to develop. Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Tablet
▶Celevac(AMCo)
Methylcellulose "450" 500 mgCelevac500mg tablets|112 tabletG £3.22DT price = £3.22
Sterculia
19-Feb-2016lDRUG ACTIONSterculia is a bulk-forming laxative. It relieves constipation by increasing faecal mass which stimulates peristalsis.
lINDICATIONS AND DOSE Constipation
▶BY MOUTH
▶Child 6–11 years:0.5–1sachet1–2times a day, alternatively, half to one heaped5-mL spoonful once or twice a day; washed down without chewing with plenty of liquid after meals
▶Child 12–17 years:1–2sachets1–2times a day, alternatively, one to two heaped5-mL spoonfuls once or twice a day; washed down without chewing with plenty of liquid after meals
▶Adult:1–2sachets1–2times a day, alternatively, one to two heaped5-mL spoonfuls once or twice a day;
washed down without chewing with plenty of liquid after meals
lCONTRA-INDICATIONSColonic atony
.
difficulty in swallowing.
faecal impaction.
intestinal obstruction lCAUTIONSAdequatefluid intake should be maintained toavoid intestinal obstruction CAUTIONS, FURTHER INFORMATION
▶In adultsIt may be necessary to supervise elderly or debilitated patients or those with intestinal narrowing or decreased motility to ensure adequatefluid intake.
lSIDE-EFFECTSAbdominal distension (especially during thefirst few days of treatment)
.
flatulence (especially during thefirst few days of treatment).
gastro-intestinal impaction.
gastro-intestinal obstruction.
hypersensitivity lDIRECTIONS FOR ADMINISTRATIONMay be mixed with soft food (e.g. yoghurt) before swallowing, followed by plenty of liquid.lPATIENT AND CARER ADVICEPatients and their carers should be advised that the full effect may take some days to develop. Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Granules
CAUTIONARY AND ADVISORY LABELS25, 27
▶Normacol(Norgine Pharmaceuticals Ltd)
Sterculia 620 mg per 1 gramNormacol granules7g sachets|60 sachetG £6.35DT price = £6.35
Normacol granules|500gramG£7.54DT price = £7.54
Sterculia with frangula
The properties listed below are those particular to the combination only. For the properties of the components please consider, sterculia above.
lINDICATIONS AND DOSE After haemorrhoidectomy
▶BY MOUTH
▶Adult:1–2sachets1–2times a day, alternatively,1–2 heaped5mL spoonfuls once or twice a day; washed down without chewing with plenty of liquid after meals Constipation
▶BY MOUTH
▶Adult:1–2sachets1–2times a day, alternatively,1–2 heaped5mL spoonfuls once or twice a day; washed down without chewing with plenty of liquid after meals
lPREGNANCYManufacturer advises avoid.
lBREAST FEEDINGManufacturer advises avoid.
lPATIENT AND CARER ADVICEPatients and their carers should be advised that the full effect may take some days to develop. Preparations that swell in contact with liquid should always be carefully swallowed with water and should not be taken immediately before going to bed.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Granules
▶Normacol Plus(Norgine Pharmaceuticals Ltd) Frangula 80 mg per 1 gram, Sterculia 620 mg per
1 gramNormacol Plus granules7g sachets|60sachetG£6.78 DT price = £6.78
Normacol Plus granules|500gramG£8.05DT price = £8.05
LAXATIVES
›
CHLORIDE-CHANNEL AGONISTSLubiprostone
23-Mar-2016lNATIONAL FUNDING/ACCESS DECISIONS NICE technology appraisals (TAs)
▶Lubiprostone for treating chronic idiopathic constipation (July 2014)NICE TA318
Lubiprostone is recommended as an option for treating chronic idiopathic constipation for adults in whom treatment with at least2laxatives from different classes, at the highest tolerated recommended doses for at least 6months, has failed to provide adequate relief and for whom invasive treatment for constipation is being considered. If treatment with lubiprostone is not effective after2weeks, the patient should be re-examined and the benefit of continuing treatment reconsidered.
