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1.5 Treatment of chronic diarrhoeas

Drugs listed in Section 1.4 plus the following for Ulcerative Colitis and Crohn's disease:

1.5.1 Aminosalicylates

Mesalazine tablets, granules, enema, suppositories
Sulfasalazine tablets, suppositories, enema        
Balsalazide- for consultant gastroenterologist initiation only, 2nd line in patients unresponsive to Mesalazine

 

Interchangeability of oral mesalazine products

There is no evidence to show that any one oral preparation of meslazaine is more effective than another. However, the delivery charcteristics of oral mesalazine preparations may vary. If it is necessary to switch a patient to a different brand of mesalazine, the patient should be advised to report any changes in symptoms. Asacol MR and Octasa, however, are virtually identical and are interchangeable.  

 

1.5.2 Corticosteroids

Beclometasone MR - see note
Hydrocortisone suppositories, foam enema
Prednisolone suppositories, foam enema, retention enema
Prednisolone retention (>1hour) enemas
Budesonide - gastro-resistant capsules (Budenofalk), modified-release capsules (Entocort CR), modified-release tablets (Cortiment), gastro-resistant prolonged release granules (Budenofalk), enema
VSL#3 - see note

Note:

Beclometasone MR (Clipper) for Consultant use for patients that suffer serious side effects on conventional steroids and need acute treatment for a mild to moderate colitis flare-up. This is for a maximum of 4 weeks only and needs to be prescribed from the hospital Pharmacy.(RED drug)

All Budesonide modified-release preparations have been classified as BROWN – specialist initiated for mild to moderate active ulcerative colitis in patients who cannot tolerate prednisolone. Also, may be used off-licence as low dose maintenance therapy in patients with microscopic or collagenous colitis, and in auto-immune hepatitis.

 

1.5.3 Drugs affecting the immune response

Azathioprine tablets - see shared care guidelines 
Ciclosporin capsules - see shared care guidelines
Methotrexate tablets - see shared care guidelines

 

Others

Adalimumab
Golimumab injection
Infliximab
Ustekinumab IV and Subcutaneous injection – NICE TA 456 
Vedolizumab infusion – see NICE TA 342 (moderate-to-severely active ulcerative colitis) and NICE TA 352 (moderate-to-severely active Crohn’s disease)

NICE guidance on biologic drugs for the treatment of Crohn’s disease (May 2011) ; Acute exacerbations of severely active ulcerative colitis (May 2011)

1. Adalimumab & infliximab are recommended as treatment options for adults with severe active Crohn's disease refractory to or intolerant of other appropriate therapies e.g. corticosteroids, immunosuppressants. Please see NICE guidelines - TA 187. Infliximab can be used in children over 6 years of age. Infliximab may also be used in active fistulising disease.

2. Acute severe exacerbations of ulcerative colitis may be treated for selected patients (with infliximab) for whom ciclosporine is contraindicated or clinically inappropriate. See NICE TA 163.

3. Infliximab, adalimumab, and golimumab are recommended as options for use in moderate-to-severely active ulcerative colitis – see NICE TA 329 

4. Ustekinumab IV and Subcutaneous injection is recommended for the treating moderately to severely active Crohn's disease, that is, for adults who have had an inadequate response with, lost response to, or were intolerant to either conventional therapy or a TNF‑alpha inhibitor or have medical contraindications to such therapies see TA 456     
 

Note:

1. Mesalazine - Patients established on one formulation should stay on it, as switching to another formulation may cause a disease flare up

2. Budesonide should be reserved for consultant use only for selected patients (according to protocol) in whom standard oral steroids are absolutely or relatively contra-indicated e.g. previous intolerance of prednisolone, osteoporosis, osteonecrosis, prolonged use in patients in with  mild to moderate Crohn's disease affecting the ileum and ascending colon.

3. Despite theoretical advantages, there is little clear evidence that the newer aminosalicylates are more effective than sulfasalazine although they may cause slightly fewer adverse effects. If a patient is receiving sulfasalazine and this is well tolerated it should be continued.

4.VSL#3 is for maintaining remission in patients with chronic frequent recurring pouchitis.Treatment is to continue for 12 months and then stop.

 

Link to the BNF section: 1.5 Chronic bowel disorders