netFormulary South East London Joint Medicines Formulary NHS
Guy's and St Thomas' NHS Foundation Trust
Kings College Hospital NHS Foundation Trust
Lewisham and Greenwich NHS Trust
 
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 Formulary Chapter 1: Gastro-intestinal system - Full Chapter
Notes:

Where a formulary entry does not detail a medicine’s indications for use, the medicine can be assumed to be approved for all licensed indications.

Formulary approved "off-label" use is detailed separately.

 Details...
01.01  Dyspepsia and gastro-oesophageal reflux disease
 note 
Pepto-Bismol chewable tabs  (off-label indication)
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Formulary
Green

Approved off-label indication:

H. Pylori eradication as per detail in NICE CG184 for bismuth containing regimens.  To be used in combination with a proton pump inhibitor and metronidazole and tetracycline. 

(see link below for full advice)

Note: 262.5mg Bismuth subsalicylate/tablet.

Dose = 2 tablets four times a day for a 1-2 week course

 

 
Link  NICE CG184: Gastro-oesophageal reflux disease and dyspepsia in adults: investigation and management
   
01.01.01  Antacids and simeticone
01.01.01  Aluminium and magnesium containing antacids
Co-magaldrox 195/220 in 5ml oral suspension (Mucogel®)
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Formulary  
   
Magnesium trisilicate Mixture BP
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Formulary  
   
01.01.01  Antacid preparations containing simeticone
01.01.01  Simeticine alone to top
Infacol® oral suspension
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Restricted Drug Restricted

Approved off-label indication:

Surfactant to improve visualisation in capsule endoscopy

 
   
01.01.02  Compound alginates and proprietary indigestion preparations
01.01.02  Compound alginate preparations
Gaviscon Advance® suspension
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Formulary  
   
Peptac® suspension
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Formulary  
   
Gastrocote® tabs
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Restricted Drug Restricted Use is restricted to the Community Health Inclusion Team only 
   
01.02  Antispasmodics and other drugs altering gut motility
Sildenafil tablets (oesophageal spasm - off-label indication)
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Formulary
Red

Approved off-label indication:

Oesophageal spasm

  • Gastroenterology prescribing only after manometry confirmed diagnosis
  • Usual dose = 25 mg - 50 mg up to twice daily
 
   
Botulinum toxin A (Xeomin® - gastroenterology endoscopic indications off-label)
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Restricted Drug Restricted
Red
High Cost Medicine

Approved off-label indications (via endoscopic injection):

Category B* form required for all indications

Diabetic gastroparesis:

  • Restricted to use where prokinetics have failed
  • Dose = 200 units (50 units into each quadrant)

Oesophageal spasm:

  • Restricted to use in patients where pharmacological treatment has been ineffective or not tolerated, including calcium channel blockers and nitrates
  • Dose = 100 or 200 units

Achalasia:

  • Restricted to use in patients where treatment with surgery or pneumatic dilatation is contra-indicated or not appropriate
  • Dose = 100 units
 
Link  SE London APC recommendation: Botulinum toxin for diabetic gastroparesis
Link  SE London APC recommendation: Botulinum toxin for oesophageal spasm
Link  SE London APC reocmmendation: Botulinum toxin for achalasia
   
Aprepitant caps, oral suspension (gastroparesis - off-label)
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Restricted Drug Restricted
Red
High Cost Medicine

Approved off-label indication:

Last line treatment of nausea and vomiting associated with gastroparesis where the following options have failed:

  • Diet and nutritional support
  • Optimising glycaemic control
  • Prokinetics (domperidone, metoclopramide and erythromycin)
  • Antiemetics
  • Intrapyloric botulinum toxin

Dose = 125 mg as first dose, then 80 mg daily if using capsules.  If enteral administration is required 125 mg daily can be given from the powder for oral suspension.

