobacter pylori 
  •    
    Sucralfate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Suspension 1G/5ml

    • AMBER 2 for gastric / duodenal ulceration and gastritis
     
       
    01.03.04  Expand sub section  Prostaglandin analogues to top
    Misoprostol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet
    Not first line for gastro protection.  
       
    01.03.05  Expand sub section  Proton pump inhibitors (PPIs)
    Lansoprazole
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green
    • Capsules first line. 15mg and 30mg (approx £2/month).
    • Capsules can be opened and beads swallowed without crushing, or can be mixed with food or drink.
    • FasTab (approx £5/month) restricted for use in patients with swallowing difficulties or who are on enteral tube feeding. They are also licensed to be given via a NG tube or oral syringe if diluted in 5-10ml water.
    • OTC Patients may be advised to purchase a suitable product over the counter

     
    Omeprazole (oral)
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green
    • Capsules first line. 10mg and 20mg (approx £2/month)
    • Most brands of capsules can be opened and beads swallowed without crushing, or can be mixed with food or drink.
    • Losec MUPS (approx £12/month) available for when the beads in the capsule are too large and lansoprazole FasTabs are not acceptable (eg children with fine bore NG tubes). Tablets dissolve [See pictures] to leave tiny beads. 10mg can be quartered (2.5mg) or halved (5mg) to enable paediatric dosing.
    • Amber Amber 2 - Omeprazole 4mg/ml powder for suspension for children less than 10kg receiving PPI via enteral tube. 
    • OTC Patients (adults) may be advised to purchase a suitable product over the counter where appropriate.

     
    Omeprazole (IV)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    • For IV infusion over 20-30 min only (see SPC).
    • Generic injection does not come with diluent. Use ~5ml from the 100ml infusion bag to reconstitute the vial.
    • NUH: Restricted as per guideline for high dose infusion - All use must be approved by a Consultant or SpR in Gastroenterology or GI surgery.
    • SFH: Only in paediatric and maternity areas. Other areas use pantoprazole IV.
     
    Link  SFH: GI bleed clinical pathway
    Link  SFH: How to set up a omeprazole continuous infusion
       
    Pantoprazole (IV)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    40mg injection

    • First choice IV PPI at SFH
    • Can be given as a bolus over 2min or as an infusion over 15min. (From SPC)
     
    Link  SFH: GI bleed clinical pathway
    Link  SFH: How to set up a pantoprazole continuous infusion
       
    Pantoprazole (oral)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets

    • OTC Patients may be advised to purchase a suitable product over the counter

     
       
    Esomeprazole
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Capsules, Tablets, Sachets (only for children >10kg via enteral tube)

    • Restricted use for Gastro specialists (severe grade III, IV oesophagitis only) when omeprazole and lansoprazole have been tried and failed.
    • Amber 2: Approved only for an 8 week course for severe oesophagitis
    • Amber 2: Esomeprazole sachets for children more than 10kg receiving PPI via enteral tube.
     
    Link  Independent drug reviews
       
    01.03.06  Expand sub section  Other ulcer-healing drugs
    01.04  Expand sub section  Acute diarrhoea
    01.04.01  Expand sub section  Adsorbents and bulk-forming drugs
    01.04.02  Expand sub section  Antimotility drugs to top
    Loperamide
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green
  • Capsule and syrup (1mg in 5ml) available.
  • Paediatric liquid special (unlicensed) available on request. Not traffic light classified. NUH only use their Non Sterile Manufacturing (NSM) 1mg in 1mL suspension in neonates.  
  • Codeine
    (Antidiarrhoeal)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablets 15mg, 30mg, Syrup (25mg/5mL) 
       
    01.04.03  Expand sub section  Enkephalinase Inhibitors
    01.05  Expand sub section  Chronic bowel disorders
    01.05.01  Expand sub section  Aminosalicylates
    Mesalazine (Octasa®)
    View adult BNF View SPC online View childrens BNF
    First Choice
    Amber 2

    Tablets 400mg & 800mg

    • Prescribe by brand name.
    • Octasa® is the preferred brand for new patients. Asacol® may be continued for existing patients, but is effectively interchangeable with Octasa®- See price comparison graph
    • 800mg are large tablets and are relatively more expensive than 400mg tablets.
    • 1600mg tablets are Grey due to extremely large tablet size and relative cost compared to lower strengths.
    • This drug has monitoring requirements - See BNF.
     
