Is it safe to give rabeprazole (proton pump inhibitor) 20mg and levosulpiride (prokinetic agent) 75mg to a patient with diarrhea (loose motion)?

Rabeprazole and Levosulpiride Should Not Be Given in Patients with Diarrhea

Rabeprazole 20mg and levosulpiride 75mg should not be administered to patients with diarrhea (loose motion) as these medications may worsen the condition. This recommendation is based on the pharmacological properties and side effect profiles of both medications.

Rabeprazole in Diarrhea

Rabeprazole is a proton pump inhibitor (PPI) that works by inhibiting gastric acid secretion. While effective for acid-related disorders, it has important considerations in patients with diarrhea:

• PPIs including rabeprazole are associated with an increased risk of Clostridium difficile-associated diarrhea, which could potentially worsen existing diarrheal illness 1
• The FDA label for rabeprazole specifically warns that PPI therapy may be associated with Clostridium difficile-associated diarrhea, especially in hospitalized patients 2
• Diarrhea is listed as one of the common adverse events of rabeprazole in clinical trials 3, 4
• PPIs should be used at the lowest effective dose and for the shortest duration appropriate to the condition being treated 2

Levosulpiride in Diarrhea

Levosulpiride is a prokinetic agent that stimulates gastrointestinal motility, which makes it contraindicated in patients with diarrhea:

• Levosulpiride accelerates gastric emptying time, which can worsen diarrhea by pushing intestinal contents forward more rapidly 5
• As a prokinetic agent, levosulpiride increases gastrointestinal motility, which is counterproductive in patients already experiencing increased intestinal transit time (diarrhea) 1
• Levosulpiride is primarily indicated for functional dyspepsia, not diarrheal conditions 1

Alternative Approaches for Diarrhea Management

Instead of rabeprazole and levosulpiride, consider these evidence-based approaches for diarrhea:

• For mild diarrhea, supportive measures such as rehydration and anti-motility drugs like loperamide are recommended 1
• Loperamide starting dose is 2 tablets (4 mg), followed by an additional 2 mg after each additional loose stool, with a maximum of 16 mg per day 1
• If diarrhea is accompanied by moderate-severe symptoms (fever, moderate to severe abdominal pain, or bloody diarrhea), appropriate antibiotics should be considered 1
• For travelers' diarrhea, antibiotic treatment is not recommended for mild cases, but loperamide or bismuth subsalicylate may be considered 1

Special Considerations

• If the patient has suspected infectious diarrhea, prokinetic agents like levosulpiride are particularly contraindicated as they may spread the infection more rapidly through the gastrointestinal tract 1
• If the patient has both GERD and diarrhea, consider treating the diarrhea first before initiating PPI therapy, or use H2-receptor antagonists which may have a lower risk of exacerbating diarrhea 1
• In cases where diarrhea doesn't improve with standard treatments, further diagnostic evaluation should be considered to rule out underlying conditions 1

Conclusion

The combination of rabeprazole and levosulpiride is inappropriate for patients with diarrhea. Rabeprazole may increase the risk of C. difficile-associated diarrhea, while levosulpiride's prokinetic action would likely worsen diarrheal symptoms by accelerating intestinal transit. Treatment should instead focus on appropriate anti-diarrheal medications and addressing the underlying cause of the loose motions.