Treatment should be discontinued if there is no response in the first 2 weeks

Hospital prescribing and supply only

See APC recommendation for further information (link below)

 
Link  SE London APC recommendation: Aprepitant for the treatment of severe nausea and vomiting in adults with gastroparesis
   
01.02  Antimuscarinics (including use in hypersalivation)
Hyoscine hydrobromide chewable tablets (hypersalivation - off-label - Kwells®, Kwells Kids® and Joy-rides®)
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Formulary
Amber 2

Approved off-label indication:

  • Hypersalivation

Dose in adults = 150 to 300 micrograms up to three times a day

Refer to SE London hypersalivation guidelines for further information (link above)

 
   
Hyoscine hydrobromide patch 1.5 mg (hypersalivation - off-label)
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Formulary
Amber 2

Approved off-label indication:

  • Hypersalivation

Dose in adults = 1 patch applied behind the ear every 72 hours, titrated to 1/4 of a patch to 2 patches every 72 hours as appropriate

Refer to SE London hypersalivation guidelines for further information (link above)

 
   
Glycopyrronium bromide oral solution (hypersalivation - Sialanar® and Colonis® brands)
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Formulary
Amber 2

Approved for use in severe sialorrhoea in patients with chronic neurological disorders (including off-label use in adults)

  • The Colonis® and Sialanar® products are both approved for use in this indication
  • The Colonis® product is 1 mg in 5 mL of glycopyronnium bromide
  • The Sialanar® product is 400 micrograms in 1 mL glycopyrronium bromide (2 mg in 5 mL)

The packaging of the Sialanar product however states the dosage of glycopyrronium base (320 micrograms glycopyrronium base in 1 mL), therefore patients should ideally not be switched between brands, and the brand should be clearly detailed when prescribing, including the dosage in mg and volume.

  • Dose of glycopyrronium bromide in adults = 0.5 mg to 1 mg three times a day, titrating to 2 mg three times a day if required
  • See APC recommendation for further information (link below)
  • See APC guidance for the management of hypersalivation in adults with neurological conditions (link above)
 
Link  APC recommendation: Glycopyrronium bromide oral solution (licensed preparations) for the treatment of severe sialorrhoea in adults with chronic neurological disorders
   
Atropine sulphate eye drops 1% (hypersalivation - off-label)
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Formulary
Amber 2

Approved off-label indication:

For management of hypersalivation in neurology conditions (sublingual administration).

  • Dose = 1-2 drops once daily, titrated to a maximum of 2 drops 4 times a day

Refer to SE London hypersalivation guidelines for further information (link above)

 
   
Botulinum toxin A (hypersalivation - off-label - Xeomin®)
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Restricted Drug Restricted
Red
High Cost Medicine

Approved off-label indication:

Hypersalivation

Category B* form required

Restricted to use where antimuscarinics have failed or are inappropriate

Total dose = 100 units (administered into salivary glands)

ENT, neurology, and oral and maxillofacial surgery use only

 
Link  SE London APC Recommendation: Botulinum toxin type A injection for the treatment of hypersalivation
   
Dicycloverine oral solution
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Formulary  
   
Hyoscine butylbromide injection
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Formulary
Amber 1

GPs may be asked to prescribe hyoscine butylbromide injections as part of palliative care in the community setting

Palliative care recommendation only

 
   
Hyoscine butylbromide tabs, injection
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Formulary  
Link  MHRA Feb 2017: Hyoscine butylbromide (Buscopan) injection: risk of serious adverse effects in patients with underlying cardiac disease
   
Propantheline bromide tabs (gastroenterology and neurology use)
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Formulary

Approved for use in:

  • Symptom control in GI disorders characterised by smooth muscle spasm
  • Reducing adverse effects pyridostigmine (e.g. abdombinal cramps) in myaesthenia gravis patients: Usual dose = 15 mg to 30 mg three times a day
 
   
01.02  Other antispasmodics to top
Alverine citrate caps
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Formulary  
   
Mebeverine hydrochloride tabs
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Formulary  
   
Mebeverine hydrochloride oral suspension
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Formulary  
   
Peppermint oil caps
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Formulary  
   
Peppermint water
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Formulary  
   
01.02  Motility stimulants
Erythromycin tabs, oral suspension
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Formulary

Approved off-label indication:

Resistant diabetic gastroparesis.