    Mesalazine (Pentasa®)
    View adult BNF View SPC online View childrens BNF
    First Choice
    Amber 2
    Tablet, Granules, Retention enema, suppositories
  • Oral formulations licensed up to 4g once daily or in two or three divided doses.
  • This drug has monitoring requirements - See BNF 
  • Mesalazine (Salofalk®)
    View adult BNF View SPC online View childrens BNF
    First Choice
    Amber 2
    Tablets, Granules M/R, Enema, Foam enema.
  • Licensed up to 3g/day once daily. 
  • Balsalazide Sodium (Colazide®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Capsule
  • Amber 2 for ulcerative colitis 
  •    
    01.05.02  Expand sub section  Corticosteroids
    Beclometasone (Clipper®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    MR Tablets
  • for add-on therapy to high dose oral aminosalicylate to induce remission for adults non-responsive to oral aminosalicylates with a mild to moderate presentation or inflammatory exacerbation of left-sided or extensive ulcerative colitis.
  • Acute courses to induce remission only - not licensed or NICE recommended for maintenance of remission.
  • Added to formulary November APC 2014 in line with NICE CG166: ulcerative colitis 
  • Link  Link to reviews
       
    Budesonide (Budenofalk®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsules (containing EC granules), Rectal foam 

    • Rectal foam (£57 for 14 doses) - now first choice rectal foam as Hydrocortisone (Colifoam®) discontinued
    • Prescribe by brand name
     
    Link  Link to reviews
    Link  SFH: Prescribe by brand general guidance
       
    Budesonide (Cortiment®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    MR Tablets
  • Restricted to those who have failed to obtain control of their ulcerative colitis using salicylates; but are unable to tolerate or unwilling to take high dose steroids.
  • Clinicians must prescribe by brand (Cortiment®) to ensure the correct preparation of modified release budesonide is dispensed.
     
  • Link  Link to reviews
    Link  NICE: Evidence Summary (ESNM58)
       
    Budesonide (Entocort®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    • MR Capsules - once daily administration
    • Prescribe by brand name
    • Entocort liquid enema is non formulary. See prednisolone instead. Cost comparison chart here.
     
    Link  SFH: Prescribe by brand general guidance
       
    Budesonide 1mg orodispersible tablets (Jorveza®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Orodispersible tablets

    • Approved for the treatment of eosinophilic esophagitis (EoE) in adults (older than 18 years of age).

    Awaiting NICE TA publication expected in July 2020. 

     
       
    Prednisolone
    (Gastro (oral))
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
     
       
    Prednisolone
    (Rectal)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Available as:

    • Suppositories 5mg (£114! for 10, June 2020)
    • Liquid Enema 20mg/100ml
    • Foam Enema is non-formulary see below
    • See cost comparison chart here
    • See oral prednisolone notes in section 6.3.2
     
       
    01.05.03  Expand sub section  Drugs affecting the immune response to top
    Cytotoxic Drug Azathioprine
    (Gastroenterology)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 1

    Tablets

    • Maintenance of remission of acute ulcerative colitis and Crohn’s disease in adults.
    • Amber 1: For use in adults with Inflammatory Bowel Disease as per shared care protocol- see below
    • Amber 1: For use in Inflammatory Bowel disease for children >12 years old as per shared care protocol - see below
    • Oral suspension (expensive) available as an unlicensed special - recommended strength is 50mg/5mL as per RCPCH guidance. At SFH send patients to SFH pharmacy for supplies
     
    Link  COVID19: DMARD shared care monitoring during COVID19 (Notts CCG)
    Link  Nottinghamshire APC Shared Care Protocol: Azathioprine for IBD info sheet
    Link  Nottinghamshire APC Shared Care Protocol: IBD overarching document
    Link  Notts APC Shared Care Protocol: Azathioprine for IBD in children >12 years old
    Link  UKMI Q and A: Can mothers breast feed while taking azathioprine?
       
    Cytotoxic Drug Azathioprine
    (Autoimmune Hepatitis)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 1

    Tablets

     
    Link  COVID19: DMARD shared care monitoring during COVID19 (Notts CCG)
    Link  Notts APC Shared Care Protocol: Azathioprine for Auto-Immune Hepatitis info sheet
    Link  Notts APC Shared Care Protocol: Azathioprine for Auto-Immune Hepatitis overarching document
    Link  UKMI Q and A: Can mothers breast feed while taking azathioprine?
       
