Cumbria Minor Ailments Formulary and Prescribing Notes Gastrointestinal (a) Indigestion



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Cumbria Minor Ailments Formulary and Prescribing Notes

Gastrointestinal

(a) Indigestion

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ADULT

Antacids -

First Choice:




co-magaldrox
(Mucogel®)




Alginates -

First Choice:




compound alginic acid preparations
(Peptac® suspension or Gastrocote® tablets)




H2 receptor antagonists -

First Choice:




ranitidine




CHILD

First Choice:




compound alginic acid preparations
Peptac® suspension




Dose/quantity

  • Mucogel® 500mL suspension (magnesium hydroxide 195mg, dried aluminium hydroxide
    220mg/5mL):
    10-20mL, 20 minutes-1 hour after meals, and at bedtime or when required

  • Peptac® 500mL suspension (sodium alginate 250mg, sodium bicarbonate 133.5mg, calcium carbonate 80mg per 5mL)

  • Gastrocote® tablets (alginic acid 200mg, dried aluminium hydroxide gel 80mg, magnesium 40mg sodium bicarbonate 70mg): 1-2 tablets chewed 4 times daily after meals and at bedtime

  • ranitidine 75 mg tablets: 1 tab PRN up to maximum of 2 in 24 hours.

Prescribing Notes

  • Peptac® is the most cost effective liquid compound alginic acid preparation

  • Liquid formulations of antacids are more effective than tablets or capsules

  • Compound alginic acid preparations are less powerful antacids than co-magaldrox but may be more effective for heartburn

  • Refer to pregnancy section for advice in pregnancy

  • Ranitidine should only be used short term, if the problem persists refer to GP. Advise
    patient to lose weight if overweight, stop smoking, avoid trigger foods.

When to advise patient to contact GP

Child under 6 years


Difficulty swallowing
Symptoms are persistent (longer than 5 days) or recurrent
Pain is severe or radiating
Blood in vomit or stools
Pain worsens on effort
Persistent vomiting
Treatment has failed (no improvement in symptoms after 5 days)
Adverse drug reaction is suspected
Associated weight loss
First episode at age over 40

Gastrointestinal

(b) Infant colic

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CHILD

First Choice:




No treatment – see prescribing notes




Prescribing Notes

  • Colic usually resolves within 4 months

  • Try helpful strategies of gentle motion, bathing in warm water, if breast feeding avoid spicy foods, alcohol, caffeine and foods with high dairy content, if bottle feeding ensure correct size holes on teat, if too large baby may gulp in air

  • Advise parents to take a break if possible, get friends or family to help

  • Trials on effectiveness of simeticone showed no significant improvement in symptoms therefore it has not been included in the Lothian MAF.

When to advise patient to contact GP

Failure to thrive


Frequent recurrent vomiting
Feeding difficulties
Possible post natal depression – colic is often associated with parental anxiety

Gastrointestinal

(c) Constipation

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ADULT

Acute constipation -

First Choice:




dietary manipulation




Second choice:




ispaghula husk




or

senna




CHILD

First Choice:




dietary manipulation




Second choice:




lactulose




Dose/quantity

  • ispaghula husk 3.5g (Fybogel®): 1 sachet in water twice daily preferably after meals

  • lactulose 3.1-3.7g/5mL 300mL/500mL:

    • 1-5 years: 2.5mL twice daily with meals (may be diluted with water or juice)

    • 5-10 years: 10mL twice daily with meals (may be diluted with water or juice)

    • Adult: 15mL twice daily, adjust dose according to patients needs

  • senna 7.5mg 20 tablets; 7.5mg/5mL 100mL syrup:

    • Adult: 2-4 tablets at night or 10-20ml syrup at night.

Prescribing Notes

  • Ispaghula may take several days to act

  • Stimulant laxatives become less effective with long-term use

  • If bulk-forming and stimulant laxatives are unsuitable, consider at least 30mL daily of lactulose; this may take 48 hours to act

  • Refer to pregnancy section for advice in pregnancy

  • The use of laxatives in children should be discouraged unless recommended by a doctor but lactulose may be given if needed short term until dietary measures take effect

  • Dietary measures include increasing: fluid, fruit and fibre intake, avoid too many caffeine containing drinks

  • Regular exercise improves bowel habits

  • Lactulose may take up to 48 hours to act and should be used with caution in lactose intolerant patients

  • Stimulant laxatives should only be used short-term

  • After an episode of acute constipation, maintenance therapy may be required for several months or longer until regular bowel habit is established.

