What to do for a patient with vomiting (emesis) and diarrhea who has pre-existing heart problems (cardiac disease)?

From the Guidelines

For a patient with emesis (vomiting) and diarrhea who also has heart problems, immediate medical attention is recommended as this combination can be dangerous. First, focus on preventing dehydration with small, frequent sips of clear fluids or oral rehydration solutions, as recommended by the 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea 1. Avoid anti-diarrheal medications like loperamide without medical approval as they may interact with cardiac medications, and be aware that loperamide can reduce diarrhea prevalence but may also cause adverse events such as ileus, abdominal distension, and lethargy 1. For nausea, ondansetron 4-8mg every 8 hours may be used if prescribed, but be aware it can prolong QT interval in cardiac patients, as noted in the 2022 AGA clinical practice update on management of medically refractory gastroparesis 1. Monitor for signs of dehydration such as dizziness, decreased urination, or increased heart rate, which can strain the heart, and be especially cautious with diuretics and blood pressure medications during this time, as dehydration may enhance their effects and lead to hypotension. Electrolyte imbalances from vomiting and diarrhea can trigger cardiac arrhythmias, so medical evaluation is crucial, particularly if symptoms persist beyond 24 hours, if there's chest pain, palpitations, severe weakness, or bloody stool, as emphasized in the 2017 IDSA guidelines 1. The combination of gastrointestinal symptoms and heart disease requires careful management because fluid and electrolyte disturbances can significantly impact cardiac function and medication effectiveness. Some key points to consider include:

• Oral rehydration solutions are recommended as the first-line therapy for mild to moderate dehydration in infants, children, and adults with acute diarrhea from any cause 1
• Isotonic intravenous fluids such as lactated Ringer’s and normal saline solution should be administered when there is severe dehydration, shock, or altered mental status and failure of ORS therapy 1
• Antiemetic agents such as ondansetron can be beneficial in reducing vomiting, but their use should be carefully considered in patients with heart problems due to potential effects on the QT interval 1

From the FDA Drug Label

Dehydration Fluid and electrolyte depletion often occur in patients who have diarrhea In such cases, administration of appropriate fluid and electrolytes is very important. The use of loperamide hydrochloride does not preclude the need for appropriate fluid and electrolyte therapy Avoid loperamide hydrochloride in: ... patients with risk factors for QT prolongation, including patients with congenital long QT syndrome, with a history of cardiac arrhythmias or other cardiac conditions, elderly patients and those with electrolyte abnormalities.

Management of Emesis and Diarrhea with Heart Problems:

• Administer appropriate fluid and electrolytes to prevent dehydration and electrolyte depletion.
• Avoid using loperamide hydrochloride in patients with heart problems, such as cardiac arrhythmias or other cardiac conditions, due to the risk of QT prolongation and serious cardiac adverse reactions.
• Consider alternative treatments for diarrhea that do not involve loperamide hydrochloride.
• Monitor patients closely for signs of cardiac toxicity, such as syncope, ventricular tachycardia, and QT prolongation, and seek medical attention immediately if these symptoms occur 2.

From the Research

Management of Emesis and Diarrhea with Heart Problems

• For patients with emesis and diarrhea, particularly those with heart problems, it is essential to consider the underlying cause of these symptoms to provide appropriate management.
• Metoclopramide has been shown to be effective in treating and preventing various types of vomiting, including those induced by cytotoxic agents 3, 4.
• However, metoclopramide can cause side effects such as mild sedation, diarrhea, and reversible extrapyramidal reactions 4.
• In patients with chronic nausea and vomiting, the initial diagnostic evaluation involves distinguishing gastrointestinal causes from non-gastrointestinal causes 5.
• For diarrhea, the initial evaluation and treatment in the emergency department should consider the setting and circumstances under which the patient presents 6.
• In terms of antiemetic use, ondansetron and metoclopramide have been compared to placebo for adults with undifferentiated emergency department nausea and vomiting, with similar reductions in nausea severity observed for both treatments 7.

Considerations for Heart Problems

• When managing emesis and diarrhea in patients with heart problems, it is crucial to consider the potential impact of these symptoms on the patient's cardiac condition.
• The choice of antiemetic or antidiarrheal medication should take into account the patient's cardiac history and the potential for drug interactions or adverse effects.
• Further research is needed to determine the most effective management strategies for patients with emesis and diarrhea and heart problems.