East Region Formulary
NHS Scotland

Irritable bowel syndrome (IBS)

Gastrointestinal smooth muscle spasm

Older patients are particularly susceptible to the antimuscarinic effects of antispasmodics.

Mebeverine
Mebeverine 135mg tablets

135mg 3 times daily preferably 20 minutes before meals.

Mebeverine 50mg/5ml oral suspension sugar free

135mg 3 times daily preferably 20 minutes before meals.

Hyoscine butylbromide
Hyoscine butylbromide 10mg tablets

20mg 4 times daily.

Hyoscine butylbromide 20mg/1ml solution for injection ampoules

Initially by intramuscular injection, or by slow intravenous injection. 20mg, then (by intramuscular injection or by slow intravenous injection) 20mg after 30 minutes if required, dose may be repeated more frequently in endoscopy; maximum 100mg per day.

Peppermint
Peppermint oil 0.2ml gastro-resistant capsules

1-2 capsules 3 times a day for up to 2-3 months if necessary, dose to be taken before meals, swallowed whole with water.

Prescribing Notes:

  • Antispasmodics are of limited benefit but are occasionally used for acute exacerbations of irritable bowel syndrome. They should be used in conjunction with other measures such as reassurance, diet, fluid intake, exercise, bulking agents and lifestyle modifications.
  • Antimuscarinics relax the oesophageal sphincter and should be used with caution in patients with symptoms of reflux.
  • Peppermint oil capsules should be reserved for patients presenting with symptoms of bloating.
  • Peppermint oil capsules should not be chewed as they can cause irritation to mouth and/or oesophagus, causing symptoms of heartburn.

History Notes

15/12/2021

East Region Formulary content agreed.

Abdominal pain associated with irritable bowel syndrome

Consider the use of amitriptyline.

Amitriptyline
Amitriptyline 10mg tablets

Initially 5-10mg daily, to be taken at night; increased in steps of 10mg at least every 2 weeks as required; maximum 30mg per day.

Nortriptyline
Nortriptyline 10mg tablets

10mg-30mg per day maximum, titrated in 10mg increments.

Nortriptyline 25mg tablets

10mg-30mg per day maximum, titrated in 10mg increments.

History Notes

15/12/2021

East Region Formulary content agreed.

Initial management of irritable bowel syndrome and functional abdominal pain

See prescribing notes, ispaghula husk may be considered.

Ispaghula husk
Fybogel 3.5g effervescent granules sachets plain SF

For dose, refer to BNF for Children.

Fybogel Lemon 3.5g effervescent granules sachets SF

For dose, refer to BNF for Children.

Fybogel Orange 3.5g effervescent granules sachets SF

For dose, refer to BNF for Children.

Prescribing Notes:

  • Treatment of IBS is focused on symptom control in order to improve quality of life, including minimising abdominal pain and normalising the frequency and consistency of stools.
  • There is no evidence of the effectiveness of any form of dietary advice or increased fibre intake in children and it is not known whether dietary advice recommended to adult patients is of benefit to children.
  • Eating regularly, limiting fresh fruit intake, and, reducing intake of ‘resistant starch’ and insoluble fibre (e.g. bran) can be recommended. If an increase in dietary fibre is required, soluble fibre such as oats, ispaghula husk, or sterculia can be recommended. Ensuring a sufficient intake of fluids can also be recommended.
  • In Lothian additional information is available on RefHelp for Irritable Bowel Syndrome (IBS) and Functional Abdominal Pain (FAP).

History Notes

30/08/2023

East Region Formulary content agreed - ERFC 09/08/2023.

Gastrointestinal smooth muscle spasm

Mebeverine oral suspension should only be used when patients cannot tolerate or use solid formulations.

Mebeverine
Mebeverine 135mg tablets

For dose, refer to BNF for Children.

Mebeverine 50mg/5ml oral suspension sugar free

For dose, refer to BNF for Children.

Hyoscine butylbromide
Hyoscine butylbromide 10mg tablets

For dose, refer to BNF for Children.

Hyoscine butylbromide 20mg/1ml solution for injection ampoules

For dose, refer to BNF for Children.

Peppermint
Peppermint oil 0.2ml gastro-resistant capsules

For dose, refer to BNF for Children.

Prescribing Notes:

  • Antispasmodics are of limited benefit but are occasionally used for acute exacerbations of irritable bowel syndrome. They should be used in conjunction with other measures such as reassurance, diet, fluid intake, exercise, bulking agents and lifestyle modifications.
  • In Lothian additional information is available on RefHelp for Irritable Bowel Syndrome (IBS) and Functional Abdominal Pain (FAP).

History Notes

30/08/2023

East Region Formulary content agreed - ERFC 09/08/2023.

Pharmacy First - Gastrointestinal smooth muscle spasm
Hyoscine butylbromide
Hyoscine butylbromide 10mg tablets

Dose according to age and product licence.

History Notes

15/12/2021

New pathway created to align to 01/10/2021 NHS Pharmacy First Scotland - Approved List of Products.

Pharmacy First - Irritable bowel syndrome
Mebeverine
Mebeverine 135mg tablets

Dose according to age and product licence.

Prescribing Notes:

  • These products should not be supplied if the patient is presenting with IBS symptoms for the first time.
  • NICE CG 61 notes that antispasmodics should be taken as required, alongside dietary and lifestyle advice.

When to advise patient to contact GP
Patients with new onset of symptoms or worsening symptoms.
Symptoms suggestive of underlying disease e.g. blood in stools, unexplained weight loss, major change in bowel habit, anaemia-like symptoms.
Unresponsive to appropriate treatment.

History Notes

27/10/2020

Content migrated from ‘East Region Formulary: Pharmacy First - supporting minor ailments’ document.