1.2 Antispasmodics and other drugs altering gut motility

For more information see BNF 1.2

Antispasmodics

ChoiceDrugDosage
1st choiceMebeverine tablets 135mg Dose: 1 tablet three times daily preferably 20 minutes before meals
2nd choicePeppermint oil capsules (Mintec® enteric coated capsules)Dose: 1-2 capsules swallowed whole with water, three times daily before meals for up to 2-3 months if necessary

Prescribing Notes

  • Mebeverine and peppermint oil are less likely to cause adverse anti-cholinergic effects compared with hyoscine butylbromide and dicycloverine.
  • Please avoid prescribing dicloverine due to high anticholinergic burden and high cost [dicycloverine tablets and liquid both cost £180 per pack (June 2018) – see Drug Tariff for latest prices].

Management of Irritable Bowel Syndrome (IBS)

  • See NICE CG 61 for the management of irritable bowel syndrome.
  • Consider low dose amitriptyline (10-30mg daily) for abdominal pain associated with irritable bowel syndrome [unlicensed indication].
  • Consider linaclotide for people with IBS-C (Constipation) only if (NICE CG61):
    • optimal or maximum tolerated doses of previous laxatives from different classes have not helped and
    • they have had constipation for at least 12 months
    • review and stop after 4 weeks if no response
    • follow up on people taking linaclotide after 3 months
  • Consider eluxadoline for treating IBS with diarrhoea only if (NICE TA471):
    • the condition has not responded to other pharmacological treatments (for example, antimotility agents, antispasmodics, tricyclic antidepressants) or
    • pharmacological treatments are contraindicated or not tolerated and
    • it is started in secondary care

Caution

  • Older patients are particularly susceptible to the anticholinergic effects of the antimuscarinic antispasmodics (atropine sulphate, dicycloverine hydrochloride, hyoscine butylbromide, propantheline bromide).
  • Use antimuscarinic antispasmodics with caution in patients with GORD, diarrhoea, ulcerative colitis, myocardial infarction and hypertension.

Motility Stimulants

For Anti-emetics see chapter 4.6

Prescribing Notes

  • Following restrictions on the use of domperidone and metoclopramide, there are no drugs on the UK market licensed as prokinetic agents.
  • Domperidone is associated with a small risk of serious cardiac side effects. Its use is now restricted to the relief of symptoms of nausea and vomiting and the dosage and duration of use have been reduced. Treatment should generally only be given for up to one week. Domperidone is contraindicated in those with underlying cardiac conditions and other risk factors. For further information see MHRA.
  • Metoclopramide is associated with neurological effects such as short-term extrapyramidal disorders and tardive dyskinesia. In order to minimise the risk of such side effects, metoclopramide should no longer be used in chronic conditions such as gastroparesis, dyspepsia and gastro-oesophageal reflux disease.  It should only be prescribed for short-term use (up to 5 days) for prevention of postoperative nausea and vomiting; radiotherapy-induced nausea and vomiting; delayed (but not acute) chemotherapy-induced nausea and vomiting; and symptomatic treatment of nausea and vomiting, including that associated with acute migraine (where it may also be used to improve absorption of oral analgesics). For further information see MHRA.