What is the prescription management for diarrhea?

Prescription Management for Diarrhea

For adult patients with diarrhea, loperamide is the first-line medication at an initial dose of 4 mg followed by 2 mg every 2-4 hours or after every unformed stool, with a maximum daily dose of 16 mg. 1

Initial Assessment and Rehydration

Fluid Replacement

• Oral rehydration is the preferred method for mild to moderate dehydration
• For severe dehydration:
  • Initial fluid bolus of 20 mL/kg for patients with tachycardia or potential sepsis 1
  • Continue rapid fluid replacement until clinical signs of hypovolaemia improve
  • Target urine output >0.5 mL/kg/h 1

Dietary Recommendations

• Avoid spices, coffee, alcohol, and reduce insoluble fiber intake 1
• Avoid milk and dairy products (except yogurt and firm cheeses) during chemotherapy-induced diarrhea 1
• For children, the BRAT diet (bananas, rice, applesauce, toast) is recommended 2

Pharmacological Management by Patient Type

General Adult Patients

1. Loperamide:

   • Initial dose: 4 mg
   • Maintenance: 2 mg every 2-4 hours or after each unformed stool
   • Maximum: 16 mg daily 1, 3
   • Contraindicated in bloody diarrhea or suspected infectious colitis 3

2. Alternative antimotility agents:

   • Tincture of opium, morphine, or codeine can be used when loperamide is contraindicated 1

Cancer Patients with Chemotherapy-Induced Diarrhea

1. Loperamide as first-line (dosing as above)
2. Octreotide:
   • Starting dose: 100-150 μg subcutaneous/intravenous three times daily
   • Can be titrated up to 500 mg subcutaneous/intravenous three times daily or 25-50 mg/h by continuous IV infusion 1
3. Uridine triacetate:
   • 10 g orally every 6 hours for 20 doses
   • For early-onset, severe toxicity within 96 hours following 5-FU or capecitabine administration 1
4. Budesonide:
   • For chemotherapy-induced diarrhea refractory to loperamide
   • Not recommended for prophylactic use 1

Immunotherapy-Induced Diarrhea

• Grade 1: Oral rehydration and antidiarrheals (racecadotril or loperamide) 1
• Grade 2: Add budesonide 9 mg once daily if no bloody diarrhea; oral corticosteroids (0.5-1 mg/kg/day prednisone) for diffuse ulceration/bleeding 1
• Grade 3-4: IV corticosteroids (1-2 mg/kg/day prednisone); avoid loperamide; consider infliximab for persistent symptoms 1

Bile Salt Malabsorption

• Bile acid sequestrants (cholestyramine, colestipol, colesevelam) 1

Pediatric Patients

• Children <2 years: Loperamide is contraindicated due to risks of respiratory depression and cardiac adverse reactions 3
• Children ≥2 years: Loperamide can be used for symptomatic relief of acute nonspecific diarrhea 3
• Antibiotics generally not indicated for most cases of acute gastroenteritis 2

Important Warnings and Precautions

Cardiac Risks with Loperamide

• Cases of QT/QTc prolongation, Torsades de Pointes, ventricular arrhythmias, and cardiac arrest have been reported with higher than recommended doses 3
• Avoid loperamide in:
  • Combination with drugs that prolong QT interval
  • Patients with risk factors for QT prolongation
  • Patients with congenital long QT syndrome or history of cardiac arrhythmias 3

Other Precautions

• Discontinue loperamide promptly if constipation, abdominal distention, or ileus develop 3
• Avoid antimotility drugs in patients with bloody diarrhea 1, 4
• Monitor for signs of dehydration and electrolyte imbalances, especially in elderly and pediatric patients 3

When to Consider Antibiotics

Antibiotics should be reserved for specific cases:

• Shigellosis
• Campylobacteriosis
• Clostridium difficile infection
• Traveler's diarrhea
• Protozoal infections 4, 5

Red Flags Requiring Urgent Referral

• Bloody stools
• Persistent fever
• Severe dehydration
• Immunosuppression
• Weight loss
• Clinical signs of anemia
• Palpable abdominal mass 6

Remember that most cases of acute diarrhea are self-limiting and do not require diagnostic workup or antibiotics. Treatment should focus on preventing and treating dehydration while providing symptomatic relief.