page79
recommended; 4–8 years, 1 mg 3–4 times daily for up
to
3 days only
; 8–12 years, 2 mg 4 times daily for up to
5 days
. Chronic diarrhoea in adults,
initially,
4–8 mg daily in
divided doses,
subsequently adjusted according to
response and given in 2 divided doses for mainte-
nance;
max. 16 mg daily;
CHILD
under 18 years see
BNF for Children
. Faecal incontinence [unlicensed indication],
initially
500 micrograms daily, adjusted according to response;
max.
16 mg daily in divided doses
Loperamide
(Non-proprietary) A
Capsules
,
loperamide hydrochloride 2 mg,
net price
30-cap pack = £1.07
Tablets
, loperamide hydrochloride 2 mg, net price 30-
tab pack = £2.15
Brands include
Norimode
c
Note
Loperamide can be sold to the public,
provided it is licensed
and labelled for the treatment of acute diarrhoea in adults and
children over 12 years of age, or for acute diarrhoea associated with
irritable bowel syndrome (after initial diagnosis by a doctor) in adults
over 18 years of age
Imodium
c
(Janssen-Cilag) A
Capsules
,
green/grey,
loperamide hydrochloride
2 mg.
Net price 30-cap pack = £1.09
Syrup
,
sugar free,
red,
loperamide hydrochloride
1 mg/5 mL.
Net price 100 mL = £1.17
Compound preparations
Imodium
c
Plus
(McNeil)
Caplets
(= tablets),
loperamide hydrochloride 2 mg,
simeticone 125 mg,
net price 6-tab pack = £2.27,
12-
tab pack = £3.58
Dose
acute diarrhoea with abdominal colic,
initially 2 caplets
(
CHILD 12–18 years 1 caplet) then 1 caplet after each loose stool;
max.
4 caplets daily for up to 2 days;
CHILD under 12 years not
recommended
MORPHINE
Indications
see notes above; cough in terminal dis-
ease (section 3.9.1);
pain (section 4.7.2)
Cautions
see notes above and under Morphine Salts
(section 4.7.2)
Contra-indications
see notes above and under Mor-
phine Salts (section 4.7.2)
Hepatic impairment
section 4.7.2
Renal impairment
section 4.7.2
Pregnancy
section 4.7.2
Breast-feeding
see under Morphine Salts (section
4.7.2)
Side-effects
see notes above and under Morphine
Salts (section 4.7.2);
sedation and the risk of depend-
ence are greater
Dose
. See preparation
Kaolin and Morphine Mixture, BP U
(Kaolin and Morphine Oral Suspension)
Oral suspension
, light kaolin or light kaolin (natural)
20%,
sodium bicarbonate 5%, and chloroform and
morphine tincture 4% in a suitable vehicle.
Contains
anhydrous morphine 550–800 micrograms/10 mL.
Dose
ADULT and CHILD over 12 years, 10 mL every 6 hours in
water
1.5
Chronic bowel disorders
Once tumours are ruled out
individual
symptoms of
chronic bowel disorders need specific treatment includ-
ing dietary manipulation as well as drug treatment and
the maintenance of a liberal fluid intake.
Inflammatory bowel disease
Chronic inflammatory bowel diseases include
ulcerative
colitis
and
Crohn’s
disease
.
Effective
management
requires
drug therapy,
attention to nutrition,
and in
severe or chronic active disease,
surgery.
Aminosalicylates (balsalazide,
mesalazine,
olsalazine,
and
sulfasalazine),
corticosteroids
(hydrocortisone,
beclometasone,
budesonide,
and prednisolone),
and
drugs that affect the immune response are used in
the treatment of inflammatory bowel disease.
Treatment of acute ulcerative colitis and Crohn’s
disease
Acute mild to moderate disease affecting the
rectum (proctitis) or the recto-sigmoid is treated initially
with local
application of
an aminosalicylate (section
1.5.1);
alternatively,
a local
corticosteroid can be used
but it is less effective.
A combination of a local
amino-
salicylate and a local
corticosteroid can be used for
proctitis that does not respond to a local aminosalicylate
alone.
Foam preparations and suppositories are espe-
cially useful when patients have difficulty retaining liq-
uid enemas.
Diffuse inflammatory bowel disease or disease that does
not
respond to local
therapy requires oral
treatment.
Mild disease affecting the proximal colon can be treated
with an oral
aminosalicylate alone;
a combination of a
local and an oral aminosalicylate can be used in proctitis
or distal
colitis.
Refractory or moderate inflammatory
bowel disease usually requires adjunctive use of an oral
corticosteroid such as prednisolone (section 1.5.2) for
4–8 weeks. Modified-release budesonide is licensed for
Crohn’s disease affecting the ileum and the ascending
colon;
it
causes fewer systemic side-effects than oral
prednisolone but may be less effective. Beclometasone
dipropionate by mouth is licensed as an adjunct
to
mesalazine for mild to moderate ulcerative colitis, but it
is not known whether it is as effective as other corti-
costeroids.
Severe inflammatory bowel
disease or disease that
is
not responding to an oral corticosteroid requires hospi-
tal
admission
and
treatment
with
an
intravenous
corticosteroid
(such
as
hydrocortisone
or
methyl-
prednisolone, section 6.3.2);
other therapy may include
intravenous fluid and electrolyte replacement, and pos-
sibly
parenteral
nutrition.
Specialist
supervision
is
required for patients who fail to respond adequately to
these measures.
Patients with severe ulcerative colitis
that has not responded to intravenous corticosteroids,
may benefit from a short course of intravenous ciclos-
porin [unlicensed indication]
(section 1.5.3).
Patients
with unresponsive or chronically active Crohn’s disease
may
benefit
from azathioprine
(section
1.5.3),
mercaptopurine
(section
1.5.3),
or
once-weekly
methotrexate (section 1.5.3)
[all
unlicensed indica-
tions];
these drugs have a slower onset of action.
Infliximab (section 1.5.3)
is licensed for the manage-
ment of severe active Crohn’s disease and severe ulcer-
ative
colitis
in
patients
whose
condition
has
not
BNF 61
1.5 Chronic bowel disorders
59
1
Gastro-intestinal system