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1.2 Antispasmodics and other drugs altering gut motility

Antispasmodics


Eluxadoline – as per NICE TA 471 Red drug
Glycopyrronium (Sialanar) oral solution – second-line for sialorrhoea in children (hyoscine patch is first-line)
Hyoscine butylbromide tablets, injection ("Buscopan") – see note            
Mebeverine tablets, liquid ("Colofac")                
Peppermint oil enteric coated capsules  ("Mintec")
Propantheline tablets

Eluxadoline should not be used in patients without a gallbladder or in patients with known or suspected biliary tree or pancreatic duct obstruction (eg, gallstones, tumour, periampullary duodenal diverticulum) or sphincter of Oddi disease due to the risk of pancreatitis (MHRA link

Dicycloverine has been removed from the formulary on cost effective grounds. There is insufficient evidence to demonstrate a significant difference in effectiveness between hyoscine, mebeverine, peppermint oil and dicycloverine. Prescribers may want to consider other cost effective options such as: Peppermint oil e/c capsules (Mintec), Mebeverine 135mg tablets or Hyoscine butylbromide 10mg tablets.


Motility Stimulants

Metoclopramide tablets, syrup, injection - see note                                                        
Domperidone tablets, suspension, suppositories
Erythromycin tablets, injection

 Notes:

1. Domperidone is preferred in patients where the risk of dystonic reactions is high i.e. young women and children, the elderly, and those with Parkinson's disease. However, it is associated with a small increased risk of serious cardiac side effects, and so its use is now restricted to the relief of nausea and vomiting. Max recommended dose: 30 mg/d. Max Duration: 7 days. See MHRA Drug Safety Update May 2014

Other Documents

Domperidone: new restrictions in use
Revised dosing for domperidone use in babies and children

2. Metoclopramide in young adults is more likely to cause dystonic reactions. In children, metoclopramide should only be used as a second-line option for prevention of delayed chemotherapy-induced nausea and vomiting and treatment of established PONV. It is no longer recommended for use in gastroparesis, dyspepsia, or GORD (but see Gastroenterologists' Position Statement). See also EMA recommendation and MHRA Drug Safety Update.

The dose and duration of metoclopramide are now restricted to help minimise the risk of potentially serious neurological adverse effects.For adults, the maximum dose in 24 hours is 30 mg (0.5 mg/kg). In children age 1 year or older, the recommended dose is 0.1–0.15 mg per kg bodyweight, repeated up to three times a day; the maximum dose in 24 hours is 0.5 mg per kg bodyweight. The drug is contraindicated in children under one year of age. Metoclopramide should only be prescribed for short-term use (up to 5 days). Intravenous doses of metoclopramide should be given as a slow bolus over at least 3 minutes to reduce adverse effects.

3. Erythromycin for gastroparesis. Various studies have suggested a role for erythromycin in improving gastric motility in patients with diabetic gastroparesis and post-vagotomy gastroparesis. (There is, however, no evidence of efficacy in post-operative ileus.) Whilst this is an unlicensed use, erythromycin 250mg o/iv may be given two to three times daily in patients refractory to, or intolerant of, treatment with metoclopramide or domperidone. Caution: drug interactions. 

4. Hyoscine butylbromide injection can cause serious adverse effects including tachycardia, hypotension, and anaphylaxis. These can result in a fatal outcome in patients with underlying cardiac disease, such as heart failure, cardiac arrhythmias, or hypertension. Hyoscine butylbromide is contraindicated in the presence of tachycardia. Use with caution in patients with cardiac disease. See DSU link

5. Hyoscine butylbromide injection is also used subcutaneously (off-license route and indication) to treat secretions in end-of-life care.