    Ciclosporin
    (Gastroenterology)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Injection, Capsules- Secondary Care only

    • Treatment of ulcerative colitis
    • MHRA specify that ciclosporin must be prescribed and dispensed by brand as bioavailability differences exist between brands.
    • Capimune® is preferred brand for new patients at SFH. For advice on switching see BNF.
    • Relative prices of different brands [Hospital price][GP price]
     
    Link  SFH: Prescribing guideline for ciclosporin for ulcerative colitis
    Link  NUH Lite Bite: Importance of maintining brand for certain medicines
    Link  SFH only: IV autoprescription
    Link  SFH: IV drugs which need special giving sets
    Link  SPS: Which medicines should be considered for brand name prescribing in primary care?
    Link  SFH info on branded prescribing
    Link  Crohn’s and Colitis UK: Patient information leaflets
       
    Cytotoxic Drug Mercaptopurine
    (Gastroenterology)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 1

    Tablets, suspension.

    • Maintenance of remission of acute ulcerative colitis and Crohn’s disease in adults – unlicensed but in line with national guidelines
    • Suspension (Xaluprine®) (expensive) only for patients where tablets are not suitable (i.e. small doses in paediatrics).
    • Note that mercaptopurine use in children (under 18 years) is excluded from shared care and can be considered as Red.
    • Amber 1: For use in Inflammatory Bowel Disease as per shared care protocol
     
    Link  COVID19: DMARD shared care monitoring during COVID19 (Notts CCG)
    Link  Nottinghamshire APC Shared Care Protocol: IBD overarching document
    Link  Nottinghamshire APC Shared Care Protocol: Mercaptopurine for IBD info sheet
    Link  UKMI Q&A: Which medicines require extra care when switching between liquid and tablet/capsule formulations?
       
    Cytotoxic Drug Methotrexate
    (Gastroenterology)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 1
    Homecare

    Tablets

    • 2.5mg tablets preferred as per NPSA alert
    • Cytotoxic, do not crush and disperse in water, liquid may be available if required.
    • Amber 1 for adults (>18yrs) with inflammatory bowel disease as per the shared care protocol below
    • NUH: Metoject® injection available for paediatric patients - routinely supplied via homecare (prescribe by brand and generic name)
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
     
    Link  COVID19: DMARD shared care monitoring during COVID19 (Notts CCG)
    Link  Inflammatory bowel disease shared care protocol
    Link  Methotrexate information sheet
    Link  NUH Lite Bite: Methotrexate for non-cancer use
    Link  NUH Lite Bite: Safer use of weekly oral methotrexate
    Link  NUH: Medicines Matters Bulletin: Safer Use of Weekly oral Methotrexate
    Link  SFH: Methotrexate policy (medicines policy section 4.5.1)
    Link  UKMI Q&A: Alcohol and low dose methotrexate information
    Link  UKMI Q&A: Interaction between methotrexate and penicillins info.
       
    Vedolizumab (Entyvio®)
    (Gastroenterology)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Concentrate for intravenous infusion
    Pre-filled syringe/pre-filled pen for subcutaneous injection

    • For use in line with NICE guidance in ulcerative colitis (TA342) and Crohn's disease (TA352)
    • Subcutaneous injection available through homecare for SFH, NUH and Treatment Centre patients. Please contact pharmacy medicines homecare team for further information.
     
    Link  Vedolizumab in Gastroenterology patients (SFHT)
    Link  NICE TA352: Vedolizumab for Crohn’s disease
    Link  NICE TA342: Vedolizumab for ulcerative colitis
       
    01.05.03  Expand sub section  Cytokine inhibitors
    Adalimumab
    (Gastroenterology)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Injection

    • For use in line with NICE guidance below
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
    • Biosimilar Imraldi® is the first line option for new patients
    • Biosimilar Amgevita® can be used second line in those who are unable to tolerate Imraldi®

     

     
    Link  Link to reviews
    Link  NICE TA187: Crohn’s disease - infliximab and adalimumab
    Link  NICE TA329: Infliximab, adalimumab and golimumab for moderately to severely active ulcerative colitis
    Link  SFH: Homecare information
       
    Golimumab (Simponi®)
    (Ulcerative Colitis)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Injection

    SFH: Approved for treating moderately to severely active ulcerative colitis after the failure of conventional therapy as per NICE TA329.

    NUH: Approved for treating moderately to severely active ulcerative colitis after the failure of conventional therapy as per NICE TA329. Prior approval with pharmacy required pending full assessment of local implementation.