Lubiprostone should only be prescribed by a clinician with experience of treating chronic idiopathic
constipation, after careful review of the patient’s previous courses of laxative treatments.
www.nice.org.uk/TA318
Scottish Medicines Consortium (SMC) Decisions TheScottish Medicines Consortiumhas advised (July2014) that lubiprostone (Amitiza)®isnotrecommended for use within NHS Scotland.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Capsule
CAUTIONARY AND ADVISORY LABELS21
▶Amitiza(Sucampo Pharma Europe Ltd)A
Lubiprostone 24 microgramAmitiza24microgram capsules|28 capsuleP £29.68|56capsuleP£53.48
LAXATIVES
›
OSMOTIC LAXATIVESLactulose
lINDICATIONS AND DOSE Constipation
▶BY MOUTH
▶Child 1–11 months:2.5mL twice daily, adjusted according to response
▶Child 1–4 years:2.5–10mL twice daily, adjusted according to response
▶Child 5–17 years:5–20mL twice daily, adjusted according to response
▶Adult:Initially15mL twice daily, adjusted according to response
Hepatic encephalopathy (portal systemic encephalopathy)
▶BY MOUTH
▶Adult:Adjusted according to response to30–50mL 3times a day, subsequently adjusted to produce2–3 soft stools per day
PHARMACOKINETICS
Lactulose may take up to48hours to act.
lUNLICENSED USE
▶In adultsLactulose doses in the BNF may differ from those in product literature.
lCONTRA-INDICATIONSGalactosaemia
.
intestinal obstructionlCAUTIONSLactose intolerance lSIDE-EFFECTS
▶Common or very commonAbdominal discomfort
.
cramps.
flatulence
.
nausea.
vomiting SIDE-EFFECTS, FURTHER INFORMATION▶NauseaNausea can be reduced by administration with water, fruit juice or meals.
lPREGNANCYNot known to be harmful.
lPATIENT AND CARER ADVICE
Medicines for Children leaflet: Lactulose for constipation www.medicinesforchildren.org.uk/lactulose-for-constipation
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral solution
▶Lactulose (Non-proprietary)
Lactulose 666.667 mg per 1 mlLactulose10g/15ml oral solution 15ml sachets sugar free sugar-free|10sachetp £2.50DT price =
£2.50
Lactulose 680 mg per 1 mlLactulose3.1-3.7g/5ml oral solution| 300mlp£2.73|500mlp£4.55DT price = £2.52
▶Duphalac(Mylan Ltd)
Lactulose 680 mg per 1 mlDuphalac3.35g/5ml syrup|200mlp
£1.92
▶Lactugal(Intrapharm Laboratories Ltd)
Lactulose 680 mg per 1 mlLactugal3.1-3.7g/5ml oral solution| 500mlp£4.56DT price = £2.52|2000mlp £16.42
Macrogol 3350 with potassium chloride, sodium bicarbonate and sodium chloride
lINDICATIONS AND DOSE
Chronic constipation (dose for non-proprietary’ full-strength’sachets)
▶BY MOUTH
▶Child 12–17 years:1–3sachets daily in divided doses usually for up to2weeks; maintenance1–2sachets daily
▶Adult:1–3sachets daily in divided doses usually for up to2weeks; maintenance1–2sachets daily
Faecal impaction (dose for non-proprietary’full-strength’ sachets)
▶BY MOUTH
▶Child 12–17 years:4sachets onfirst day, then increased in steps of2sachets daily, total daily dose to be drunk within a6hour period, after disimpaction, switch to maintenance laxative therapy if required; maximum 8sachets per day
▶Adult:4sachets onfirst day, then increased in steps of 2sachets daily, total daily dose to be drunk within a 6hour period, after disimpaction, switch to maintenance laxative therapy if required; maximum 8sachets per day
MOVICOL-HALF® Chronic constipation
▶BY MOUTH
▶Child 12–17 years:2–6sachets daily in divided doses usually for up to2weeks; maintenance2–4sachets daily
▶Adult:2–6sachets daily in divided doses usually for up to2weeks; maintenance2–4sachets daily
Faecal impaction
▶BY MOUTH
▶Child 12–17 years:Initially8sachets daily onfirst day, then increased in steps of4sachets daily, total daily dose to be drunk within6hours, after disimpaction, switch to maintenance laxative therapy; maximum 16sachets per day
▶Adult:Initially8sachets daily onfirst day, then increased in steps of4sachets daily, total daily dose to be drunk within6hours, after disimpaction, switch to maintenance laxative therapy; maximum16sachets per day
MOVICOL-PAEDIATRIC®
Chronic constipation|Prevention of faecal impaction
▶BY MOUTH
▶Child 2–5 years:1sachet daily, adjust dose to produce regular soft stools; maximum4sachets per day
continued
→
BNF74
Constipation 55
Gastro-intestinalsystem
1