Dose = 125 mg three times a day before meals

 
   
Erythromycin tabs, oral suspension, injection
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Formulary

Approved off-label indication:

Prokinetic agent, motility stimulant

 
   
Metoclopramide tabs, injection
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Formulary As per MHRA advice: Maximum daily dose of 30mg for maximum duration of 5 days 
Link  MHRA Aug 2013: Metoclopramide: risk of neurological adverse effects
   
01.03  Antisecretory drugs and mucosal protectants
01.03.01  H2-receptor antagonists
Ranitidine tabs, injection
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Formulary

 

 
   
Cimetidine tabs
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Formulary  
   
01.03.02  Selective antimuscarinics
01.03.03  Chelates and complexes to top
Sucralfate tabs, suspension
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Unlicensed Drug Unlicensed

 
   
01.03.04  Prostaglandin analogues
Misoprostol tabs (GI indications)
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Formulary For prophylaxis and treatment of NSAID induced ulcers 
   
01.03.05  Proton pump inhibitors (PPIs)
Omeprazole caps
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First Choice

First line oral PPI of choice at all Trusts

Not to be prescribed for patients on clopidogrel

 
Lansoprazole caps
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Formulary PPI of choice for patients on clopidogrel 
   
Lansoprazole dispersible tabs
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Restricted Drug Restricted

Reserved for patients with swallowing difficulties and tube fed patients

 
   
Omeprazole dispersible tabs
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Restricted Drug Restricted

Reserved for patients with swallowing difficulties

 
   
Omeprazole injection
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Formulary Parenteral PPI of choice at KCH and LGT 
   
Pantoprazole injection
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Formulary Parenteral PPI of choice at GSTFT 
   
Pantoprazole injection
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Formulary
Red

Approved off-label indication:

Acute upper GI bleed:

  • Use in accordance with guideline at GSTFT
  • Dose: 80 mg followed by an infusion of 8 mg/h for 72 hours
 
   
01.03.06  Other ulcer-healing drugs
01.04  Acute diarrhoea
Dioralyte® oral powder
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Formulary  
   
Electrolade® oral powder
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Formulary  
   
01.04.01  Adsorbents and bulk-forming drugs to top
01.04.02  Antimotility drugs
Codeine tabs
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Formulary  
   
Co-phenotrope tabs
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Formulary  
   
Loperamide caps, tabs, syrup
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Formulary Capsules = first line 
Link  MHRA Sept 2017: Loperamide: reports of serious cardiac adverse reactions with high doses of loperamide associated with abuse or misuse
   
01.04.03  Enkephalinase Inhibitors
01.05  Chronic bowel disorders
01.05  Irritable bowel syndrome
Amitriptyline tabs (IBS - off-label)
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Formulary

Approved off-label indication:

2nd line pharmacological treatment of IBS-D (diarrhoea predmoninant irritable bowel syndrome) after failure of loperamide Dose = 10mg - 30mg at night

 
   
Citalopram tabs (IBS - off-label)
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Formulary

Approved off-label indication:

2nd line pharmacological treatment of IBS-C (constipation predmoninant irritable bowel syndrome) after failure of bulk forming laxatives Dose = 10mg - 20mg daily

 
   
Fluoxetine caps, tabs (IBS - off-label)
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Formulary

Approved off-label indication:

2nd line pharmacological treatment of IBS-C (constipation predmoninant irritable bowel syndrome) after failure of bulk forming laxatives Dose = 20mg daily

 
   
