What is the best medication to discharge a patient with gastrointestinal (GI) upset?

Best Medication for Discharge with GI Upset

For patients being discharged with gastrointestinal upset, prescribe omeprazole 20 mg once daily taken before meals, as this addresses the most common cause of GI upset (acid-related symptoms) with an excellent safety profile and is FDA-approved for symptomatic GERD treatment. 1

Primary Recommendation: Proton Pump Inhibitor

Omeprazole 20 mg once daily is the optimal discharge medication for general GI upset because it effectively treats the most prevalent causes of upper GI symptoms including heartburn, nausea, and epigastric discomfort. 1 The medication should be taken before meals and can be used concomitantly with antacids if needed for breakthrough symptoms. 1

Dosing and Administration

• Standard dose: 20 mg once daily before meals 1
• Duration: Up to 4 weeks for symptomatic GERD 1
• For patients unable to swallow capsules: Open capsule and mix pellets with one tablespoon of applesauce, swallow immediately without chewing 1
• If dose is missed: Take as soon as possible unless next dose is due; never double dose 1

Alternative Medications Based on Specific Symptoms

For Nausea-Predominant GI Upset

Metoclopramide 10 mg orally 20-30 minutes before meals is effective for nausea and has prokinetic properties that improve gastric emptying. 2, 3 This is the only FDA-approved medication specifically for gastroparesis-related symptoms. 4 However, avoid in patients with seizure disorders, GI bleeding, or GI obstruction. 2

For Diarrhea-Predominant GI Upset

Loperamide 4 mg initially, then 2 mg after each loose stool (maximum 16 mg/day) is the first-line antidiarrheal agent. 2, 5 This should be accompanied by:

• Oral hydration: 8-10 large glasses of clear liquids daily 2, 6, 5
• BRAT diet (Bananas, Rice, Applesauce, Toast) 2, 6, 5
• Elimination of lactose-containing products and alcohol 2, 6, 5

Critical escalation point: If diarrhea persists on loperamide for 24 hours, add oral fluoroquinolone for 7 days. 2 If persisting for 48 hours, stop loperamide and consider hospitalization with IV fluids. 2

For Pain-Predominant GI Upset

Tricyclic antidepressants (TCAs) rank first for abdominal pain relief in functional GI disorders, with relative risk of persistent pain 0.53 (95% CI: 0.34-0.83). 2 Start at low doses and titrate according to symptom response. 2

Alternatively, antispasmodics rank second with relative risk 0.64 (95% CI: 0.49-0.84) for pain relief. 2

Common Pitfalls to Avoid

Do Not Discharge Without Addressing Red Flags

• New onset after age 50 years 2
• Rectal bleeding not attributable to hemorrhoids 2
• Unintentional weight loss 2
• Iron deficiency anemia 2
• Nocturnal diarrhea 2
• Family history of colon cancer, inflammatory bowel disease, or celiac disease 2

Avoid These Medications for General GI Upset

• NSAIDs cause GI upset as an adverse effect (aspirin, ibuprofen, naproxen, ketorolac all list GI upset as common side effect). 2 Do not prescribe for GI symptoms.
• Opioids should be avoided in painful functional GI disorders as they worsen symptoms. 2
• SSRIs have minimal efficacy for GI pain and the 2022 AGA guideline conditionally recommends against their use in IBS-D. 2

Special Populations

Post-Chemotherapy Patients

These patients require aggressive management with octreotide 100-150 μg subcutaneously three times daily plus empiric fluoroquinolone for 7 days if presenting with diarrhea and weakness. 6 This population should not receive simple discharge medications but requires hospitalization for IV fluids and comprehensive workup. 6

Diabetic Patients

Monitor blood glucose closely as GI upset with dehydration increases risk of acute kidney injury, particularly in those on calcineurin inhibitors. 7 Adjust insulin/oral hypoglycemics as needed. 7

Post-Antibiotic Diarrhea

For patients with diarrhea after antibiotics like Augmentin, maintain hydration and consider loperamide for mild cases. 5 However, seek immediate medical attention if symptoms persist beyond 2-3 days, or if there are signs of dehydration, high fever, or severe abdominal pain. 5 Test for C. difficile if diarrhea is moderate to severe. 2