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information

     
    Link  NICE TA329: Infliximab, adalimumab and golimumab for moderately to severely active ulcerative colitis
       
    Infliximab (Remicade®)
    (Gastroenterology)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Infusion
  • For use in line with NICE guidance-see below
  • Use 1.2 micron filter when administering.
  • SFH - Remsima® brand biosimilar to be used for all new patients. See entry below. 
  • Link  SFH: Infliximab protocol in inflammatory bowel disease patients
    Link  Link to reviews
    Link  NICE TA163: Ulcerative colitis (acute manifestations) Infliximab
    Link  NICE TA187: Crohns disease - infliximab & adalimumab
    Link  NICE TA329: Infliximab, adalimumab and golimumab for moderately to severely active ulcerative colitis
    Link  SFH: Information about IV filters
    Link  UKMI: Biosimilars - New Developments
       
    Infliximab (Remsima®)
    (Gastroenterology)
    View adult BNF View SPC online
    Restricted Drug Restricted
    High Cost Medicine
    Infusion (Infliximab biosimilar)
  • SFH - Remsima® brand biosimilar to be used for all new patients.
    Red Traffic Light NUH and Nottingham Treatment Centre:
  • Approved for the treatment of Crohn’s disease and ulcerative colitis in adult in line with NICE approved indications.
    Red Traffic Light NUH:
  • Approved for the treatment of Crohn’s disease and ulcerative colitis in paediatric patients.
  • Approved for the treatment of immunotherapy induced colitis in oncology patients who fail to respond to high dose steroids.
    Grey Traffic Light For other indications and specialities, no formal assessment (NUH DTC Mar 15)
    Infliximab biosimilar 
  • Link  NICE KTT15: Biosimilar medicines
    Link  NICE TA163: Ulcerative colitis (acute manifestations) Infliximab
    Link  NICE TA187: Crohns disease - infliximab & adalimumab
    Link  NICE TA329: Infliximab, adalimumab and golimumab for moderately to severely active ulcerative colitis
    Link  SPS: Biosimilars of infliximab guidance (taken from LMEN)
       
    Infliximab (Remsima®)
    (Neurology)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red
    High Cost Medicine

    Infusion (Infliximab biosimilar)

    • Available through NUH only:  Approved as per clinical commissioning policy for refractory or progressive neurosarcoidosis (adults and post-pubescent children). Unlicensed indication.
     
    Link  Clinical Commissioning Policy: Infliximab for Refractory or Progressive Neurosarcoidosis (Adults and Post-pubescent Children)
       
    01.05.03  Expand sub section  Vedolizumab
    01.05.04  Expand sub section  Food allergy
    01.06  Expand sub section  Laxatives
    01.06.01  Expand sub section  Bulk-forming laxatives to top
    Ispaghula Husk
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Granules

    • Adequate fluid intake is important to prevent obstruction (6 – 8 cups per day) and not to be taken immediately before bed. Not suitable for frail patients who are unlikely to be able to drink the required volume of fluid.

    • Note: The fluid is quite thick and should be taken as soon as possible as it gets thicker on standing.

    • Time to effect is approximately 48 – 72 hours.

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if dietary and lifestyle measures alone are ineffective.

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased.

     
       
    01.06.02  Expand sub section  Stimulant laxatives
    Bisacodyl
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet, Suppository

    Supply probem with suppositories (Oct 2020). For children, where other routes are not appropriate, Lecicarbn C may be used as a temporary alternative (contra-indicated in soya and peanut allergy)

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if lifestyle and dietary measures alone are ineffective.

    • MHRA Warning: Advise patients that dietary and lifestyle measures should be used first-line for relieving short-term occasional constipation and that stimulant laxatives should only be used if these measures and other laxatives are ineffective.

    • May be prescribed if appropriate to in-patients for short term constipation; patients should be advised on discharge that further supply should be purchased.

     
       
    Senna
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet (7.5mg)
    Syrup (strong taste may be disliked by some

    • Time to effect approximately 8 to 12 hours

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if lifestyle and dietary measures alone are ineffective

    • MHRA Warning: Advise patients that dietary and lifestyle measures should be used first-line for relieving short-term occasional constipation and that stimulant laxatives should only be used if these measures and other laxatives are ineffective

    • May be prescribed if appropriate to in-patients for short term constipation; patients should be advised on discharge that further supply should be purchased.

     
       
    Docusate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Capsule
    Solution (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.