01.05.01  Aminosalicylates to top
Mesalazine MR tabs (Octasa®)
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First Choice  
Mesalazine MR tabs (Mezavant® XL and Pentasa®)
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Formulary  
   
Mesalazine modified release granules
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Formulary  
   
Mesalazine enemas and foam enemas
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Formulary  
   
Mesalazine suppositories
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Formulary  
   
Balsalazide caps
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Restricted Drug Restricted Acute management of ulcerative colitis only 
   
01.05.02  Corticosteroids
Beclometasone MR tabs (Clipper® - licensed use)
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Restricted Drug Restricted
Amber 1

Second-line option (after prednisolone tabs) for active mild or moderate ulcerative colitis

  • As add-on to 5-ASA in patients who have insufficient response to 5-ASA, or
  • As monotherapy where 5-ASA and prednisolone are contraindicated or not tolerated (off-label)
  • Maximum course length = 4 weeks
 
   
Budesonide controlled release caps (Entocort®)
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Formulary

Controlled release caps are only licensed for induction of remission in Crohn's disease

  • Dose = 9mg daily
  • Usual course length = 4-6 weeks
 
   
Budesonide prolonged release tabs (Cortiment®)
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Restricted Drug Restricted
Red

Prolonged release tabs only licensed for use in induction of remission in ulcerative colitis

Restricted to patients with active ulcerative colitis with insufficient response to 5-ASA who:

  • Would be suitable for beclometasone m/r capsules (Clipper®) but are at increased risk of severe side effects from systemic steroids or
  • Have failed/not tolerated beclometasone m/r treatment

Course length = up to 8 weeks

 
Link  SE London APC Recommendation: Budesonide prolonged release tablets (Cortiment®) for mild to moderate active ulcerative colitis
   
Budesonide rectal foam
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Formulary

 
   
Hydrocortisone foam enema
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Formulary  
   
Prednisolone tabs, retention enema, rectal foam, suppositories
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Formulary Prednisolone enteric coated tablets are non-formulary 
   
Beclometasone MR tabs (Clipper® - Graft vs Host Disease - off-label)
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Formulary
Red

Approved off-label indication:

Treatment of acute intestinal Graft vs Host Disease (GvHD) following Haematopoietic Stem Cell Transplantation as per NHSE policy 16069/P

  • Approved for short courses and dosing in line with licensed use in inflammatory bowel disease
 
Link  NHS England Clinical Commissioning Policy 16069/P: Treatments for Graft versus Host Disease (GvHD) following Haematopoietic Stem Cell Transplantation
   
Budesonide controlled release caps, gastroresistant caps (Entocort®, Budenofalk® - Graft vs Host Disease - off-label)
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Formulary
Red

Approved off-label indication:

Treatment of acute intestinal Graft vs Host Disease (GvHD) following Haematopoietic Stem Cell Transplantation as per NHSE policy 16069/P

Approved for short courses and dosing in line with licensed use in inflammatory bowel disease

 

 
Link  NHS England Clinical Commissioning Policy 16069/P: Treatments for Graft versus Host Disease (GvHD) following Haematopoietic Stem Cell Transplantation
   
01.05.02  Oral
01.05.02  Topical
01.05.02  Parenteral
Triamcinolone acetonide injection (oesophageal stricture - off-label)
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Formulary
Red
Approved off-label indication:
Management of refractory oesophageal stricture (intralesional endoscopic injection)
  • For use in patients refractory to standard dilatation
  • Consultant gastroenterologist use only
  • Dose = 40 mg to 80 mg 
  •    
    01.05.03  Drugs affecting the immune response to top
    Cytotoxic Drug Azathioprine tablets (gastroenterology indications - off-label)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link below at end of BNF section)

     
       
    Cytotoxic Drug Mercaptopurine tabs (gastroenterology indications, including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link below at end of BNF section)

     
       
    Cytotoxic Drug Methotrexate tablets (gastroenterology indications, including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link below at end of BNF section)

