Can any of the medications my 67‑year‑old patient is taking—donepezil (Aricept), aspirin, ramipril, vitamin D3, vitamin B12, sertraline, ezetimibe, empagliflozin, bisoprolol, atorvastatin, amlodipine—cause loose bowel movements?

Medications That Can Cause Loose Bowel Movements

Yes, several medications in this regimen can cause loose bowel movements, with donepezil (Aricept) and sertraline being the most likely culprits, followed by empagliflozin and ezetimibe as less common but documented causes.

Primary Offenders

Donepezil (Aricept 5mg)

• Diarrhea is one of the most common side effects of donepezil, listed explicitly in the FDA drug label 1
• The cholinomimetic mechanism of action increases gastrointestinal motility and secretions, which directly causes loose stools 1, 2
• This side effect typically occurs early in treatment and may improve with continued use, though it can persist 1
• The FDA label specifically lists nausea, diarrhea, and vomiting among the most common adverse effects 1

Sertraline (50mg)

• Selective serotonin reuptake inhibitors (SSRIs) like sertraline accelerate small bowel transit, which can lead to loose stools 3
• SSRIs have fewer constipating effects compared to tricyclic antidepressants, but the trade-off is increased risk of diarrhea 3
• The mechanism involves serotonin's prokinetic effects on intestinal motility 3

Secondary Contributors

Empagliflozin (25mg)

• SGLT2 inhibitors can cause osmotic diarrhea through their mechanism of increasing urinary glucose excretion and altering fluid balance
• While not as commonly associated with diarrhea as donepezil or sertraline, gastrointestinal side effects have been reported with this drug class

Ezetimibe (10mg)

• Diarrhea is a recognized adverse effect of ezetimibe, though less common than with other lipid-lowering agents
• The mechanism may relate to altered cholesterol absorption in the intestine

Medications Unlikely to Cause Diarrhea

Medications That Typically Cause Constipation

• Ramipril: ACE inhibitors rarely affect bowel function significantly
• Bisoprolol: Beta-blockers are not typically associated with diarrhea
• Amlodipine: Calcium channel blockers occasionally cause constipation, not diarrhea
• Atorvastatin: While statins can cause GI upset, diarrhea is uncommon with atorvastatin specifically

Neutral Medications

• Aspirin 81mg: At this low dose, GI effects are minimal and more likely to cause gastric irritation than diarrhea
• Vitamin D3 and B12: These supplements do not typically cause loose stools at standard doses

Clinical Management Algorithm

Step 1: Identify the temporal relationship

• Determine when loose bowel movements started relative to medication initiation
• Donepezil was started most recently based on the prescription dates, making it the prime suspect 1

Step 2: Consider dose-dependent effects

• The patient is on donepezil 5mg (starting dose), where GI side effects are most prominent 1
• Sertraline at 50mg is a moderate dose where serotonergic GI effects can occur 3

Step 3: Trial discontinuation or dose adjustment

• If donepezil is the suspected cause and symptoms are bothersome, consider temporary discontinuation to assess symptom resolution 1
• The FDA label warns that if donepezil is missed for 7 days or more, consultation with a physician is required before restarting 1
• For sertraline, dose reduction may help if this is contributing 3

Important Caveats

• Multiple medication interactions: The combination of donepezil with NSAIDs (though only low-dose aspirin is present here) increases risk of GI complications, though this typically manifests as ulcers rather than diarrhea 1
• Age-related considerations: At 67 years old, this patient may be more susceptible to medication side effects, and donepezil can cause serious adverse reactions in elderly patients 4
• Do not abruptly stop donepezil: The FDA label emphasizes not stopping or changing the dose without physician consultation 1
• Monitor for dehydration: Loose bowel movements from multiple medications can lead to fluid and electrolyte imbalances, particularly important given the patient's diabetes and cardiovascular medications