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if lifestyle and dietary measures alone are ineffective.

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased

     
       
    Docusate (Norgalax® Micro-enema)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Micro enema
    NB: not recommended for children under 12 years old

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if lifestyle and dietary measures alone are ineffective.

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
     
       
    Glycerol (Glycerin)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Suppository

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
     
       
    Sodium Picosulfate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Elixir or sachets available

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if lifestyle and dietary measures alone are ineffective

    • MHRA Warning: Advise patients that dietary and lifestyle measures should be used first-line for relieving short-term occasional constipation and that stimulant laxatives should only be used if these measures and other laxatives are ineffective

    • May be prescribed if appropriate to in-patients for short term constipation; patients should be advised on discharge that further supply should be purchased.

     
       
    01.06.03  Expand sub section  Faecal softeners
    Arachis Oil
    (Fletchers arachis oil retention enema)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Enema

    • DO NOT give to patients with PEANUT ALLERGY
    • Warm before use
    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
     
    Link  UKMI Q&A medicines containing soya in peanut allergy
       
    01.06.04  Expand sub section  Osmotic laxatives
    Macrogol oral powder
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if dietary and lifestyle measures alone are ineffective. May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased.

    • Preferred adult brands in primary care are Laxido® and Cosmocol®. See Preferred Prescribing List.
    • Preferred paediatric brands in primary care are Laxido® Paediatric Plain and Cosmocol® Paediatric.
    • Movicol® is less cost effective.
     
       
    Micolette® Sodium Citrate
    (Micro-enema)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Micro-Enema

    • Same as Relaxit® and Micralax® brands (QMC use Micralax)
    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if dietary and lifestyle measures alone are ineffective.

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
     
       
    Phosphates (Rectal)
    (Fletchers phosphate enema, Fleet ready to use enema)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Enema

    • OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if lifestyle and dietary measures alone are ineffective.

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
     
       
    Lactulose
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Solution

    • Lactulose is not recommended for treatment of constipation in adults because many patients find it unpalatable. Docusate is a similar softening laxative which is more palatable.

    • Lactulose is still included in the formulary for other indications e.g. hepatic encephalopathy.

    • Lactulose is commonly underdosed. BNF dose: constipation: 15ml bd and adjust according to patient needs. (May take up to 48hours to act)

    •  OTC Patients should be advised to purchase a suitable product over the counter for short term/infrequent constipation if lifestyle and dietary measures alone are ineffective.

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased

     
       
    01.06.05  Expand sub section  Bowel cleansing preparations
    Fleet Phospho-soda®
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    NUH use only
    Oral solution
  • Traffic light classification= green when used pre-procedure. 
  •    
    Macrogols (Klean-Prep®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Oral powder
  • Traffic light classification = green when used pre-procedure. 
  •    
    Macrogols (Moviprep®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Restricted to use as bowel prep prior to colonoscopy. Oral powder sachets.

    • Traffic light classification = green when used pre-procedure.
    • Patient guides for procedures at different times of the day: [Morning] [Afternoon] [Evening]
     
    Link  Link to reviews
       
    Picolax®
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    NUH and SFH use only

     
    Link  SFH: Bowel prep prescription & assessment form
       
    Plenvu®
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Oral Powder for oral solution

    • Usually second line to Moviprep for use as a bowel prep prior to colonoscopy.
    • NB: The ingredients of Plenvu® are contained in three separate sachets. The first dose is supplied in one sachet and the second dose is supplied in two sachets, A and B.
    • Patient guides for procedures at different times of the day: [Morning] [Afternoon] [Evening]
     
       
    01.06.06  Expand sub section  Peripheral opioid-receptor antagonist to top
    Methylnaltrexone (Relistor®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Injection.

    • For use by palliative care teams only.
    • Restricted: For use only in the management of intractable opioid induced constipation in palliative patients not responding to usual laxative treatment.
    • No formal assessments for opioid induced constipation in adults
     
    Link  Link to reviews
       
    Naloxegol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Specialist initiation for the treament of opioid induced constipation in line with NICE TA345.
  • Follow local guidance (appendix 2) for the treatment of opioid induced constipation.
  • If naloxegol is being considered, note contraindications/ interactions (See SPC).
  • May be crushed and dispersed in water for oral or NG use.
  • Costs £51 per month. See laxative prices). 
  • Link  Link to reviews
       
    01.06.07  Expand sub section  Other drugs used in constipation
    Prucalopride
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Tablets

    • Available for prescribing in men and women following review at APC May 2017
    • Restricted to consultant initiation for the treatment of chronic, resistant constipation in line with NICE. GPs may continue the prescribing only if a review after a month's therapy demonstrates benefit.
    • Should not be used in children and adolescents
    • Disperses easily in water into a fine powder which may be flushed well down enteral tubes.
     
