Name of Trust / Logo s1

Name of Trust / logo Memo – discontinuation of supply

To: From: Date:

Re: Co-danthramer capsules (25/200 and 37.5/500)

Description of product affected

Co-danthramer capsules contain dantron (25mg) and poloxamer 188 (200mg) and strong co-danthramer capsules contain 37.5mg and 500mg, respectively. Dantron is an anthraquinone stimulant laxative, which acts on nerve endings in the colonic mucosa. Poloxamer 188 is a wetting agent, which acts as a stool softener. Co- danthramer is licensed for the treatment of constipation in terminally ill patients. The dose is one or two capsules to be taken at bedtime.1

Background

The discontinuation has arisen because of problems sourcing one of the active ingredients, danthron. Stocks of Co-danthramer capsules are expected to last until the end of June 2015 and stocks of strong Co-danthramer capsules will last until December 2015.2

Alternative agents and management options

For patients on the capsules, Co-danthramer is also available as an oral peach flavoured, yellow suspension.3,4 The standard strength suspension contains 25mg dantron and 200mg poloxamer 188 per 5ml.3 The strong suspension contains 75mg and 1000mg per 5mL, respectively.4 They are licensed for the prophylaxis and treatment of constipation in terminally ill patients.3,4 The licensed dose of standard strength suspension is 5-10mL at bedtime2 and that of strong suspension is 5mL at bedtime.3 It should be noted that the suspension is significantly more costly than the capsules and other laxatives. An alternative to a Co-danthramer product is use of a stimulant (e.g. senna) in combination with a stool softener (e.g. docusate) or with an osmotic laxative such as macrogols (e.g. Movicol)5. In cases where a combination product is required to improve adherence, Co-danthrusate suspension is available, which contains dantron (50mg) and docusate sodium (60mg). Co-danthrusate is licensed for the treatment of constipation in terminally ill patients. Dose in adults is 5- 15mL at bedtime.6 Co-danthrusate is more costly than senna and docusate.

Strategies will need to be put into place for supporting patients on capsules who will be asked to convert to alternative preparations. Organisations will need to revise/update palliative care constipation guidelines that recommend Co-danthramer capsules7, ensure medicines formulary reflects these changes in terms of product availability, and liaise with colleagues in primary care, where most of the prescribing of Co-danthramer capsules is done. Local guidance should be consulted or specialist advice obtained from palliative care teams on alternative treatment options. References

1. Napp Pharmaceuticals Limited. Co-danthramer capsules and Strong Co- danthramer capsule. SPC (date of revision of text, July 2011): http://www.medicines.org.uk/emc/medicine/1219 2. Napp Pharmaceuticals Limited. Communication on discontinuation, May 2015. 3. Pinewood Healthcare. Co-Danthramer Suspension 25/200 Oral Suspenson. SPC (date of revision of text, March 2013): http://www.medicines.org.uk/emc/medicine/24440 4. Pinewood Healthcare. Strong Co-Danthramer Suspension 75/1000 Oral Suspenson. SPC (date of revision of text, 26/02/13): http://www.medicines.org.uk/emc/medicine/1219 5. Guy's and St Thomas' NHS Foundation Trust Guidelines for the management of constipation in adult palliative care patients, 29 August 2014 6. Pinewood Healthcare. Co-danthrusate suspension. SPC (date of revision of text, 04 September 2015). 7. Dr Shaheen Khan, Consultant in Palliative Medicine, Guy's and St Thomas' NHS Foundation Trust. Personal communication 21 May 2015

Acknowledgements

 Dr Shaheen Khan, Consultant in Palliative Medicine, Guy's and St Thomas' NHS Foundation Trust

 Steve Wanklyn, Consultant Pharmacist for Palliative & End of Life Care, Guy’s and St Thomas’ Hospital NHS Foundation Trust

Original document prepared by: Guy’s and St Thomas’ NHS Foundation Trust Medicines Information Centre Prepared 02 June 2015, updated 15 July 2016 (to reflect discontinuation of co- danthrusate capsules)

Document modified by: Name of individual at other centre using the product with modifications, centre, date

For all correspondence please contact: Name of person at base hospital where memo is circulated (i.e. NOT the original author at Guy’s and St Thomas’ NHS Foundation Trust

Disclaimer: The content of some of this memo is based on clinical opinion from practitioners. Users should bear this in mind in deciding whether to base their policy on this document.