When to advise patient to contact GP

New or worsening symptoms without adequate explanation


Persistent change in bowel habit
Abdominal pain, blood in stools, weight loss, nausea and vomiting
Prescribed medication suspected of causing symptoms
Failure of OTC medication (no relief of symptoms within 7 days)
Child feeling weak or dizzy
Marked anal pain on defecation

(d) Diarrhoea

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ADULT

First Choice:




oral rehydration therapy (Electrolade®)
(for acute diarrhoea)




Second Choice:




loperamide




CHILD

First Choice:




oral rehydration therapy (Electrolade®)
(for acute diarrhoea)




Formulations/Dose

  • Electrolade® oral powder 6 sachets containing sodium chloride 236mg, potassium chloride
    300mg, sodium bicarbonate 500mg, anhydrous glucose 4g/sachet
    : reconstitute one sachet with 200mL of water (freshly boiled and cooled for infants)

    • 1 month–1 year: 1-1½ times usual feed volume

    • 1-12 years: 200mL after every loose motion

    • Adults and over 12 years: 200-400mL after every loose motion

  • loperamide 2mg 12 capsules:

    • Adults and over 12 years acute diarrhoea: 4mg then 2mg after each loose stool for up to 5 days. Max. 12mg daily.

Prescribing Notes

  • First-line treatment for acute diarrhoea is to prevent dehydration, advise 3L fluids in 24 hours if not eating, or 2L fluids in 24 hours if eating

  • Any unused solution should be discarded no later than 1 hour after preparation unless stored in a fridge when it can be kept for maximum of 24 hours

  • Eat as normally as possible. Ideally include fruit juices and soups which will provide sugar and salt and also foods high in carbohydrate such as bread, pasta etc

  • Always wash hands after going to the toilet/changing nappies

  • Antidiarrhoeal drugs should not be given in acute inflammatory bowel disease or pseudomembranous colitis, as they may increase the risk of developing toxic megacolon, nor in acute infective diarrhoea with bloody stools.

When to advise patient to contact GP

 Children <1 year: diarrhoea of duration greater than 1 day


Children 1-3 years: diarrhoea of duration greater than 2 days
Adults and children >3 years: duration of diarrhoea greater than 3 days

Concerns about dehydration e.g. not passing much urine


In severe cases referral should be recommended immediately
Associated with severe vomiting and fever
Suspected drug-induced reaction to prescribed medicine
History of change in bowel habit
Presence of blood or mucus in the stools
Drowsiness or confusion

e) Haemorrhoids

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ADULT

First Choice:




Anusol Plus HC ®




Formulations/Dose

  • Anusol Plus HC® 15g ointment with rectal nozzle, 12 suppositories (containing benzyl benzoate, bismuth oxide, bismuth subgallate, hydrocortisone, peru balsam, zinc oxide): apply (or insert 1 suppository) night, morning and after defecation, for up to 7 days.

Prescribing Notes

  • Anusol Plus HC® can be used to provide symptomatic relief of haemorrhoids and pruritus ani

  • Provide lifestyle advice to minimise constipation and straining

  • Keep anal area clean, perhaps use moist wipes

  • Warm baths may soothe

  • Refer to pregnancy section for advice in pregnancy.

When to advise patient to contact GP

Haemorrhoids in children


Duration of longer than 3 weeks
Presence of blood in the stools
Change of bowel habit (persisting alteration from normal bowel habit)
Suspected drug-induced constipation
Associated abdominal pain/vomiting

Oropharynx

(a) Oral ulceration and inflammation

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ADULT

First Choice:




benzydamine hydrochloride (Difflam®)




+/-

chlorhexidine gluconate




Second Choice:




hydrocortisone sodium succinate lozenge




CHILD

First Choice:




benzydamine hydrochloride spray (Difflam®)




Formulations/Dose

  • benzydamine hydrochloride 0.15% 200mL oral rinse: rinse or gargle with 15mL (diluted with water if stinging occurs) every 1½-3 hours as required, usually for not more than 7 days

  • benzydamine hydrochloride 0.15% 30mL spray:

    • under 6 years: 1 puff per 4kg body-weight to max. 4 puffs onto affected area every 1½-3 hours

    • 6-12 years: 4 puffs onto affected area every 1½-3 hours

    • over 12 years: 4-8 sprays onto affected area every 1½-3 hours

  • chlorhexidine gluconate 0.2% 300mL mouthwash: rinse mouth with 10mL for about 1 minute twice daily

  • chlorhexidine gluconate 0.2% 60mL oral spray: apply as required to tooth and gingival surfaces using up to a maximum of 12 actuations (approximately 0.14mL/actuation) twice daily

  • hydrocortisone sodium succinate 2.5mg 20 lozenges: 1 lozenge 4 times daily, allowed to dissolve slowly in the mouth in contact with the ulcer. Use for a maximum of 5 days.

Prescribing Notes

  • There is some evidence that chlorhexidine gluconate may reduce the duration and severity of each episode of ulceration

  • Benzydamine mouthwash can be used 10 minutes before meals to relieve pain in patients suffering from mouth ulcers.