    Link  Link to reviews
    Link  TA211 - Constipation (women) - prucalopride
       
    Linaclotide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsules

     

    • Indicated for patients with moderate to severe IBS-C which has not responded adequately to or can not tolerate all other suitable treatment options as per algorithm.
    • Initiated and prescribed by consultant gastroenterologist for the first 8 weeks of treatment.
    • Consultant gastroenterologist to review at 8 weeks to assess efficacy and tolerability.
    • Consultant gastroenterologist to complete audit form for each patient (one year audit starting from May 2014).
    • GP to be requested to prescribe ongoing treatment after 8 weeks if patient gaining significant benefit.
    • GP to review patient every 3 months and stop linaclotide if patient no longer benefiting from treatment.
     
    Link  Link to reviews
       
    01.07  Expand sub section  Local preparations for anal and rectal disorders
    01.07.01  Expand sub section  Soothing haemorrhoidal preparations
    Haemorrhoid relief ointment
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    eg Anusol®, but other brands also available.

    • OTC Patients should be advised to purchase over the counter

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
     
       
    Haemorrhoid relief suppositories
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    eg Anusol®, but other brands also available.

     

    • OTC Patients should be advised to purchase over the counter

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that further supply should be purchased
     
       
    01.07.02  Expand sub section  Compound haemorrhoidal preparations with corticosteroids
    Scheriproct
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Ointment and Suppositories (cinchocaine and prednisolone)

    • See also BNF section "soothing haemorrhoid preparations".
    • OTC Patients should be advised to purchase a soothing product such as Anusol as a first line over the counter treatment

    • May be prescribed if appropriate to in-patients; patients should be advised on discharge that a soothing product such as Anusol maybe purchased as a first line treatment
     
       
    Proctosedyl®
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Ointment (Cinchocaine Hydrochloride and Hydrocortisone)
    NUH only:
  • Pelvic radiotherapy patients 
  •    
    01.07.03  Expand sub section  Rectal sclerosants to top
    Oily phenol injection BP
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Injection 
       
    01.07.04  Expand sub section  Management of anal fissures
    Glyceryl Trinitrate 0.4% rectal ointment
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green

    Ointment

    • Licensed and easily available
    • Costs ~£33 per tube (June 18)
     
    Diltiazem 2% Cream/Ointment
    View adult BNF View childrens BNF
    Restricted Drug Restricted
    Green
    • For anal fissures.
    • Unlicensed - May not be easy to acquire in community.
    • Dose 2cm bd (or tds). 1 tube lasts one month, store in fridge.
     
    Link  Link to reviews
    Link  NICE evidence summary
    Link  SFH: Use white hospital prescriptions not green FP10s for supplies of unlicensed medicines.
       
    01.08  Expand sub section  Stoma care
     note  For expert advice on stoma care contact clinical nurse specialist in stoma therapy.
    Stoma Care
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
     
       
    01.09  Expand sub section  Drugs affecting intestinal secretions
    01.09.01  Expand sub section  Drugs affecting biliary composition and flow
    Obeticholic acid (Ocaliva®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Tablets

    • NUH only: Approved in accordance with NICE TA443 for treating primary biliary cholangitis.
    • Risk of severe liver injury in pre-existing hepatic impairment. MHRA information
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
     
    Link  MHRA: Risk of liver injury with obeticholic acid, adjust dosage according to liver function
    Link  NICE TA443: Obeticholic acid for treating primary biliary cholangitis
       
    Ursodeoxycholic acid
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablets, Capsule, Suspension 
    Link  Link to reviews
       
    01.09.02  Expand sub section  Bile acid sequestrants to top
    Colestyramine
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Powder, sugared and sugar free options

     
       
    01.09.03  Expand sub section  Aprotinin
    01.09.04  Expand sub section  Pancreatin
    Pancreatin (Creon® )
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsule: Available as Creon® 10000, 25000, 40000
    Restricted Item Granules: Creon Micro® - Not routinely stocked. Only for paediatrics as the dose is easier to measure.

