Can Xeloda (capecitabine) cause enterocolitis?

Capecitabine (Xeloda) and Enterocolitis

Yes, capecitabine (Xeloda) can cause enterocolitis, which is a rare but potentially serious adverse event that requires prompt recognition and management. 1

Clinical Presentation and Diagnosis

Enterocolitis associated with capecitabine presents with:

• Diarrhea (most common symptom, present in 92% of cases) 2
• Abdominal pain
• Weight loss
• Fever
• Vomiting
• Possible hematochezia (bloody stools)

Diagnostic Approach

When enterocolitis is suspected in a patient taking capecitabine:

1. Endoscopic evaluation is essential:

   • Flexible sigmoidoscopy or colonoscopy with biopsies should be performed for patients with grade >1 diarrhea 2
   • Endoscopic findings may include erythema/loss of vascular pattern, erosions, and ulcerations 2

2. Imaging studies:

   • CT scan may show bowel wall thickening but has insufficient sensitivity for definitive diagnosis 2
   • Ultrasound can identify bowel wall thickening and monitor response to treatment 2

3. Laboratory tests:

   • Complete blood count
   • Serum electrolytes (hypokalemia is a common finding) 3
   • C-reactive protein
   • Stool studies to rule out infectious causes (especially Clostridioides difficile) 2

Management Algorithm

Grade 1 (Mild) Enterocolitis:

• Low-fiber diet
• Loperamide (4 mg initially, then 2 mg after every loose stool, maximum 16 mg/day) 2
• Oral hydration
• Capecitabine may be continued under close medical supervision 2

Grade 2 (Moderate) Enterocolitis:

• Withhold capecitabine
• Oral corticosteroids 2
• For non-responders, consider vedolizumab or infliximab 2
• Resume capecitabine at reduced dose once symptoms resolve to grade ≤1

Grade 3-4 (Severe) Enterocolitis:

• Hospitalization required
• Permanently discontinue capecitabine 4, 1
• Intravenous corticosteroids 2
• Infliximab for non-responders with acute, severe colitis 2
• Intravenous fluids and electrolyte replacement
• Consider octreotide (100-150 μg three times daily) for refractory cases 2

Special Considerations

Electrolyte Abnormalities

• Monitor for hypokalemia, which occurs in approximately 20% of patients on capecitabine even without significant diarrhea 3
• Potassium replacement (oral or IV) may be required

Risk Factors

• Prior history of inflammatory bowel disease
• Concurrent use of NSAIDs may increase risk of enterocolitis 2
• Advanced age may increase risk of 5-FU-associated diarrhea 2

Prevention

• Patient education about early recognition of symptoms
• Prompt reporting of diarrhea, abdominal pain, or fever
• Avoid NSAIDs during capecitabine treatment 2

Clinical Pitfalls

1. Delayed recognition: Enterocolitis can occur at any time during treatment and even several months after discontinuation 2

2. Misdiagnosis: Symptoms may be attributed to other causes such as infectious diarrhea or disease progression

3. Electrolyte disturbances: Hypokalemia can occur even without significant diarrhea and may lead to cardiac complications if not addressed 3

4. Severe complications: Without proper management, capecitabine-induced enterocolitis can progress to ileus, toxic megacolon, perforation, and death 4, 1

5. Recurrence: Reintroduction of capecitabine after an episode of enterocolitis carries a high risk of relapse and should be carefully considered 2