1.1 Chronic bowel disorders

Antibiotic associated colitis - see Chapter 5

1.1.1 Inflammatory bowel disease

NICE Guidance NG129: Crohn's Disease: management

NICE Guidance NG130: Ulcerative Colitis: management

Aminosalicylates

Patients should not be switched between products without gastroenterology advice. All products are not considered interchangeable.

Recommended:

Mesalazine granules (Salofalk^®) (TLS Green)

• First line for uncomplicated new patients only
• Tablets for patients who dislike the granules only

Salofalk^® retention enema/suppositories/foam enema (TLS Green)

Brand alternatives (TLS Blue) - For established patients or where Salofalk^® has failed / inappropriate. Clinicians should initiate the most cost-effective preparation available.

Octasa^® modified-release

Pentasa^® tablets, granules modified-release

Asacol^® modified-release tablets

Specific Indication: (TLS Blue)

Mezavant XL^®

• For those patients that Octasa^® is unsuitable, and where a once daily regimen is required for compliance purposes

Olsalazine

• For those patients with ulcerative colitis with proximal constipation

Sulfasalazine (TLS Amber 1 month)

• SCP to be developed

Corticosteroids

Link to chapter 6.2

Recommended: (TLS Green)

Prednisolone (oral)

• 5mg tablets, (25mg tablets in specific patients)

Alternatives:

Budesonide foam enema (TLS Green)

Prednisolone suppository (TLS Blue)

Prednisolone retention enema (TLS Blue)

Hydrocortisone (intravenous use) (TLS Green)

Methylprednisolone sodium succinate (intravenous use) (TLS Blue)

Specific indications:

Beclometasone dipropionate (Clipper^®) (TLS Blue)

• For the treatment of patients who have been previously diagnosed with established UC experiencing a flare in accordance with NICE Guideline NG130

Budesonide (Budenofalk^®) (oral) (TLS Amber Specialist Recommended)

• Terminal ileal or ileo-colonic Crohn's Disease and microscopic colitis
• Oral budesonide preparations should be prescribed by brand as are not interchangeable due to mode of action and licensing in IBD

Budesonide MMX (Cortiment^®) prolonged release tablets (TLS Amber Specialist Recommended)

• For induction of remission in patients with mild to moderate active ulcerative colitis where 5-ASA treatment is not sufficient or not tolerated, as an alternative to other topical/oral corticosteroids if these are unsuitable.
• Oral budesonide preparations should be prescribed by brand as are not interchangeable due to mode of action and licensing in IBD

Drugs Affecting Immune Response

Recommended:

Azathioprine IBD (TLS Amber 1 month) (SCP click here)

• N.B. unlicensed for IBD

Ciclosporin (TLS Red)

• N.B. unlicensed for ulcerative colitis

Mercaptopurine IBD (TLS Amber 1 month) (SCP click here)

• N.B. unlicensed for IBD

Methotrexate IBD (TLS Amber 1 month) (SCP click here)

• N.B. unlicensed for IBD

Mycophenolate (TLS Amber 3 months) (SCP click here)

• N.B. unlicensed for IBD

Monoclonal Antibodies

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

See BNSSG IBD Biologics Pathway documents

Recommended: (TLS Red)

Adalimumab

• Specify brand when prescribing Imraldi^®, Amgevita^®, Hyrimoz^®, Humira^®
• Crohn's disease - infliximab & adalimumab for the treatment of Crohn's disease as per NICE TA187
• Ulcerative colitis - as per NICE TA329
  

Infliximab (intravenous & subcutaneous)

• Specify brand when prescribing - Remicade^®, Inflectra^®, Remsima^®
• Ulcerative colitis - as per NICE TA329
• Ulcerative colitis (acute exacerbations)-infliximab as per NICE TA163
• Crohn's disease - infliximab & adalimumab for the treatment of Crohn's disease as per NICE TA187

Golimumab

• Ulcerative colitis - as per NICE TA329

Mirikizumab

• NICE TA925 Mirikizumab for treating moderately to severely active ulcerative colitis

Risankizumab

• NICE TA888 Risankizumab for previously treated moderately to severely active Crohn's disease

Ustekinumab

• Crohns disease - as per NICE TA456 Ustekinumab for moderately to severely active Crohn’s disease after previous treatment
• Ulcerative colitis - as per NICE TA633 Ustekinumab for treating moderately to severely active ulcerative colitis

Vedolizumab (intravenous & subcutaneous)

• Ulcerative colitis - as per NICE TA342 Vedolizumab for treating moderately to severely active ulcerative colitis
• Crohns disease - as per NICE TA352 Vedolizumab for treating moderately to severely active Crohn's disease after prior therapy

Protein Kinase Inhibitors

Filgotinib (TLS Red)

• Ulcerative colitis - NICE TA792 Filgotinib for treating moderately to severely active ulcerative colitis

Tofacitinib (TLS Red)

• Ulcerative colitis - as per NICE TA547 Tofacitinib for moderately to severely active ulcerative colitis

Upadacitinib (TLS Red)

• Ulcerative colitis - as per NICE TA856 Upadacitinib for treating moderately to severely active ulcerative colitis
• Crohn’s disease - as per NICE TA905 for previously treated moderately to severely active Crohn’s disease 

Sphingosine l-phosphate Receptor Modulators

Ozanimod (TLS Red)

• Ulcerative colitis - as per NICE TA828 Ozanimod for treating moderately to severely active ulcerative colitis

Etrasimod (TLS Red)

• Ulcerative colitis - as per NICE TA956 Etrasimod for treating moderately to severely active ulcerative colitis

1.1.2 Irritable bowel syndrome

NICE Guidance CG61 Irritable bowel syndrome in adults: diagnosis and management of irritable bowel syndrome in primary care

Guanylate Cyclase-C Receptor Agonists

Linaclotide (TLS Amber Specialist Recommended) 

• For those patients with moderate to severe irritable bowel syndrome with constipation (IBS-C), who have failed on first line therapy of laxatives and/or antispasmodics and have had constipation for at least 12 months. 
• See BNSSG constipation guidelines and NICE CG61 for more information

1.1.3 Short bowel syndrome

Glucagon-Like Peptide-2 Analogues

Teduglutide (TLS Red)

• NICE TA804 Teduglutide for treating short bowel syndrome

1.1.4 Intestinal Failure

Intestinal Failure Registry available via this link: https://ifregistry.streetsheaver.thirdparty.nhs.uk/ifregistry/login

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