1.2 Antispasmodics and other drugs altering gut motility

Although these medications are frequently prescribed for functional bowel symptoms such as irritable bowel syndrome, their value in clinical trials has not been proved. Lifestyle changes and identifying food triggers are the mainstay of treating functional gut symptoms.

NICE CG61 (February 2008) gives advice on the pharmacological management of Irritable Bowel Syndrome (IBS). Antispasmodic agents should be considered alongside dietary and lifestyle advice. Laxatives (not lactulose) may be offered for constipation, and loperamide for diarrhoea. A low dose tricyclic antidepressant, unlicensed, (e.g. amitriptyline starting at 5-10mg at night) may be considered if first line treatments do not help.

Antimuscarinics

Hyoscine butylbromide
  • Tablets 10mg (£12.00 = 20mg four times daily)
  • Solution for injection 20mg in 1ml (£0.29 = 1ml ampoule)

Indications and dose

  • Symptomatic relief of gastro-intestinal or genito-urinary disorders characterised by smooth muscle spasm
    • By mouth:
      • Child 6–11 years: 10mg 3 times daily
      • Child 12–17 years: 20 mg 4 times daily
      • Adult: 20 mg 4 times a daily
  • Irritable bowel syndrome
    • By mouth:
      • Adult: 10mg 3 times daily, increased if required up to 20mg 4 times daily
  • Acute spasm and spasm in diagnostic procedures (specialist)
    • By intramuscular or slow intravenous injection:
      • Adult: 20mg repeated after 30 minutes if required (may be repeated more frequently in endoscopy), maximum 100mg daily
  • Excessive respiratory secretions and bowel colic in palliative care (specialist)
    • By mouth: (unlicensed under 6 years)
      • Child 1 month–1 year: 300–500 micrograms/kg 3–4 times daily (max. per dose 5 mg)
      • Child 2–4 years: 5 mg 3-4 times daily
      • Child 5–11 years: 10 mg 3–4 times daily
      • Child 12–17 years: 10–20 mg 3–4 times daily
    • By intramuscular injection, or by intravenous injection (unlicensed)
      • Child 1 month–4 years: 300–500 micrograms/kg 3–4 times daily (max. per dose 5 mg)
      • Child 5–11 years: 5–10 mg 3–4 times daily
      • Child 12–17 years: 10–20 mg 3–4 times a day
    • By subcutaneous injection
      • Adult: 20 mg every 4 hours if required, adjusted according to response to up to 20 mg every 1 hour.
    • By subcutaneous infusion
      • Adult:
        • (Excessive respiratory secretions) 20–120 mg/24 hours
        • (Bowel colic) 60–300 mg/24 hours

Notes

  1. MHRA Drug Safety Update (February 2017) Hyoscine butylbromide injection: risk of serious adverse effects in patients with underlying cardiac disease.
    1. hyoscine butylbromide injection can cause serious adverse effects including tachycardia, hypotension, and anaphylaxis
    2. these adverse effects can result in a fatal outcome in patients with underlying cardiac disease, such as those with heart failure, coronary heart disease, cardiac arrhythmia, or hypertension
    3. hyoscine butylbromide injection should be used with caution in patients with cardiac disease
    4. monitor these patients, and ensure that resuscitation equipment, and personnel who are trained how to use this equipment, are readily available
    5. hyoscine butylbromide injection remains contraindicated in patients with tachycardia
  2. Tablets not licensed for use in children under 6 years
  3. Injection not licensed for use in children (age range not specified by manufacturer)
  4. Hyoscine butylbromide may be useful in gastro-intestinal disorders characterised by smooth muscle spasm and in palliative care, but its anticholinergic side effects limit its use and administration by mouth is associated with poor absorption
Sialanar®

(Glycopyrronium bromide)

  • Oral solution SF 400micrograms/ml (320micrograms/ml glycopyrronium base) (£320.00 = 250ml)

Indications and dose

  • Symptomatic treatment of severe sialorrhoea (chronic pathological drooling) in children and adolescents aged 3 years and older with chronic neurological disorders

Notes

  1. Prescribe by brand: Different formulations of glycopyrronium oral solution are not bioequivalent
  2. Unlicensed specials should not be prescribed.
  3. Sialanar description on packaging and on GP prescribing systems is 320micrograms/ml – this is the amount of glycopyrronium BASE per ml and is equivalent to 400micrograms/ml of the SALT, glycopyrronium bromide
  4. Specify doses as glycopyrronium bromide (not glycopyrronium base)
  5. The routine commissioning of glycopyrronium bromide oral solution is accepted in Devon for the symptomatic treatment of severe sialorrhoea (chronic pathological drooling) in children and adolescents aged 3 years and older with chronic neurological disorders (see Commissioning Policy for more details)
  6. NICE NG62 recommends both glycopyrronium bromide oral solution and hyoscine hydrobromide transdermal patches (off-label, see section 4.6) as options to reduce the severity and frequency of drooling in children and young people with cerebral palsy. Glycopyrronium bromide is licensed for this indication but is available at significantly increased cost, and there is a lack of evidence of clinical benefit of glycopyrronium over hyoscine. Local specialists may indicate a preference for either drug as the first line treatment
  7. The choice of treatment will be made by the specialist, taking into account the preferences of the child or young person and their parents or carers, and the age range and indication covered by the marketing authorisations.
Glycopyrronium bromide
  • Tablets 1mg (£230.71 = 30 tablets)
  • Injection 200 micrograms in 1ml ampoule (10 x 1ml = £9.96)
  • Injection 600 micrograms in 3ml ampoule (£1.50)
  • Topical solution 0.05% (unlicensed preparation)

Indications

Notes

  1. The circumstances under which treatments for focal hyperhidrosis are commissioned in Devon can be found in the commissioning policy
Propantheline Bromide
  • Tablets 15mg (£15.56 = 28 days)

Indications

Dose

  • 15mg 3 times daily at least 1 hour before meals and 30mg at night, maximum 120mg daily

Notes

  1. The circumstances under which treatments for focal hyperhidrosis are commissioned in Devon can be found in the commissioning policy

Antispasmodics

Mebeverine
  • Tablets 135mg (£5.90 = 135mg three times daily)
  • Oral suspension 50mg/5ml (£163.43 = 300ml)

Indications

  • Adjunct in gastro-intestinal disorders characterised by smooth muscle spasm

Dose

  • 135-150mg 3 times daily preferably 20 minutes before meals

Notes

  1. Mebeverine liquid should only be prescribed for people unable to swallow tablets as there is approximately an 30 fold difference in cost compared to tablets
Peppermint oil
  • Gastro resistant capsules 0.2ml (£7.04 - £14.08)

Indications

  • Relief of abdominal colic and distension, particularly in irritable bowel syndrome

Dose

  • 1-2 capsules swallowed whole with water, 3 times daily before meals for up to 2-3 months if necessary

Antipropulsives

Eluxadoline
  • Tablets 75mg, 100mg

Notes

  1. NICE TA471: Eluxadoline for treating irritable bowel syndrome with diarrhoea (August 2017)
Last updated: 11-10-2019

 

Home > Formulary > Chapters > 1. Gastrointestinal > 1.2 Antispasmodics and other drugs altering gut motility

 

  • First line
  • Second line
  • Specialist
  • Hospital