What are the treatment options for chronic diarrhea?

From the Guidelines

Chronic diarrhea treatment should prioritize loperamide as a first-line medication, as suggested by the AGA clinical practice guideline on the pharmacological management of irritable bowel syndrome with diarrhea 1. When managing chronic diarrhea, it's essential to address the underlying cause while controlling symptoms.

• Dietary modifications are crucial, including eliminating potential triggers like lactose, fructose, gluten, or caffeine.
• Increasing soluble fiber intake gradually and staying hydrated with water, clear broths, and electrolyte solutions can help alleviate symptoms.
• Over-the-counter medications like loperamide (Imodium) at 2-4mg after each loose stool (maximum 8mg/day) or bismuth subsalicylate (Pepto-Bismol) at 30ml or 2 tablets every 30-60 minutes (maximum 8 doses/day) can help control symptoms.
• Prescription medications may include bile acid binders like cholestyramine (4g before meals), as suggested by the Canadian Association of Gastroenterology clinical practice guideline on the management of bile acid diarrhea 1.
• Antibiotics for bacterial overgrowth (rifaximin 550mg three times daily for 14 days) or anti-inflammatory drugs for inflammatory bowel disease may also be considered.
• Probiotics containing Lactobacillus or Bifidobacterium strains (taken daily as directed) may help restore gut flora balance.
• Medical evaluation is essential if diarrhea persists beyond 2-4 weeks, especially with warning signs like blood in stool, weight loss, fever, or severe abdominal pain, as emphasized by the ESMO clinical practice guidelines for diarrhea in adult cancer patients 1. The treatment approach should be tailored to the underlying cause of chronic diarrhea, whether it's a functional disorder like IBS, an inflammatory condition, a malabsorption syndrome, or a medication side effect.
• Proper diagnosis through stool tests, blood work, or endoscopy is crucial for targeted therapy.
• The use of loperamide, as recommended by the AGA guideline 1, can help manage symptoms and improve quality of life for patients with chronic diarrhea.

From the FDA Drug Label

The adverse events with an incidence of 1. 0% or greater, which were reported at least as often in patients on loperamide hydrochloride as on placebo, are presented below in the table below. Chronic Diarrhea Loperamide Hydrochloride Placebo No. of treated patients 285 277 Gastrointestinal AE% Constipation 5.3% 0.0%

Loperamide can be used for the treatment of chronic diarrhea.

• The most common adverse event reported in patients with chronic diarrhea is constipation, which occurred in 5.3% of patients taking loperamide hydrochloride compared to 0.0% of patients taking placebo 2.
• It is essential to use loperamide hydrochloride with caution and follow the recommended dosage to minimize the risk of adverse events.
• Patients should be monitored for signs of cardiac toxicity, such as QT/QTc interval prolongation, Torsades de Pointes, and other ventricular arrhythmias, especially when taking higher than recommended doses 2.

From the Research

Chronic Diarrhea Treatment Options

• Chronic diarrhea can be treated by addressing the underlying cause of the condition, if possible 3
• If the cause is unknown, treatment may involve the use of opiates or bile-sequestering agents to alleviate symptoms 3
• Pharmacologic agents such as loperamide, 5-hydroxytryptamine type 3 (5-HT3) receptor antagonists, diosmectite, cholestyramine, probiotics, antispasmodics, rifaximin, and anti-inflammatory agents may be used to treat chronic diarrhea 4
• Dietary alterations, enteral or parenteral nutrition, and oral rehydration solutions may also be used to manage chronic diarrhea 5
• Strategic use of dietary fiber can improve stool consistency and may be of special value when fecal incontinence is present concurrently 5

Medications for Chronic Diarrhea

• Opiate antidiarrheal drugs, such as loperamide and diphenoxylate, may be used to treat chronic diarrhea 5
• Clonidine has both proabsorptive and motility effects that facilitate its antidiarrheal effect, but its antihypertensive action limits its utility 5
• Octreotide is of great value in treating diarrhea due to endocrine tumors and dumping syndrome 5
• Bile acid binders, such as cholestyramine or colestipol, have several specific uses but have limited utility in nonspecific chronic diarrhea 5
• Eluxadoline, rifaximin, and alosetron are US Food and Drug Administration-approved agents for the management of irritable bowel syndrome with diarrhea (IBS-D) 6

Nonpharmacological Interventions

• Dietary and lifestyle modification are generally used as first-line therapy for IBS-D 6
• Probiotics have demonstrated efficacy and safety in patients with IBS, but studies are inconsistent in strains examined, dosing, and treatment duration 6
• Psychological therapies, such as cognitive behavioral therapy and hypnotherapy, may improve IBS symptoms 6
• Empiric antidiarrheal therapy can be used to mitigate symptoms in most patients for whom a specific treatment is not available 7