Lomotil (Diphenoxylate/Atropine) for High Ostomy Output
Lomotil can be used as an alternative antimotility agent for high ostomy output, but loperamide should be preferred as first-line therapy because it is non-addictive, non-sedating, and more gut-specific. 1
Why Loperamide is Preferred Over Lomotil
Loperamide is the recommended first-line antimotility agent for managing high ostomy output because it lacks central nervous system effects, has no addiction potential, and demonstrates superior gut-specific action compared to diphenoxylate. 1, 2
Loperamide is more effective than diphenoxylate in reducing stool output and electrolyte losses, with fewer side effects in comparative studies. 3
High-dose loperamide (up to 32 mg daily, or 16 tablets) is frequently needed in patients with short bowel syndrome or high-output ostomies, as the drug enters enterohepatic circulation which is disrupted when the ileum is absent. 1
Optimal dosing timing: Administer loperamide 30 minutes before meals and at bedtime for maximum effectiveness. 1, 2
When Lomotil May Be Considered
Lomotil is FDA-approved as adjunctive therapy for diarrhea management and can be used when loperamide alone is insufficient or not tolerated. 4
Combination therapy may be beneficial: Loperamide and codeine (another opiate) have shown synergistic effects when used together, suggesting that adding diphenoxylate to loperamide could provide additional benefit in refractory cases. 1
Use objective measurements of stool/ostomy output to guide whether adding or switching to diphenoxylate provides meaningful benefit. 1, 2
Critical Contraindications for Lomotil
Do not use Lomotil in patients with:
- Obstructive jaundice 4
- Diarrhea associated with Clostridioides difficile or other enterotoxin-producing bacteria 4
- Known hypersensitivity to diphenoxylate or atropine 4
Important Caveats for Your Patient
In the context of diverticulitis: Ensure there is no active infection or C. difficile before using any antimotility agent, as these drugs are contraindicated with enterotoxin-producing bacteria. 4
With uncontrolled diabetes: Both loperamide and diphenoxylate can cause constipation and bowel distention; monitor carefully as antimotility agents may worsen bacterial overgrowth in patients with bowel dilatation. 1
Addiction and sedation risk: Diphenoxylate (and codeine, opium) have central nervous system side effects including sedation and addiction potential, making them less desirable than loperamide for chronic use. 1
Comprehensive Management Beyond Antimotility Agents
Restrict hypotonic fluids to <1000 mL daily (tea, water) as these paradoxically increase ostomy output and worsen dehydration. 1
Use oral rehydration solutions: Provide isotonic glucose-saline solutions (1 liter water + 6 teaspoons glucose + 1 teaspoon salt) for remaining fluid needs. 1
Monitor urinary sodium: Random urinary sodium <20 mmol/L indicates sodium depletion requiring aggressive replacement. 1
Consider proton pump inhibitors to reduce gastric secretions, which can contribute to high output. 1
Octreotide may be needed for refractory high-output jejunostomy where fluid/electrolyte management remains problematic despite conventional treatments, though it should be used cautiously. 1