     
       
    Sulfasalazine tabs, oral suspension
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    Formulary
    Amber 3

    Acute management of ulcerative colitis only

    Refer to SE London immunomodulatory shared care guidance (link below at end of BNF section)

     
       
    Anti-MAP (mycobacterium avium paratuberculosis) therapy (clarithromycin, rifabutin and clofazimine)
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    Formulary
    Red

    Specialist gastroenterology use only

    Follow local guidelines for use at GSTT Patient Information Leaflet available on GTi (GSTT intranet)

    Last line option for Crohn's disease patients who have not responded to/have been intolerant of or have a contraindication to treatment options and strategies for Crohn’s disease outlined within the SEL IBD Pathways (including immunosuppressants and biologics) and do not wish to have surgery.

    Regimen:

    • Clarithromycin 250 mg each morning and 500 mg at night
    • Rifabutin 150 mg daily for 1 week, then 150 mg twice daily. If >50kg the dose may be increased to 450mg total daily dose
    • Clofazimine 100 mg daily (unlicensed product) The maximum treatment duration is 2 years
     
    Link  SE London APC recommendation: Clofazimine in combination with clarithromycin and rifabutin as anti-MAP (Mycobacterium avium subspecies paratuberculosis) therapy for the treatment of Crohn’s disease in adults
       
    Ciclosporin injection (ulcerative colitis - off-label)
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    Formulary
    Red

    Approved off-label indication:

    Severe acute ulcerative colitis refractory to corticosteroid treatment. Dose: 2 mg/kg over 24hours and dose adjusted according to blood-ciclosporin concentration and response

     
       
    Tacrolimus (Adoport®) (IBD - off-label)
    (Prescribe by brand)
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    Formulary
    Red

    Approved off-label indication:

    Refractory Crohn’s disease or ulcerative colitis, in patients who have failed or are contraindicated to all other conventional immunosuppressant and biological treatments.

     
       
    Cytotoxic Drug Tioguanine tabs (IBD - off-label)
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    Formulary
    Red

    Approved off-label indication:

    3rd line oral immunosuppressive agent for maintaining remission in adult patients with Crohn’s disease and ulcerative colitis

    • For use in patients who are intolerant or unresponsive to both azathioprine and mercaptopurine
    • Hospital prescribing and supply only
    • Dose: 20 mg to 40 mg daily
     
    Link  SE London APC recommendation: Tioguanine for the treatment of adults with inflammatory bowel disease
       
    Tacrolimus ointment (perianal Crohn’s disease - off-label)
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    Formulary

    Approved off-label indication:

    Ulcerating perianal Crohn’s disease and pyoderma gangrenosum as a last-line option if all other therapies and surgery have failed or are unsuitable

     
       
    01.05.03  Cytokine inhibitors
    Adalimumab injection (IBD)
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    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance  
    Link  NICE TA187: Infliximab and adalimumab for the treatment of Crohn’s disease
    Link  NICE TA329: Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy
       
    Infliximab injection (IBD)
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    Formulary
    Red
    High Cost Medicine

    Approved as per NICE technology appraisal guidance

    Biosimilar products available, to be prescribed by brand name. Contact pharmacy department for advice on brand for routine prescribing if unsure

     
    Link  NICE TA163 Infliximab for acute exacerbations of ulcerative colitis
    Link  NICE TA187: Infliximab and adalimumab for the treatment of Crohn’s disease
    Link  NICE TA329: Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy
    Link  SE London APC position statement: Biosimilar infliximab
       
    Golimumab injection (ulcerative colitis)
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    Formulary
    Red
    High Cost Medicine

    Approved as per NICE technology appraisal guidance 

     
    Link  NICE TA329: Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy
       
    Infliximab injection (cancer immunotherapy related colitis - off-label)
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    Formulary
    Red
    High Cost Medicine

    Approved off-label indication:

    Treatment of cancer immunotherapy (ipilimumab, nivolumab and pembrolizumab) related corticosteroid refractory colitis

    • The infliximab brand with the lowest acquisition cost should be used
    • Category B* form required
    • Restricted to use in in patients where conservative measures (e.g. loperamide, fluid replacement, withholding immunotherapy treatment) and high dose intravenous corticosteroids have failed
    • Approved for a maximum of 2 doses at 5mg/kg

    Biosimilar products available. Use of best value product for infliximab to be implemented.  To be prescribed by brand name.