▶Child 6–11 years:2sachets daily, adjust dose to produce regular soft stools; maximum4sachets per day Faecal impaction
▶BY MOUTH
▶Child 5–11 years:Initially4sachets daily onfirst day, then increased in steps of2sachets daily, total daily dose to be taken over a12-hour period, after disimpaction, switch to maintenance laxative therapy;
maximum12sachets per day MOVICOL®LIQUID
Chronic constipation
▶BY MOUTH
▶Child 12–17 years:25mL1–3times a day usually for up to2weeks; maintenance25mL1–2times a day
▶Adult:25mL1–3times a day usually for up to2weeks;
maintenance25mL1–2times a day MOVICOL®ORAL POWDER
Chronic constipation
▶BY MOUTH
▶Child 12–17 years:1–3sachets daily in divided doses usually for up to2weeks; maintenance1–2sachets daily
▶Adult:1–3sachets daily in divided doses usually for up to2weeks; maintenance1–2sachets daily
Faecal impaction
▶BY MOUTH
▶Child 12–17 years:Initially4sachets daily onfirst day, then increased in steps of2sachets daily, total daily dose to be drunk within a6hour period, after disimpaction, switch to maintenance laxative therapy if required; maximum8sachets per day
▶Adult:Initially4sachets daily onfirst day, then increased in steps of2sachets daily, total daily dose to be drunk within a6hour period, after disimpaction, switch to maintenance laxative therapy if required;
maximum8sachets per day
lUNLICENSED USE
MOVICOL-PAEDIATRIC® Movicol®Paediatricnot licensed for use in faecal impaction in children under5years, or for chronic constipation in children under2years.
lCONTRA-INDICATIONSCrohn’s disease
.
intestinal obstruction.
intestinal perforation.
paralytic ileus.
severe inflammatory conditions of the intestinal tract.
toxic megacolon.
ulcerative colitisMOVICOL-PAEDIATRIC® Cardiovascular impairment
.
renal impairmentlCAUTIONSCardiovascular impairment (should not take more than2’full-strength’sachets or4’half-strength’
sachets in any one hour)
.
discontinue if symptoms offluid and electrolyte disturbanceMOVICOL-PAEDIATRIC® Impaired consciousness (with high doses)
.
impaired gag reflex (with high doses).
refluxoesophagitis (with high doses)
lSIDE-EFFECTSAbdominal distention
.
addominal pain.
flatulence
.
nausealPREGNANCYLimited data, but manufacturer advises that it can be used.
lBREAST FEEDINGManufacturer advises that it can be used.
lRENAL IMPAIRMENT
MOVICOL-PAEDIATRIC® Contra-indicated in renal impairment.
lDIRECTIONS FOR ADMINISTRATIONContents of each’full strength’sachet of oral powder to be dissolved in half a glass (approx.125mL) of water; after reconstitution the solution should be kept in a refrigerator and discarded if unused after6hours.
MOVICOL®LIQUID25mL of oral concentrate to be diluted with half a glass (approx.100mL) of water. After dilution the solution should be discarded if unused after24hours.
MOVICOL-PAEDIATRIC®Contents of each sachet to be dissolved in quarter of a glass (approx.60–65mL) of water;
after reconstitution the solution should be kept in a refrigerator and discarded if unused after24hours.
MOVICOL®ORAL POWDERContents of each sachet to be dissolved in half a glass (approx.125mL) of water; after reconstitution the solution should be kept in a refrigerator and discarded if unused after6hours.
MOVICOL-HALF®Contents of each sachet to be dissolved in quarter of a glass (approx.60–65mL) of water; after reconstitution the solution should be kept in a refrigerator and discarded if unused after6hours.
lPRESCRIBING AND DISPENSING INFORMATIONFlavours of oral liquid formulations may include orange.
Flavours of oral powder formulations may include chocolate, lime and lemon, or plain.
MOVICOL®LIQUID25mL of oral concentrate when diluted with100mL water provides K+5.4mmol/litre.
MOVICOL®ORAL POWDERAmount of potassium chloride varies according toflavour ofMovicol®as follows:
plain-flavour (sugar-free) =50.2mg/sachet; lime and lemonflavour =46.6mg/sachet; chocolateflavour = 31.7mg/sachet.1sachet when reconstituted with125mL water provides K+5.4mmol/litre.
lPATIENT AND CARER ADVICE
Patients or carers should be counselled on how to take the oral powder and oral solution.
Medicines for Children leaflet: Movicol for constipation www.medicinesforchildren.org.uk/movicol-for-constipation MOVICOL®LIQUIDPatients or carers should be counselled on how to takeMovicol®oral solution.
