Drug reference
Moderate to severe irritable bowel syndrome with constipation ▶BY MOUTH ▶Adult: 290 micrograms once daily, dose to be taken at least 30 minutes before meals, review treatment if no response after 4 weeks
PDF page 74
Gastro-intestinal obstruction. inflammatory bowel disease
PDF page 74
Predisposition to fluid and electrolyte disturbances
PDF page 74
Dispense capsules in original container (contains desiccant); discard any capsules remaining 18 weeks after opening.
PDF page 74
Scottish Medicines Consortium (SMC) decisions SMC No. 869/13 The Scottish Medicines Consortium has advised (June 2013) that linaclotide (Constella ®) is accepted for restricted use within NHS Scotland for moderate to severe irritable bowel syndrome with constipation in patients whose condition has not responded adequately to all other treatments, or who are intolerant of them.
PDF page 74
▶Common or very common Diarrhoea. dizziness. gastrointestinal discomfort. gastrointestinal disorders ▶Uncommon Appetite decreased. dehydration. haemorrhage. hypokalaemia. nausea. postural hypotension. vomiting ▶Frequency not known Rash SIDE-EFFECTS, FURTHER INFORMATION Manufacturer advises if diarrhoea severe or prolonged, consider suspending treatment.
PDF page 74
Manufacturer advises avoid.
PDF page 74
Unlikely to be present in milk in significant amounts, but manufacturer advises avoid.
PDF page 74
There can be variation in the licensing of different medicines containing the same drug. Capsule CAUTIONARY AND ADVISORY LABELS 22 ▶Constella (Allergan Ltd) Linaclotide 290 microgram Constella 290microgram capsules | 28 capsule P £37.56 DT = £37.56 1.5 Short bowel syndrome Short bowel syndrome Description of condition Patients with a shortened bowel due to large surgical resection (with or without stoma formation) may require medical management to ensure adequate absorption of nutrients and fluid. Absorption of oral medication is also often impaired. Aims of treatment The management of short bowel syndrome focuses on ensuring adequate nutrition and drug absorption, thereby reducing the risk of complications resulting from these effects. Drug treatment Nutritional deficiencies g Patients with a short bowel may require replacement of vitamins and minerals depending on the extent and position of the bowel resection. Deficiencies in vitamins A, B12, D, E, and K, essential fatty acids, zinc, and selenium can occur. Hypomagnesaemia is common and is treated with oral or intravenous magnesium supplementation (see Magnesium imbalance p. 1111), though administration of oral magnesium may cause diarrhoea. Occasionally the use of oral alfacalcidol p. 1144 and correction of sodium depletion may be useful. Nutritional support can range from oral supplements to parenteral nutrition, depending on the severity of intestinal failure. h Diarrhoea and high output stomas Diarrhoea is common in short bowel syndrome and can be due to multiple factors. g The use of oral rehydration salts can be considered in order to promote adequate hydration. Oral intake influences the volume of stool passed, so reducing food intake will lessen diarrhoea, but will also exacerbate the problems of undernutrition. A patient may require parenteral nutrition to allow them to eat less, if the extent of diarrhoea is unacceptable. Pharmacological treatment may be necessary, with the choice of drug depending on the potential for side-effects and the degree of resection. h Antimotility drugs g Loperamide hydrochloride p. 71 and codeine phosphate p. 475 reduce intestinal motility and thus exert antidiarrhoeal actions. Loperamide hydrochloride is preferred as it is not sedative and does not cause dependence or fat malabsorption. High doses of loperamide hydrochloride [unlicensed] may be required in patients with a short bowel due to disrupted enterohepatic circulation and rapid gastrointestinal transit time. If the desired response is not obtained with loperamide hydrochloride, codeine phosphate may be added to therapy. Co-phenotrope p. 71 has traditionally been used alone or in combination with other medications to help decrease faecal output. Co-phenotrope crosses the blood–brain barrier and can produce central nervous system side-effects, which may limit its use; the potential for dependence and anticholinergic effects may also restrict its use. h Colestyramine g In patients with an intact colon and less than 100 cm of ileum resected, colestyramine p. 210 can be used to bind the unabsorbed bile salts and reduce diarrhoea. When colestyramine is given to these patients, it is important to monitor for evidence of fat malabsorption (steatorrhoea) or fat-soluble vitamin deficiencies. h Antisecretory drugs g Drugs that reduce gastric acid secretion reduce jejunostomy output. Omeprazole p. 85 is readily absorbed in the duodenum and upper small bowel, but if less than 50 cm of jejunum remains, it may need to be given intravenously. Use of a proton pump inhibitor alone does not eliminate the need for further intervention for fluid control (such as antimotility agents, intravenous fluids, or oral rehydration salts). Octreotide [unlicensed indication] reduces ileostomy diarrhoea and large volume jejunostomy output by inhibiting multiple pro-secretory substances. There is insufficient evidence to establish its role in the management of short bowel syndrome. h Growth factors Growth factors can be used to facilitate intestinal adaptation after surgery in patients with short bowel syndrome, thus enhancing fluid, electrolyte, and micronutrient absorption. Teduglutide below is an analogue of endogenous human glucagon-like peptide 2 (GLP-2) which is licensed for use in the management of short bowel syndrome. It may be considered after a period of stabilisation following surgery, during which intravenous fluids and nutritional support should have been optimised. Gastro-intestinal system Drug absorption For Prescribing in patients with stoma, see Stoma care p. 105. g Many drugs are incompletely absorbed by patients with a short bowel and may need to be prescribed in much higher doses than usual (such as levothyroxine, warfarin, oral contraceptives, and digoxin) or may need to be given intravenously. h Several factors can alter the absorption of drugs taken by mouth in patients with a compromised gastrointestinal system. The most important factors are the length of intestine available for drug absorption, and which section has been removed. The small intestine, with its large surface area and high blood flow, is the most important site of drug absorption. The larger the amount of the small intestine that has been removed, the higher the possibility that drug absorption will be affected. Other factors, such as gastric emptying and gastric transit time, also affect drug handling. g Enteric-coated and modified-release preparations are unsuitable for use in patients with short bowel syndrome, particularly in patients with an ileostomy, as there may not be sufficient release of the active ingredient. Dosage forms with quick dissolution (soluble tablets) should be used. Uncoated tablets and liquid formulations may also be suitable. hg Before prescribing liquid formulations, prescribers should consider the osmolarity, excipient content and volume required. Hyperosmolar liquids and some excipients (such as sorbitol) can result in fluid loss. The calorie density of oral supplements should also be considered, as it will influence the volume to be taken. l Other drugs used for Short bowel syndrome Cimetidine, p. 79 AMINO ACIDS AND DERIVATIVES
PDF pages 74, 75
290 micrograms once daily, dose to be taken at
First-line fragment. Read the complete Indications and Dose section above.
PDF page 74