    Contact pharmacy department for advice on brand for routine prescribing if unsure

     
       
    Tofacitinib tabs (gastroenterology indications)
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    Formulary
    Red
    High Cost Medicine

    Approved as per NICE technology appraisal guidance

     
    Link  MHRA Drug Safety Update May 19: Tofacitinib (Xeljanz▼): restriction of 10 mg twice-daily dose in patients at high risk of pulmonary embolism while safety review is ongoing
    Link  NICE TA547: Tofacitinib for moderately to severely active ulcerative colitis
       
    Ustekinumab injection (Crohn's disease)
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    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  NICE TA456: Ustekinumab for moderately to severely active Crohn’s disease after previous treatment
       
    01.05.03  Vedolizumab
    Vedolizumab injection
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    Formulary
    Red
    High Cost Medicine
     
    Link  NICE TA342 Vedolizumab for treating moderately to severely active ulcerative colitis
    Link  NICE TA352 Vedolizumab for treating moderately to severely active Crohn’s disease after prior therapy
       
    01.05.04  Food allergy
    Sodium cromoglicate caps (Nalcrom®)
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    Formulary
    Amber 2
    Approved for:
    Gastrointestinal symptoms due to food allergy in adults and children aged ≥2 years
    Allergy clinic initiation only 
    Link  SE London APC Recommendation: Sodium cromoglicate caps for food allergy
       
    01.06  Laxatives
    01.06.01  Bulk-forming laxatives to top
    Ispaghula husk granules
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    Formulary  
       
    Methylcellulose tabs
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    Formulary  
       
    01.06.02  Stimulant laxatives
    Bisacodyl tabs, suppositories
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    Formulary  
       
    Co-danthramer caps, suspension
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    Restricted Drug Restricted Palliative care use only 
       
    Co-danthramer strong caps, strong suspension
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    Restricted Drug Restricted Palliative care use only 
       
    Docusate sodium caps, liquid
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    Formulary  
       
    Docusate sodium enema
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    Formulary  
       
    Glycerol (Glycerin) suppositories
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    Formulary  
       
    Senna tabs, syrup
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    Formulary  
       
    Senna granules
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    Formulary  
       
    Sodium picosulfate oral solution
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    Formulary  
       
    01.06.03  Faecal softeners
    Arachis oil enema
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    Formulary  
       
    01.06.04  Osmotic laxatives
    Lactulose oral solution
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    Formulary  
       
    Liquid paraffin and magnesium hydroxide emulsion 25%/6%
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    Restricted Drug Restricted Specialist use only 
       
    Macrogol oral compund powder
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    Formulary For use when other laxatives have failed 
       
    Phosphates enema
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    Formulary  
       
    Sodium citrate enema
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    Formulary  
       
    01.06.05  Bowel cleansing preparations
    Citrafleet® oral powder
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    Formulary
    Red
     
       
    Citramag® oral powder
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    Formulary
    Red
     
       
    Klean-Prep®
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    Formulary
    Red
     
       
    Klean-Prep® (pseudo-obstruction - off-label)
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    Formulary
    Red

    Approved off-label indication:

    For use in colonic pseudo-obstruction, following resolution by successful colonoscopic decompression or use of neostigmine

    • Dose: Dissolve 1 sachet in 1 litre of water and give 250mL twice a day (discard remainder) until normal food intake is re-established.