When to advise patient to contact GP or Dental Practitioner

Duration of longer than 3 weeks


Associated weight loss
Involvement of other mucous membranes
Rash
Suspected adverse drug reaction
Diarrhoea

(b) Teething

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CHILD

First Choice:




self care - rub gum with clean finger,
allow infant to bite on a clean cool object




Second Choice:




lidocaine dental gel (Dentinox®)




Formulations/Dose

  • Dentinox® Teething Gel 15g gel (lidocaine hydrochloride 0.33% w/w and cetylpyridium chloride 0.1% w/w): place a small quantity of gel on a clean finger tip or cotton wool pad and rub gently onto the baby’s gums. Can be repeated after 20 minutes if necessary.

Prescribing Notes

  • Oral analgesics might be helpful in managing the pain associated with teething, see CNS section for detail

  • Petroleum jelly or aqueous cream applied around the mouth and chin may prevent rashes and soreness from excessive dribbling.

(c) Oral fungal infection (thrush)

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ADULT AND CHILD

First Choice:




miconazole gel




Formulations/Dose

  • miconazole 24mg/mL 15gm oral gel: prevention and treatment of oral fungal infections

    • 4 months–2 years: 2.5mL twice daily

    • 2-6 years: 5mL twice daily

    • 6 years-12 years: 5mL 4 times daily

    • over 12 years: 5-10mL 4 times daily

Place in the mouth after food and retain near lesions. Localised lesions, smear small
amount on affected areas with clean finger 4 times daily for 5-7 days.

Prescribing Notes

  • Avoid concomitant use in patient taking warfarin, simvastatin and sulphonylureas

  • Dental prostheses should be removed at night and brushed with gel

  • Treatment is continued for 48 hours after lesions have resolved

  • Pre-term or slower developing babies should not be given miconazole gel until they are 5-6 months old, as detailed in the product literature

  • Never put the whole dose in the mouth of a child at once – divide each dose into smaller applications. The gel should be placed in the front of the mouth, never put a large portion of gel in the back of the throat.

When to advise patient to contact GP

Child under 4 months


Duration of longer than 3 weeks
Associated weight loss
Involvement of other mucous membranes
RashSuspected adverse drug reaction
Diarrhoea

Respiratory & Nasal

(a) Hay fever/rhinitis

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ADULT

Allergic rhinitis -

First Choice:




beclometasone




Antihistamines -

First Choice:




cetirizine  







chlorphenamine




Second Choice:




loratadine




CHILD

Non sedating antihistamines -

First Choice:




cetirizine




Sedating antihistamines -

First Choice:




chlorphenamine




Formulations/Dose

  • beclometasone dipropionate 50micrograms/puff 100 or 180 dose nasal spray: over 18 only, 100 micrograms (2 sprays) into each nostril twice daily or 50 micrograms (1 spray)into each nostril 3-4 times daily; max total 400 micrograms (8 sprays) daily; when symptoms controlled, reduce dose to 50 micrograms (1 spray) into each nostril twice daily

  • cetirizine 10mg 30 tablets:

    • Adults and over 6 years: 10mg daily or 5mg twice daily

  • cetirizine 5mg/5mL 100mL oral liquid: NB: P packs only not GSL

    • 2-6 years: 5mg daily or 2.5mg twice daily

    • over 6 years: 10mg daily or 5mg twice daily

  • loratadine 10mg 30 tablets: 10mg daily

  • chlorphenamine 2mg/5mL 150mL syrup; (NB: syrup not licensed for use in children
    under 1 year; tablets not licensed for use in children under 6 years)

    • 1-2 years: 1mg twice daily

    • 2-6 years: 1mg every 4-6 hours, max 6mg daily

    • 6-12 years: 2mg every 4-6 hours, max 12mg daily

    • 12 years: 4mg every 4-6 hours, max 24mg daily

  • chlorphenamine 4mg 30 tablets; over 12 years, 4mg every 4-6 hours, max 24mg daily.

Prescribing Notes

  • For seasonal allergic rhinitis, prophylaxis should begin 1 week before the start of the pollen season and continue throughout

  • Beclometasone nasal spray will not give instant relief of symptoms; maximum efficacy is achieved after a few days. Patient must be over 18 and maximum use of 3 months

  • Non-sedating antihistamines may be of value in the treatment of nasal allergies, especially hayfever, and vasomotor rhinitis. They reduce rhinorrhoea and sneezing but are usually less effective for nasal congestion

  • Cetirizine causes less sedation than chlorphenamine but is more expensive

  • See also section - Eyes (b) Hayfever symptoms

  • Refer to pregnancy section for advice in pregnancy.
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