Short bowel syndrome
Step 1 – Loperamide and a PPI.
Loperamide may be initiated on specialist advice for reduction in stoma output (high output stomas). Capsules are the preferred loperamide formulation, see prescribing notes.
4mg four times daily, can be increased to 8mg four times daily if no improvement, if still no improvement, then increase dose in increments of 4mg to max 16mg four times daily. Dose to be taken 30-60mins before food and drink.
4mg four times daily, can be increased to 8mg four times daily if no improvement, if still no improvement, then increase dose in increments of 4mg to max 16mg four times daily. Dose to be taken 30-60mins before food and drink.
PPI – Omeprazole or lansoprazole.
40mg daily, increase to 40mg twice daily if stoma contents pH<6.
30mg daily, increase to 30mg twice daily if stoma contents pH<6.
Step 2 – if no improvement with optimised loperamide, dietary advice, PPI and fluid restriction add in codeine (unless contra-indicated).
30-60mg 3-4 times a day. Dose to be taken 30-60mins before food and drink.
Step 3 – if no improvement with optimised loperamide, PPI, dietary advice, fluid restriction and codeine refer to gastroenterology for review and consider octreotide (initiated only on advice of specialist consultant).
By subcutaneous injection, initially 50micrograms twice daily, dose can be titrated up to 100micrograms three times daily according to response.
By subcutaneous injection, initially 50micrograms twice daily, dose can be titrated up to 100micrograms three times daily according to response.
By subcutaneous injection, initially 50micrograms twice daily, dose can be titrated up to 100micrograms three times daily according to response.
By subcutaneous injection, initially 50micrograms twice daily, dose can be titrated up to 100micrograms three times daily according to response
By subcutaneous injection, initially 50micrograms twice daily, dose can be titrated up to 100micrograms three times daily according to response.
Prescribing Notes:
- Non-pharmacological interventions to reduce stoma output include restricting fluid intake, increasing salt intake and reducing fibre intake.
- Ispaghula husk and stericulia may be used for regulation of bowel contents for patients with stoma and for intestinal dysmotility in GI disorders.
- Optifibre is an alternative nutritional supplement included in the list of borderline substances. Endorse prescription "ACBS" when prescribed for: Short bowel syndrome, intractable malabsorption, pre-operative preparation of patients who are undernourished, patients with proven inflammatory bowel disease, following total gastrectomy, bowel fistulae, disease-related malnutrition. Not to be prescribed for any child under five years of age.
- The food supplement Solgar Psyllium husks fibre 500mg capsules (Solgar UK Limited) is available for purchase for patients who prefer a capsule formulation in preference to ispaghula husk sachets, sterculia or Optifibre.
- Loperamide capsules can be opened, and the contents mixed with water prior to administration (off-label). The orodispersible tablets may be considered as an alternative formulation for patients with poor dexterity or where compliance is an issue.
- Perform baseline ECG for loperamide doses greater than 4mg four times daily. Repeat in 3 years if patient remains on high doses. Loperamide toxicity should be considered in any patient with fainting episodes not accounted for by dehydration or other drugs.
- For prescribing guidance refer to NHS Lothian “Management of High Output Stoma”
- Octreotide is rarely used. Octreotide may be considered for use on the advice of a specialist consultant in high output stoma and enterocutaneous fistula to reduce output when other means have failed. Octreotide is usually given as a short course of treatment for hospital in-patients. A small group of patients will require a longer course of octreotide continuing after hospital discharge with treatment remaining under the supervision of the specialist clinical team.
History Notes
02/03/2023
New pathway, ERWG Jan 2023
Loperamide is indicated for treatment of short bowel syndrome only on consultant recommendation. See prescribing notes for administration in patients who cannot swallow tablets.
For dose, refer to BNF for Children.
For dose, refer to BNF for Children.
The high strength loperamide oral suspension is reserved for patients with short bowel syndrome where the capsules and tablets are not tolerated.
For dose, refer to BNF for Children.
Prescribing Notes:
- Loperamide capsules and tablets may be opened, and contents dispersed in water prior to administration. For doses less than 2mg disperse contents in water and give a proportion to deliver the intended dose, this recommendation is based on local experience in practice.
- Alternatively, for a 1mg dose tablets may be halved.
- Loperamide 25mg/5ml oral suspension is used in some patients with short bowel syndrome. It does not contain sorbitol therefore does not increase GI transit time.
- Seek specialist advice for administration via enteral feeding tubes.
History Notes
30/08/2023
East Region Formulary content agreed - ERFC 09/08/2023.