    Refer to local guideline at GSTT

     
       
    Moviprep®
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    Formulary
    Red

    As per consensus guidelines for the safe use of oral bowel cleansing agents in patients:

    • With end-stage chronic kidney disease

    • With congestive cardiac failure on high-dose diuretics

    • Where previous colonoscopy failed to achieve adequate preparation with CitraFleet®

    • With UC or CD requiring surveillance colonoscopy

     
       
    Picolax®
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    Formulary
    Red
     
       
    01.06.06  Peripheral opiod-receptor antagonist to top
    Methylnaltrexone bromide injection
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    Restricted Drug Restricted
    Red

    Prescribing to be under the supervision of a Consultant Specialist

    To be used in accordance with local/Palliative Care Network guidelines

    Last-line pharmacological option for the treatment of opioid-induced constipation in advanced illness patients who are receiving palliative care when response to usual laxative therapy has not been sufficient

     
       
    Naloxegol tabs
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    Formulary  
    Link  NICE TA345 Naloxegol for treating opioid‑induced constipation
       
    01.06.07  5HT4 receptor agonists and guanylate cyclase-C receptor agonists
    Linaclotide capsules
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    Formulary
    Green

    For treatment of moderate-to-severe IBS with constipation (IBS-C) in adults, in line with APC recommendation (see links below)

    For moderate to severe IBS-C in adults as a second line option if the following recommended by NICE have been ineffective or not tolerated:

    • Antispasmodics or laxatives (not lactulose)

    • Second line tricyclic antidepressants if diarrhoea predominant or SSRIs if constipation predominant

    • If IBS-C more than 12 months and not responding to maximum dose of different laxatives

    Refer to the SEL Irritable Bowel Syndrome Pathway for further detail.

     
    Link  SE London APC recommendation: Linaclotide for moderate-to- severe IBS-C in adults.
       
    Prucalopride tablets
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    Formulary
    Green

    Approved as per criteria in NICE TA211 and SE London Chronic Constipation Pathway (see links below)

    Restricted to use where at least two laxatives from different classes, at the highest tolerated recommended doses for at least 6 months, has failed to provide adequate relief and invasive treatment for constipation is being considered

    Following the licence extension, the SE London APC have approved use in men under the same criteria as NICE TA211

     
    Link  NICE TA211: Constipation (women) - prucalopride
       
    01.06.08  Other preparations for bowel obstruction
    Meglumine amidotrizoate with sodium amidotrizoate (Gastrografin® - small bowel adhesions - off-label)
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    Formulary
    Red

    Approved for the following off-label indication:

    Management of adhesive small bowel obstruction

    Dose: 100mL

     
       
    01.07  Local preparations for anal and rectal disorders
    01.07.01  Soothing haemorrhoidal preparations
    Lidocaine gel 2%, ointment 5%
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    Formulary  
       
    01.07.02  Compound haemorrhoidal preparations with corticosteroids to top
    Anusol® ointment, suppositories
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    Formulary  
       
    Anusol-HC® ointment, suppositories
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    Formulary  
       
    Hydrocortisone ointment
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    Formulary  
       
    Proctofoam HC® foam
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    Formulary  
       
    Xyloproct® ointment
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    Formulary  
       
    01.07.03  Rectal sclerosants
    Oily phenol injection BP
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    Formulary  
       
    01.07.04  Management of anal fissures
    Glyceryl trinitrate 0.4% ointment
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    First Choice

     
    Botulinum toxin A (Xeomin® - anal-fissures - off-label)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    Approved off-label indication:

    Management of anal fissures unresponsive to all other appropriate non-surgical, pharmacological (e.g. topical glyceryl trinitrate, topical diltiazem) and dietary strategies.

    Category B* form required

    See APC recommendation and SE London pathway for the management of anal fissures (links below) for detailed information.

