BNF for Children (BNFC) 2018-2019

Several factors can alter the absorption of drugs taken by

mouth in children 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 bloodflow, 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.

gEnteric-coated and modified-release preparations are

unsuitable for use in patients with short bowel syndrome,

particularly in children with an ileostomy, as there may not

be sufficient release of the active ingredient.

Dosage forms with quick dissolution (such as soluble

tablets) should be used. Uncoated tablets and liquid

formulations may also be suitable.hgBefore

prescribing liquid formulations, prescribers should consider

the osmolarity, excipient content, and volume required.

Hyperosmolar liquids and some excipients (such as sorbitol)

can result influid loss. The calorie density of oral

supplements should also be considered, as it will influence

the volume to be taken.l

AMINO ACIDS AND DERIVATIVES

Teduglutide 15-May-2018

lDRUG ACTIONTeduglutide is an analogue of human

glucagon-like peptide- 2 (GLP- 2 ), which preserves mucosal

integrity by promoting growth and repair of the intestine.

lINDICATIONS AND DOSE

Short bowel syndrome (initiated under specialist

supervision)

▶BY SUBCUTANEOUS INJECTION

▶Child 1–17 years: 0. 05 mg/kg once daily, dose to be

administered to alternating quadrants of the abdomen;

alternatively the thigh can be used, for optimal

injection volume per body weight, consult product

literature. Review treatment after 12 weeks

lCONTRA-INDICATIONSActive or suspected malignancy.

history of gastro-intestinal malignancy (in previous

5 years)

lCAUTIONSAbrupt withdrawal of parenteral support

(reduce gradually with concomitant monitoring offluid

status).cardiac insufficiency.cardiovascular disease.

colo-rectal polyps.hypertension

CAUTIONS, FURTHER INFORMATION

▶Colo-rectal polypsManufacturer recommends faecal occult

blood testing in children before initiation of treatment and

yearly thereafter. Manufacturer also advises colonoscopy

or sigmoidoscopy in children aged 12 years and older

before initiation of treatment, after 1 year of treatment

and then every 5 years thereafter. Colonoscopy or

sigmoidoscopy should be performed in all children with

unexplained blood in stool.

lSIDE-EFFECTS

▶Common or very commonAnxiety.appetite decreased.

congestive heart failure.cough.dyspnoea.fluid

imbalance.gallbladder disorders.gastrointestinal

discomfort.gastrointestinal disorders.headache.

influenza like illness.insomnia.nausea.pancreatitis.

peripheral oedema.respiratory tract infection.vomiting

▶UncommonSyncope

lALLERGY AND CROSS-SENSITIVITYManufacturer advises

caution in patients with tetracycline hypersensitivity.

lPREGNANCYgSpecialist sources indicate use if

necessary—no human data available.k

lBREAST FEEDINGManufacturer advises avoid—toxicity in

animalstudies.

lRENAL IMPAIRMENT

Dose adjustmentsManufacturer advises use half the daily

dose in moderate or severe impairment and end-stage

renal disease.

lMONITORING REQUIREMENTSManufacturer advises

monitoring of small bowel function, gall bladder, bile

ducts and pancreas during treatment.

lTREATMENT CESSATIONCaution when discontinuing

treatment—risk of dehydration.

lPATIENT AND CARER ADVICEPatients with cardiovascular

disease should seek medical attention if they notice

sudden weight gain, swollen ankles or dyspnoea—may

indicate increasedfluid absorption.

lNATIONAL FUNDING/ACCESS DECISIONS

Scottish Medicines Consortium (SMC) Decisions

SMC No. 1139/16

TheScottish Medicines Consortiumhas advised (April 2018 )

that teduglutide (Revestive®) is accepted for restricted use

within NHS Scotland for the treatment of short bowel

syndrome, initiated in paediatric patients aged 1 to

17 years. Patients should be stable following a period of

intestinal adaptation after surgery. This advice is

contingent upon the continuing availability of the patient

access scheme in NHS Scotland or a list price that is

equivalent or lower.

lMEDICINAL FORMS

There can be variation in the licensing of different medicines

containing the same drug.

Powder and solvent for solution for injection

▶Revestive(Shire Pharmaceuticals Ltd)A

Teduglutide 1.25 mgRevestive 1. 25 mg powder and solvent for

solution for injection vials| 28 vialP£ 7 , 307. 70

Teduglutide 5 mgRevestive 5 mg powder and solvent for solution for

injection vials| 28 vialP£ 14 , 615. 39

2 Constipation and bowel

cleansing

2.1 Bowel cleansing

Other drugs used for Bowel cleansingBisacodyl, p. 45.

Docusate sodium, p. 44

DIAGNOSTIC AGENTS›RADIOGRAPHIC

CONTRAST MEDIA

Meglumine amidotrizoate with sodium

amidotrizoate

(Diatrizoates)

lDRUG ACTIONMeglumine amidotrizoate with sodium

amidotrizoate is a radiological contrast medium with high

osmolality.

lINDICATIONS AND DOSE

Uncomplicated meconium ileus

▶BY RECTUM

▶Neonate: 15 – 30 mL for 1 dose.

Distal intestinal obstruction syndrome in children with

cystic fibrosis

▶BY MOUTH, OR BY RECTUM

▶Child 1–23 months: 15 – 30 mL for 1 dose

▶Child (body-weight 15–25 kg): 50 mL for 1 dose

▶Child (body-weight 26 kg and above): 100 mL for 1 dose

Radiological investigations

▶Child:Dose to be recommended by radiologist

36 Constipation and bowel cleansing BNFC 2018 – 2019

Gastro-intestinal system

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