Lomotil Dosing for Adult Post-Ileostomy Patients

Direct Recommendation

Do not use Lomotil (diphenoxylate/atropine) for managing ileostomy output—use loperamide instead as the first-line antimotility agent. 1, 2, 3

Loperamide is uniformly endorsed by major gastroenterological societies (American Gastroenterological Association, ESPEN, British Society of Gastroenterology) as the drug of choice for controlling high-output stomas because it lacks sedative and addictive properties and does not cause fat malabsorption. 2, 3
Lomotil is less effective than loperamide for reducing ileostomy output and carries problematic anticholinergic side effects (dry mouth, urinary retention) from the atropine component. 1
Direct comparative evidence shows loperamide superiority: Oral loperamide 4 mg four times daily was more effective in reducing the weight and sodium content of ileostomy fluid than codeine phosphate 60 mg four times daily, and by extension, more effective than Lomotil. 1

Only if loperamide is unavailable or contraindicated, the FDA-approved adult dosing for Lomotil is: 4

Initial dose: 2 tablets (5 mg diphenoxylate) four times daily (20 mg/day total)
Maintenance: Reduce to as little as 2 tablets daily once control is achieved
Duration: If no improvement within 10 days at maximum dose (20 mg/day), further administration is unlikely to help 4

Begin with 2–4 mg loperamide taken 30 minutes before each meal to reduce postprandial intestinal output. 5, 3

For patients with disrupted enterohepatic circulation or very rapid transit, doses of 12–24 mg at a time may be required, with total daily doses up to 32 mg frequently needed in short-bowel syndrome patients. 1, 5, 2

If tablets emerge unchanged in stomal output, crush them or open capsules and mix with water or food to improve absorption. 1, 5, 3
Avoid sustained-release or delayed-release formulations in short-bowel or high-output settings, as absorption is markedly reduced. 2, 3

When ostomy output exceeds 2 L per day, add a proton pump inhibitor (omeprazole 40 mg daily or twice daily IV) or H2-receptor antagonist (ranitidine 300 mg twice daily) to reduce gastric hypersecretion. 1, 2, 3

Reserve octreotide 50 µg subcutaneously twice daily for very high-output stomas (>3 L/24 hours) that remain refractory to loperamide plus antisecretory agents; it can lower output by 1–2 L per 24 hours but does not improve nutrient absorption. 1, 2

Codeine phosphate 60 mg three times daily may be combined with loperamide in refractory high-output cases to achieve synergistic reduction of stoma output. 2, 6

Limit oral hypotonic fluids (water, tea, coffee, juice) to <500 mL per day, as they paradoxically increase sodium loss through the stoma. 2
Replace fluid deficits with glucose-saline oral rehydration solution containing 90–100 mmol/L sodium to promote coupled sodium-glucose absorption. 5, 2, 3
Discourage large-volume water intake, as excessive intake creates a vicious cycle of increased output and worsening dehydration. 2

Do not use Lomotil as first-line therapy—it is inferior to loperamide and carries unnecessary anticholinergic burden. 1, 2
Before escalating therapy, exclude other causes of high output: intra-abdominal sepsis, partial obstruction, Clostridioides difficile infection, or Crohn's disease recurrence. 2
Monitor 24-hour stomal output volumes regularly to assess ongoing benefit; expect approximately 20–30% reduction in water and sodium output with effective loperamide therapy. 1, 5, 3
Continue loperamide indefinitely as long as it provides objective benefit—do not discontinue arbitrarily after a set time period, as this can precipitate high-output crisis requiring IV fluid resuscitation. 3