Radiation proctitis (Guidelines)

The only four treatments with any evidence from randomised controlled trials are: sucralfate enemas, a 4 week course of oral metronidazole, Vitamin A, and hyperbaric oxygen therapy.

Although many consider argon plasma coagulation (APC) delivered via flexible sigmoidoscopy to be an effective treatment, the evidence supporting its effect is weak and the risk of serious complications (e.g. explosions in inadequately prepared bowel) are relatively high.

Topical treatment alone with corticosteroids eg Predfoam or mesalazine are considered ineffective.

Presentation of enemas

• Currently, there is not a commercial or licensed preparation for sucralfate enemas. Where this therapy is indicated, the patient has to administer the 'oral' suspension rectally, using catheter tubing and a syringe.
• Sucralfate oral suspension may be given rectally as an enema. It is used in this way by multiple heath boards/NHS Trusts as an effective treatment for radiation proctitis. It requires 14 Fr female syringe tip catheters, lubricating jelly and 60mL syringes to administer rectally.
• The oral suspension is a licensed product and can be readily sourced from both community and secondary care.
• A leaflet has been developed to support patient with administration.

Initiation of therapy

• The first course of enemas will be prescribed and supplied by secondary care. The consultant colorectal surgeon advising sucralfate enemas will contact the surgical pharmacy team to arrange a supply and write a yellow outpatient prescription.
• When commencing a patient on treatment, the method of preparation and administration is to be fully discussed with the patient, including the fact that this is an unlicensed method of administering the 'oral' suspension.
  The patient information leaflet may be emailed to the patient to support counselling and decision-making, if appropriate.
  Counselling will be performed by a specialist surgical pharmacist, and is likely to be via telephone, unless the patient is able to attend Raigmore.
• Patients who are unable to self-administer may require district nursing support, and will be referred by the surgical pharmacy team.

Prescription of enemas

First course: secondary care

• Prescribe on a yellow outpatient prescription:
  • Sucralfate 1g/5mL suspension, 2 x 200mL bottles
  • Lubricating jelly, 1 x 82g,
• Label:
  • Administer 10mL rectally TWICE a day for 2 weeks, as directed
• Supply the following items (procured through PECOS):
  • 1 box x 14 Fr female syringe tip catheters (Hollister Infyna 14, code 88141 or Lofric Sense)
  • 4 x 60mL luer-lock syringes.
  • Include a patient information leaflet with the prescription.
• Should the patient indicate they will have difficulty washing and re-using the syringes and catheters (during the initial consultation with pharmacy), sufficient stock may be given to allow each item to be used once and disposed of, ie, 3 boxes of 10 catheters and 28 syringes
• Arrange for patients to either collect from Raigmore Pharmacy or send out via transport to their GP practice.
• Any remaining suspension at the end of the treatment course should be returned to the community pharmacy for disposal, unless the course is extended for a further two weeks.

Repeat Courses: primary care

• Subsequent courses of sucralfate enemas may be prescribed by the patient’s GP in primary care.
• The initial course may also be extended by 2 weeks to a total of 4 weeks, if improvement has been noted but there are still symptoms present.
• Maximum duration 4 weeks unless further discussion with secondary care has occurred.
• If no improvement in symptoms has occurred within the two week period, the patient should be referred to the colorectal team via SCI gateway or advice sought via Clinical Dialogue.
• Prescribe:
  • Sucralfate 1g/5mL suspension, 2 x 200mL bottles
  • Lubricating jelly 1 x 82g
• Check with the patient if they still have sufficient supplies of 60mL syringes and catheters from their initial course.
  • If further Luer-lock syringes are required, these will be supplied according to who is supporting the patient:
    • District Nurses: Supplied via the district nurse team
    • GP: Supplied via the GP Practice/Treatment Centre
  • If further catheters are required, prescribe:
    • 1 box x 14 Fr female syringe tip catheters (Hollister Infyna 14, code 88141 or Lofric Sense), or 3 boxes if patient is unable to wash and re-use. 
    • Arrange collection from their community pharmacy and advise the patient that there may be a short wait while their pharmacy orders these in.
• If patients previously required district nursing support to administer, ascertain if this is required again and refer to their district nursing team.
• Any remaining suspension at the end of the treatment course should be returned to the community pharmacy for disposal. 

Suitable catheters:

• Hollister infyna chic intermittent self-catheters
  • Size 14
  • Code: 88141 (non-catalogue item)
• Lofric sense 

Patient information leaflet: Sucralfate for radiation proctitis