MOVICOL®ORAL POWDERPatients or carers should be counselled on how to takeMovicol®oral powder.
MOVICOL-HALF®Patients or carers should be given advice on how to administerMovicol-Half®oral powder.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral solution
CAUTIONARY AND ADVISORY LABELS13
ELECTROLYTES:May contain Bicarbonate, chloride, potassium, sodium
▶Movicol(Norgine Pharmaceuticals Ltd)
Macrogol’3350’105 gram per 1 litre, Potassium 5.4 mmol per 1 litre, Bicarbonate 17 mmol per 1 litre, Chloride 53 mmol per 1 litre, Sodium 65 mmol per 1 litreMovicol Liquid sugar-free|500 mlp£5.15DT price = £5.15
Powder
CAUTIONARY AND ADVISORY LABELS13
ELECTROLYTES:May contain Bicarbonate, chloride, potassium, sodium
▶Movicol(Norgine Pharmaceuticals Ltd)
Macrogol’3350’52.5 gram per 1 litre, Potassium 5.4 mmol per 1 litre, Bicarbonate 17 mmol per 1 litre, Chloride 53 mmol per 1 litre, Sodium 65 mmol per 1 litreMovicol-Half oral powder6.9g sachets sugar-free|20sachetp £3.37sugar-free|30sachetp
£5.06DT price = £4.38
Movicol Paediatric Plain oral powder6.9g sachets sugar-free|30 sachetP £4.38DT price = £4.38
Movicol Paediatric Chocolate oral powder6.9g sachets sugar-free|30 sachetP £4.38DT price = £4.38
Macrogol’3350’105 gram per 1 litre, Potassium 5.4 mmol per 1 litre, Bicarbonate 17 mmol per 1 litre, Chloride 53 mmol per 1 litre, Sodium 65 mmol per 1 litreMovicol Plain oral powder13.7g sachets sugar-free|30sachetp £7.72DT price = £4.27sugar-free| 50sachetp£12.85
Movicol Chocolate oral powder13.9g sachets sugar-free|30 sachetp £7.72DT price = £4.27
Movicol oral powder13.8g sachets lemon & lime sugar-free|20 sachetp £5.15sugar-free|30sachetp £7.72DT price = £4.27 sugar-free|50sachetp£12.85
56 Constipation and bowel cleansing
BNF74Gastro-intestinalsystem
1
Magnesium hydroxide
lINDICATIONS AND DOSE Constipation
▶BY MOUTH
▶Adult:30–45mL as required, dose to be given mixed with water at bedtime
lCONTRA-INDICATIONSAcute gastro-intestinal conditions lCAUTIONSDebilitated patients
.
elderlylINTERACTIONS→Appendix1: magnesium lSIDE-EFFECTSColic
lHEPATIC IMPAIRMENTAvoid in hepatic coma if risk of renal failure.
lRENAL IMPAIRMENTAvoid or reduce dose. Increased risk of toxicity in renal impairment.
lPRESCRIBING AND DISPENSING INFORMATIONWhen prepared extemporaneously, the BP states Magnesium Hydroxide Mixture, BP consists of an aqueous suspension containing about8% hydrated magnesium oxide.
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral suspension
▶Phillips’Milk of Magnesia(Omega Pharma Ltd)
Magnesium hydroxide 83 mg per 1 mlPhillips’Milk of Magnesia 415mg/5ml oral suspension sugar-free|200mlG£3.22DT price
= £3.22
Combinations available:Liquid paraffin with magnesium hydroxide,p.59
Sodium acid phosphate with sodium phosphate
lINDICATIONS AND DOSE
Constipation (using Phosphates Enema BP Formula B)| Bowel evacuation before abdominal radiological procedures, endoscopy, and surgery (using Phosphates Enema BP Formula B)
▶BY RECTUM
▶Child 3–6 years:45–65mL once daily
▶Child 7–11 years:65–100mL once daily
▶Child 12–17 years:100–128mL once daily
▶Adult:128mL daily FLEET®READY-TO-USE ENEMA
Constipation|Bowel evacuation before abdominal radiological procedures|Bowel evacuation before endoscopy|Bowel evacuation before surgery
▶BY RECTUM
▶Adult:118mL FLEET®PHOSPHO-SODA
Bowel evacuation before colonic surgery|Bowel evacuation before colonoscopy|Bowel evacuation before radiological examination
▶BY MOUTH
▶Adult:45mL twice daily, each dose must be diluted with half a glass (120mL) of cold water, followed by one full glass (240mL) of cold water, timing of doses is dependent on the time of the procedure, for morning procedure, thefirst dose should be taken at7a.m. and second at7p.m. on day before the procedure.; for afternoon procedure,first dose should be taken at 7p.m. on day before and second dose at7a.m. on day of the procedure
PHARMACOKINETICS
ForFleet®Phospho-soda:Onset of action is within half to 6hours offirst dose.
