What are the common prescription treatments for diarrhea in India?

Common Prescription Treatments for Diarrhea in India

Oral rehydration therapy (ORT) with WHO-recommended oral rehydration solution (ORS) is the cornerstone of diarrhea management in India, with antimotility agents like loperamide as effective second-line treatments for adults. 1

First-Line Treatment: Oral Rehydration

WHO-ORS Formulation

• Standard WHO-ORS contains (in mmol/L): sodium 90, potassium 20, chloride 80, base 30, and glucose 111 (2%) 2
• Available as pre-packaged sachets throughout India
• Dissolve one sachet in 1 liter of clean water
• Adults should consume 200-400 mL after each loose stool

Fluid Management

• For mild to moderate dehydration: ORS is sufficient
• For severe dehydration: Initial IV fluid bolus of 20 mL/kg if tachycardic 2
• Aim for adequate urine output (>0.5 mL/kg/h) 2

Second-Line Treatments for Adults

Antimotility Agents

1. Loperamide (Imodium):

   • First-choice antimotility agent in India
   • Dosage: 4 mg initially, then 2 mg after each loose stool (maximum 16 mg/day) 2, 3
   • Acts locally in intestine with minimal systemic absorption
   • Common side effect: constipation (2.6% in acute diarrhea) 3
   • Available as 2 mg tablets/capsules
   • Cost: ₹2-5 per tablet (generic versions)

2. Other opioids (for refractory cases):

   • Tincture of opium
   • Codeine phosphate
   • Diphenoxylate with atropine (Lomotil)

Antisecretory Agents

1. Racecadotril (Hidrasec):
   • Enkephalinase inhibitor
   • Reduces intestinal hypersecretion without affecting transit time
   • Dosage: 100 mg three times daily
   • Available as 100 mg capsules
   • Cost: ₹10-15 per capsule

Antibiotics (for specific indications only)

1. Quinolones:

   • First-line for dysentery or confirmed bacterial diarrhea 2
   • Ciprofloxacin 500 mg twice daily for 1-3 days
   • Cost: ₹5-10 per tablet (generic)

2. Nitrofuran derivatives:

   • Nifuroxazide and furazolidone (common in India) 2
   • Dosage: 200 mg 3-4 times daily
   • Cost: ₹3-8 per tablet

3. Azithromycin:

   • For suspected resistant pathogens
   • Dosage: 500 mg once daily for 3 days
   • Cost: ₹15-25 per tablet

Adjunctive Treatments

Probiotics

• Commonly used in India despite limited evidence
• Saccharomyces boulardii and Lactobacillus preparations
• Dosage: As per manufacturer's instructions
• Cost: ₹20-60 per strip

Adsorbents

1. Kaolin-pectin preparations:

   • Traditional remedy
   • Limited scientific evidence
   • Cost: ₹30-50 per bottle

2. Activated charcoal:

   • For suspected toxin-induced diarrhea
   • Cost: ₹5-10 per tablet

Bile Acid Sequestrants

• For bile salt malabsorption
• Cholestyramine, colestipol, colesevelam 2
• Cost: ₹30-50 per sachet

Treatment Algorithm for Adults

1. For uncomplicated acute diarrhea:

   • Start ORS immediately
   • Add loperamide if frequent stools (>4/day)
   • Maintain normal diet, avoiding spicy foods, coffee, and alcohol 2

2. For diarrhea with fever or blood in stool:

   • ORS for rehydration
   • Avoid antimotility agents
   • Consider appropriate antibiotic
   • Seek medical attention

3. For persistent diarrhea (>14 days):

   • Refer for medical evaluation
   • Consider underlying conditions (IBS, IBD, malabsorption)

Common Pitfalls in India

1. Overuse of antibiotics: Studies show 55-62% of caregivers rank antibiotics ahead of ORS as the strongest medicine for diarrhea 4

2. Incorrect ORS preparation: Nearly 1/3 of mothers mix ORS in the wrong fluid 5

3. Inadequate ORS volume: Many patients don't consume sufficient quantities

4. Poor hand hygiene: Nearly half of caregivers don't practice adequate handwashing 5

5. Bottle feeding: 32% of mothers use feeding bottles, increasing contamination risk 5

The successful management of diarrhea in India requires proper education about ORS preparation and administration, appropriate use of antimotility agents, and judicious use of antibiotics only when indicated.