     
    Link  APC recommendation: Botulinum toxin for anal fissures
       
    Diltiazem cream 2%
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    Unlicensed Drug Unlicensed
    Red

    For anal fissure and post-operative anal spasm in high-risk patients following clinical examination.

    Refer to the SE London APC pathway for the management of anal fissures for further information (link below)

    Hospital supply only - 2 tubes are usually sufficient for a treatment course

     
    Link  SE London Area Prescribing Committee recommendation: Diltiazem cream for anal fissures
       
    01.08  Stoma care
    01.09  Drugs affecting intestinal secretions
    01.09.01  Drugs affecting biliary composition and flow to top
    Obeticholic acid tabs
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    Formulary
    Red
    High Cost Medicine
    BlueTeq

    Approved for primary biliary cholangitis as per NICE TA443

     

     

    See MHRA Drug Safety Alert (link below)

     
    Link  NICE TA443: Obeticholic acid for treating primary biliary cholangitis
    Link  Obeticholic acid (Ocaliva▼): risk of serious liver injury in patients with pre-existing moderate or severe hepatic impairment; reminder to adjust dosing according to liver function monitoring
       
    Ursodeoxycholic acid tabs, caps
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    Formulary  
       
    01.09.02  Bile acid sequestrants
    Colesevelam tabs (diarrhoea due to Crohn's and pruritus due to biliary cirrhosis - off-label)
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    Restricted Drug Restricted

    Approved off-label indication:

    • Diarrhoea caused by bile salt malabsorption e.g. in Crohn’s disease or radiation enteritis
    • Pruritus and hyperlipidaemia in primary biliary cirrhosis

    Consultant hepatologists and gastroenterologists initiation only

     
       
    Colestyramine sachets (pruritus due to biliary obstruction and diarrhoea due to Crohn's)
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    Formulary

     
       
    01.09.03  Aprotinin
    01.09.04  Pancreatin
    Pancreatin capsules (Creon® )
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    Formulary
    Amber 2
     
       
    Pancreatin capsules (Pancrease® HL)
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    Formulary
    Amber 2
     
       
    Pancreatin capsules (Pancrex® V)
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    Formulary
    Amber 2
     
       
    Secretin ampoules
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    Unlicensed Drug Unlicensed
    Red
    Diagnostic agent for pancreatic disease 
       
    01.10  Unlicensed Products
    Acetic acid 2.5% solution
    Unlicensed Drug Unlicensed

    For use in Barrett’s oesophagus endoscopy surveillance. 20 mL of 2.5% solution (prepared from acetic acid 5% solution)

    To be applied topically to the oesophageal mucosa

     
       
    Mannitol 2.5% with carob bean gum 0.2% oral solution
    Unlicensed Drug Unlicensed For use by Radiology for outlining the small bowel for MRI scans  
       
     ....
     Non Formulary Items
    Darvadstrocel injection

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    Non Formulary
    Grey

    Darvadstrocel is not recommended in SE London for previously treated complex perianal fistulas in adults with non-active or mildly active luminal Crohn's disease as per NICE TA556 (link below).

    Link  NICE TA556: Darvadstrocel for treating complex perianal fistulas in Crohn’s disease
     
      
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    note Notes
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    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 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

    Red

    Specialist or hospital prescribing only. The responsibility for prescribing, monitoring, dose adjustment and review should remain with the specialist or hospital. In very exceptional circumstances a specialist may discuss individual patient need for a RED drug to be prescribed by a GP and the GP should consider informing the Medicines Management team before a decision is made to prescribe for individual patients.   

    Amber 1

    Treatment can be initiated in primary care after a recommendation from an appropriate specialist  

    Amber 2

    Specialist initiation followed by maintenance prescribing in primary care  

    Amber 3

    Specialist initiation with ongoing monitoring required. After dose stabilisation GPs can be requested to take over prescribing responsibilities using the approved APC shared care documentation  

    Green

    Specialist and non-specialist initiation  

    Grey

    Not recommended for prescribing  

    netFormulary