     
    Link  SFH: Guidelines for unblocking NG tubes
       
    Pancreatin (Pancrex® V)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Powder, Pancrex V 125mg capsules(NUH only)

    • Powder for patients requiring pancreatic enzyme supplementation via tube administration.
    • Pancrex V powder - a rounded 2.5ml spoonful weighs approx 2g but medicine spoons vary considerably.
    • Neonatal Guideline available: Management of newborn infants with suspected cystic fibrosis.
    • Care required: different strength capsules are manufactured (see non-formulary below). Formulary approval is for Pancrex V 125mg capsules at NUH only. 
     
       
     ....
     Non Formulary Items
    Acidex

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Algicon®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Suspension (low sodium)
     
    Altacite plus

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Aluminium Hydroxide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Aluminium Only Preparations  (Alu-Cap®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Discontinued 2019

     
    Alverine  (Spasmonal®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Anugesic-HC

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Suppositories discontinued Sept 2013
  •  
    Anusol-HC

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Asilone

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued September 2011
     
    Atropine
    (tablets)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    BLI-800  (Eziclen®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal submission (APC March 2016)
     
    Botulinum toxin type A

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Link to reviews
     
    Bowel Cleansing Solutions  (Citramag®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Cholic acid  (Kolbam®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine

    No formal assessment (APC Jan 2016)

    NUH: Supported in accordance with Clinical Commissioning Policy:Cholic acid and chenodeoxycholic acid for treating inborn errors of bile acid synthesis (all ages). NUH to refer patients to the specialist centre.

     
    Cholic acid  (Orphacol®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine

    No formal assessment (APC July 15)

    NUH: Supported in accordance with Clinical Commissioning Policy:Cholic acid and chenodeoxycholic acid for treating inborn errors of bile acid synthesis (all ages). NUH to refer patients to the specialist centre.

     

     
    Citrafleet®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Oral powder

     
    Co-danthramer

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Co-danthramer and Co-danthramer Strong Capsules have been discontinued. 
    • Not generally recommended due to the risk of dantron burns and control is usually achieved with alternatives.
    • Suspension is very expensive.
    • Co-danthramer is on the Nottinghamshire list of Medicines & Appliances of Limited Clinical Value that should never be prescribed.
    Link  Dantron products price comparison chart
     
    Co-danthrusate

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Dantron products price comparison chart
     
    Co-magaldrox  (Maalox®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    See Mucogel® above which is the same but cheaper.
     
    Co-Phenotrope  (Lomotil®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Contains diphenoxylate (opioid) and atropine.
    • Available for patients in whom loperamide and codeine have failed, but causes anticholinergic side effects.
     
    Dantron

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Dexlansoprazole

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal submission

     
    Dicycloverine

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Not recommended in NICE CG37 for the treatment of colic in infants due to side effects such as breathing difficulties and coma.
  •  
    Eluxadoline  (Truberzi®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Discontinued 2020
    Link  NICE TA471
    Link  Link to reviews
    Link  MHRA Drug Safety Update (December 2017): Eluxadoline (Truberzi▼) & risk of pancreatitis
     
    Esomeprazole & Aspirin  (Axanum®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal submission
     
    Gastrocote

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    This product has been discontinued
     
    Gripe Mixture

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Reviewed and rejected, November 2015

    Link  Information for patients - infantile colic
     
    Human fibrinogen  (FibCLOT® )

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal assessment
  •  
    Hydrocortisone  (Colifoam®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Foam enema

    • Supply problem since June 2018 - how discontinued (APC Jul20)
     
    Infliximab  (Inflectra®)
    (All indications)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
    Infusion
    No formal assessment (NUH DTC Mar 15)
    Infliximab biosimilar
    Link  SPS: Biosimilars of infliximab guidance
     
    Izinova®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Bowel Preparation kit.
  • Containing sodium sulphate anhydrous, magnesium sulphate heptahydrate and potassium sulphate
  •  
    Kaolin and Morphine Mixture

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Laolin, Light

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lidocaine 5% ointment

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Use Xyloproct instead
     
    Liquid Paraffin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Lubiprostone

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Withdrawn December 2018

    Capsules

    • For gastroenterology consultant initiation only in line with NICE TA318.
    • Consultant review after 2 weeks for first course (telephone consultation is acceptable). If effective, GPs may prescribe further courses.
    • GREY - non formulary for IBD (APC Sept14).
    Link  Link to reviews
    Link  NICE TA318: Lubiprostone for treating chronic idiopathic constipation
     