lCONTRA-INDICATIONS
▶With oral useAcute severe colitis
.
ascites.
congestive cardiac failure.
gastric retention.
gastro-intestinal obstruction.
gastro-intestinal perforation.
toxic megacolon▶With rectal useConditions associated with increased colonic absorption
.
gastro-intestinal obstruction.
inflammatory bowel disease lCAUTIONS
▶With oral useCardiac disease (avoid in congestive cardiac failure)
.
colitis (avoid if acute severe colitis).
elderly and debilitated patients.
fluid and electrolyte disturbances.
hypovolaemia (should be corrected before administration)
.
impaired gag reflex or possibility of regurgitation or aspiration▶With rectal useAscites
.
congestive heart failure.
elderly and debilitated patients.
electrolyte disturbances.
uncontrolled hypertension
lINTERACTIONS→Appendix1: bowel cleansing preparations
lSIDE-EFFECTS
▶Common or very common
▶With oral useAbdominal distention
.
abdominal pain (usually transient—reduced by taking more slowly).
nausea
.
vomiting▶Uncommon
▶With oral useDehydration
.
dizziness.
headache▶Frequency not known
▶With oral useArrhythmias
.
asthenia.
chest pain.
electrolyte disturbances
.
renal failure▶With rectal useElectrolyte disturbances
.
local irritation lPREGNANCY▶With oral useCaution.
lBREAST FEEDING
▶With oral useCaution.
lHEPATIC IMPAIRMENTUse with caution in cirrhosis.
lRENAL IMPAIRMENT
▶With oral useAvoid if eGFR less than 60mL/minute/1.73m2.
▶With rectal useUse with caution.
lMONITORING REQUIREMENTS
▶With oral useRenal function should be measured before starting treatment in patients at risk offluid and electrolyte disturbances.
lDIRECTIONS FOR ADMINISTRATION
FLEET®PHOSPHO-SODACopious intake of water or other clearfluids (e.g. clear soup, strained fruit juice without pulp, black tea or coffee) recommended until midnight before morning procedure and until8a.m. before afternoon procedure. At least one glass (approx240mL) of water or other clearfluid should also be taken immediately before each dose.
lPRESCRIBING AND DISPENSING INFORMATIONWhen prepared extemporaneously, the BP states Phosphates Enema BP Formula B consists of sodium dihydrogen phosphate dihydrate12.8g, disodium phosphate dodecahydrate10.24g, purified water, freshly boiled and cooled, to128mL.
lPATIENT AND CARER ADVICE
FLEET®PHOSPHO-SODAIntake of solid food should be stopped for at least6hours before starting treatment and until procedure completed.
Patients or carers should be advised that adequate hydration should be maintained during treatment.
Patients or carers should be given advice on administration ofFleet Phospho-soda®oral solution.
BNF74
Constipation 57
Gastro-intestinalsystem
1
lMEDICINAL FORMS
There can be variation in the licensing of different medicines containing the same drug.
Oral solution
CAUTIONARY AND ADVISORY LABELS10 ELECTROLYTES:May contain Phosphate, sodium
▶Fleet Phospho-soda(Casen Recordati S.L.)
Disodium hydrogen phosphate dodecahydrate 240 mg per 1 ml, Sodium dihydrogen phosphate dihydrate 542 mg per 1 mlFleet Phospho-soda oral solution sugar-free|90mlp £4.79 Enema
▶Sodium acid phosphate with sodium phosphate (Non-proprietary)
Disodium hydrogen phosphate dodecahydrate 80 mg per 1 ml, Sodium dihydrogen phosphate dihydrate 100 mg per 1 mlPhosphates enema (Formula B)128ml long tube|1enemap
£27.93DT price = £27.93
Phosphates enema (Formula B)128ml standard tube|1enemap
£3.98DT price = £3.98
▶Fleet Ready-to-use(Casen Recordati S.L.)
Disodium hydrogen phosphate dodecahydrate 80 mg per 1 ml, Sodium dihydrogen phosphate dihydrate 181 mg per 1 mlCleen Ready-to-use133ml enema|1enemap£0.68
LAXATIVES