What are the pharmacological options for treating diarrhea?

From the Guidelines

Loperamide is the recommended first-line treatment for acute, non-specific diarrhea in adults, at a dose of 4mg initially, followed by 2mg after each loose stool (maximum 16mg daily) 1. When considering pharmacological options for treating diarrhea, it's essential to take into account the cause and severity of the condition.

Treatment Options

• For acute, non-specific diarrhea, loperamide (Imodium) is often used as the first-line treatment, as suggested by the AGA clinical practice guideline on the pharmacological management of irritable bowel syndrome with diarrhea 1.
• Bismuth subsalicylate (Pepto-Bismol) can be prescribed at 30ml or two tablets every 30-60 minutes up to 8 doses daily.
• For secretory diarrhea, racecadotril (Hidrasec) at 100mg three times daily can be effective.
• In cases of bile acid diarrhea, cholestyramine at 4g up to four times daily before meals is recommended.
• For chronic diarrhea, diphenoxylate with atropine (Lomotil) at 2.5-5mg four times daily may be used.
• Antibiotics like rifaximin (550mg three times daily for 14 days) are appropriate for traveler's diarrhea or small intestinal bacterial overgrowth.
• For inflammatory bowel disease-related diarrhea, mesalamine preparations or corticosteroids may be necessary.

Important Considerations

• Patients should maintain hydration with oral rehydration solutions, especially when experiencing significant fluid loss.
• Antimotility agents should be avoided in cases of bloody diarrhea or suspected infectious diarrhea caused by invasive organisms, as they can worsen outcomes by delaying pathogen clearance 1.
• The use of antimotility drugs, such as loperamide, should not be given to children <18 years of age with acute diarrhea, and should be avoided at any age in suspected or proven cases where toxic megacolon may result in inflammatory diarrhea or diarrhea with fever 1.

Guideline Recommendations

• The 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea recommend that antimotility drugs, such as loperamide, should not be given to children <18 years of age with acute diarrhea, and should be avoided at any age in suspected or proven cases where toxic megacolon may result in inflammatory diarrhea or diarrhea with fever 1.
• The AGA clinical practice guideline on the pharmacological management of irritable bowel syndrome with diarrhea suggests using loperamide in patients with IBS-D, with a conditional recommendation and very low certainty 1.

From the FDA Drug Label

DOSAGE AND ADMINISTRATION Loperamide hydrochloride capsules are contraindicated in pediatric patients less than 2 years of age due to the risks of respiratory depression and serious cardiac adverse reactions (see CONTRAINDICATIONS) Acute Diarrhea Adults and Pediatric Patients 13 Years and Older: The recommended initial dose is 4 mg (two capsules) followed by 2 mg (one capsule) after each unformed stool. Chronic Diarrhea Adults The recommended initial dose is 4 mg (two capsules) followed by 2 mg (one capsule) after each unformed stool until diarrhea is controlled, after which the dosage of loperamide hydrochloride capsules should be reduced to meet individual requirements

The FDA drug label does not answer the question.

From the Research

Pharmacological Options for Diarrhea

There are several pharmacological options available for the treatment of diarrhea, including:

• Loperamide: a safe and effective antidiarrheal agent for the treatment of acute and chronic diarrhea 2, 3, 4, 5
• Bismuth subsalicylate: an alternative to loperamide for the treatment of acute diarrhea, although loperamide has been shown to be more effective in some studies 3, 5
• Antibiotics: such as fluoroquinolones, azithromycin, and rifaximin, which may be used for the treatment of moderate to severe travelers' diarrhea 6
• Antimotility agents: such as loperamide, which may be used as monotherapy or adjunctive therapy for the treatment of travelers' diarrhea 6

Specific Indications

• Loperamide is effective for the treatment of:
  • Acute diarrhea 2, 3, 5
  • Chronic diarrhea 4
  • Travelers' diarrhea 5, 6
• Bismuth subsalicylate is effective for the treatment of:
  • Acute diarrhea 3, 5
  • Travelers' diarrhea 6
• Antibiotics are effective for the treatment of:
  • Moderate to severe travelers' diarrhea 6
  • Dysentery (azithromycin only) 6