    Maalox Plus

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Macrogol  (Movicol liquid®, Movicol Ready to Take®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Use Laxido sachets. Reviewed and rejected- Movicol liquid offers no advantage over sachets- requires dilution in water so results in an equivalent volume
     
    Magnesium Carbonate

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Magnesium Hydroxide Mixture BP

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Solution
  • Non-formulary for the treatment of constipation. See chapter 9 for treatment options for magnesium replacement
  •  
    Mebeverine  (Colofac® MR)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Mebeverine  (Fybogel® Mebeverine)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Mesalazine  (Ipocol®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Mesalazine  (Mezavant® XL)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No longer recommended as other cheaper preparations are also now licensed once daily, eg Salofalk & Pentasa
    Link  Link to reviews
     
    Methylcellulose  (Celevac®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Olsalazine

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Mild ulcerative colitis and maintenance of remission
     
    Pancreatin  (Nutrizym® 22)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Pancreatin  (Pancrease® HL)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Pancreatin  (Pancrex® V)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Non-formulary (no formal assessment, Creon preferred):
    - Pancrex Granules
    - Pancrex V capsules
    - Pancrex V forte tablets
    - Pancrex V tablets

    Formulary (see above):
    - Pancrex V powder
    - Pancrex V capsules 125mg

     
    Peppermint Oil  (Colpermin®, Buscomint ®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Colpermin Contains arachis oil. Not suitable for patients with peanut allergy.
    • See Mintec above.
     
    Perinal

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Phosphates (Oral)  (Diafalk®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Phosphates (Oral)  (OsmoPrep®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Prednisolone Foam enema

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Use Colifoam® (hydrocortisone) instead first choice. Budesonide foam enema available if second line option required.
    • Predfoam® brand discontinued 2017, generic replacement is significantly more expensive than alternatives (See cost comparison chart here)
     
    Proctofoam HC

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Rabeprazole  (Pariet®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Tablet

    May be prescribed during the rantidine supply disruption only if formulary PPIs are not available.

     
    Racecadotril  (Hidrasec®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  • Link  Link to reviews
     
    Ranitidine Bismuth Citrate  (Pylorid®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Renie Duo

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Rowachol

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    BNF recommends less suitable for prescribing
     
    Senna  (Senokot®) (Granules)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Sodium cromoglicate  (Nalcrom®)
    (Food allergy)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Sodium hydrogen carbonate & Sodium dihydrogen phosphate  (Lecicarbon® A, Lecicarbon® C)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Suppositories
    - Lecicarbon® A (Adult)
    - Lecicarbon® C (Child)

    • No formal assessment (APC July 2015)
    • Contra-indicated in soya and peanut allergy

     - Lecicarbon C Temporarily classified as GREEN for children where Biscodyl suppositories would otherwise be indicated but due to the current shortage are unavailable (Oct 2020)

     
    Sterculia  (Normacol®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Sterculia  (Normacol® plus)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Stoma Deodorant Sprays

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Various deodorant sprays are available.  Drug Tariff Oct 19 lists the following (NB this list is not exhaustive and the grey traffic light applies to all deodorising sprays)

    Friends Ostomy Deodorant Spray®, LiMone Ostomy Deodorant Spray ®, Lemon Day-drop Spray®, Medi Citrone Ostomy Deodorant Aerosol®, NaturCare (aerosol spray®, Neutralise® (formerly OstoMart®, OstoMist®, Odour Neutralising Spray)  

     
    Sucralfate

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Tablets

    • Reclassified temporarily as GREY as both formulations are now unlicensed and markedly expensive as an import. Once supply issues are resolved, the classification will be reviewed.
     
    Sulfasalazine
    (gastro)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Existing patients may continue.
    See rheumatology chapter for info on use in rheumatological disease
    Link  SPS: Sulfa allergy, which drugs should be avoided?
     
    Teduglutide  (Revestive®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
    No formal submission
     
    Topal  (Topal®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued Sept 14
     
    Tripotassium Dicitratobismuthate  (De-Noltab®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Discontinued by manufacturer in July 2015 - See memo.
  • Pepto bismol tablets (liquid is black listed in drug tariff) may be an alternative. Phone Medicines Information for advice (3163).
  •  
    Ultraproct

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Uniroid HC

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Xyloproct® ointment

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Scheriproct ointment (see above) is a more cost-effective haemorrhoid ointment containing local anaesthetic and corticosteroid (APC May17).
     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

    netFormulary