Pharmacy Clinic
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Diarrhea
Objectives
• Understand the Pathophysiology diarrhea
• Understand the main causes of the disease
• Discuss the non Pharmacologic and Pharmacologic treatments of the disease
• Patient counseling and advice
What do we need to know
• Age
Infant, child, adult, elderly
• Duration
• Severity
• Symptoms. Associated symptoms
Nausea/vomiting
Fever
Abdominal cramps
Flatulence
• Other family members affected
• Previous history
• Recent travel abroad
• Causative factors
• Medication
Medicines tried already
Other medicines being taken
When to refer
• Diarrhea of greater than 1 day’s duration in children younger than one year, 2 days in children under three and elderly
patients, 3 days in older children and adults. (these are only rough quidelines; in severe cases referral should be recommended
immediately)
• Association with severe vomiting and fever
• Suspected drug-induced reaction to prescribed medicine
• History of change in bowel habit
• Presence of blood or mucus in the stools
Definition
Diarrhea is an increase in the water content, frequency, and volume of bowel movements.
Diarrhea can be a serious problem. Mild cases disappear within a few days. Severe cases can cause serious dehydration or
nutritional problems.
Diarrhea is a common symptom that can range in severity from an acute, self-limited annoyance to a severe, life-threatening illness.
The frequency and consistency of bowel movements vary within and between individuals. Some individuals may normally defecate as
many as three times a day, while others only two to three times per week.
Diarrhea is defined as increased volume, fluidity, or frequency of fecal discharges compared with the patient’s normal stools.
Clinical features vary greatly depending on the cause, duration, and severity of the diarrhea, on the area of bowel affected, and on
the patient’s general health.
Etiology and Pathophysiology
While there are many causes of diarrhea, it is most often due to an enteritis (inflammation of the small intestine) of infectious or
noninfectious etiology.
Most infectious diarrheas are acquired by fecal-oral transmission via contaminated food or water.
Improperly cooked meats may also be the source of infection.
Diarrhea results from an imbalance in the absorption and secretion properties of the intestinal tract; if absorption decreases or
secretion increases beyond normal, diarrhea results.
Diarrhea may be acute or chronic.
Acute diarrhea is the abrupt onset of frequent, watery, loose stools. It may be accompanied by: flatulence, malaise and abdominal
pain.
Some clinicians consider acute diarrhea to be the passage of three or more loose stools in a 24-hour period, continuing for less than
two weeks.
Usually, acute diarrheal episodes subside within 72 hours of onset.
Common diarrhea-producing pathogens are Shigella, Salmonella, Campylobacter, Staphylococcus, Bacillus cereus, and rotaviruses.
Toxigenic Escherichia coli and S. aureus cause diarrhea through an enterotoxin, while Shigella, Salmonella, Campylobacter and
invasive E. coli directly invade the mucosal epithelial cells.
Toxin-producing pathogens usually cause a watery, large-volume diarrhea. Nausea, vomiting, cramps and fever may also occur.
Invasive organisms may invade the large intestine and produce frequent small-volume stools that may contain mucus or blood.
Pseudomembranous colitis:
Clostridium difficle is the major cause of antibiotic associated colitis and Pseudomembranous colitis. This organism produces at least
two exotoxins, A and B, which cause intestinal damage. The infection occurs most often in hospitals where the organism resides in
rooms and toilets and is transmitted by hand to the patient. If the intestinal flora disturbed by antibiotics, particularly broad
spectrum antibiotics such as clindamycin. The problem starts with inflammation covered by fibrin and debris. Diarrhea may become
profuse and watery
Diarrhea may be classified into four general types, based on the mechanism:
Diarrhea may be classified into four general types, based on the mechanism:
Osmotic diarrhea, secretory diarrhea, exudative diarrhea and motility disorder diarrhea
Osmotic diarrhea occurs when ingested solute which is not fully absorbed in the small intestine draws fluid into the intestinal lumen.
The nonabsorbed material can be a maldigested or malabsorbed nutrient or drug. Diarrhea of this type may result from disorders
such as chronic pancreatitis, bile duct obstruction, celiac disease (nontropical sprue), or Whipple’s disease.
Acute osmotic diarrhea may result from ingestion of certain fruits or candy, gum, dietetic foods, lactose or the sweeteners sorbitol or
fructose.
Secretory diarrhea occurs when the small and large bowel secrete rather than absorb electrolytes and water. Bacterial toxins,
viruses and some drugs (e.g., prostaglandins) may cause this type of diarrhea. Mucosal inflammation and ulceration caused by
inflammatory diseases and cancers may result in the outpouring (تدفق) of plasma, proteins, mucus and blood into the stool, resulting
in exudative diarrhea. Loose stools can result when intestinal contents are not exposed to the absorptive surface of the GI tract for
a sufficient amount of time.
Diarrhea due to motility disorders is caused by conditions such as diabetic neuropathy or irritable bowel syndrome.
A more common cause of osmotic diarrhea is intolerance to lactose. Lactose intolerance may cause bloating, abdominal pain or
cramps, gas, or diarrhea.
An estimated 50 million Americans experience some form of gastrointestinal discomfort shortly after consuming lactose-containing
dairy products.
Lactose intolerance is caused by a deficiency of the intestinal enzyme lactase and is more common in African-Americans, Indians and
Asians. Patients who are lactose intolerant should avoid or limit their consumption of products that contain milk, lactose, dry milk
solids, or whey.
Patients should be instructed to consume one serving at a time along with solid food to help limit or offset the symptoms of lactose
intolerance.
Tablets and capsules that contain lactase (e.g., DairyEase, Lactaid) can be taken up to 30 minutes before ingestion of a milk product.
Diarrhea in infants and young children is often caused by a viral infection of the intestinal tract.
Chronic diarrhea may be caused by gastrointestinal disease, may be secondary to systemic disease, or may be psychogenic in
nature.
Pathophysiology,
Chronic diarrhea may be categorized as inflammatory diarrhea, osmotic diarrhea (malabsorption), secretory diarrhea, intestinal
dysmotility and factitious (self-induced, e.g., from laxative abuse) diarrhea.
Chronic laxative abuse can result in serious fluid and electrolyte loss, protein wasting (hypoalbuminemia) and colitis. a change in
bowel habits is one of the seven danger signals of cancer
Patient Assessment
For good assessment, the pharmacist should ascertain: the duration, onset, frequency and severity of the diarrheal episodes and
whether or not the diarrhea is accompanied by abdominal pain, vomiting, fecal overt or occult blood, steatorrhea or appetite
changes, or is associated with the consumption of certain foods or products (including dietetic food, candy or chewing gum).
It is important to determine whether the patient has recently traveled to a foreign country or has otherwise consumed
nonchlorinated water.
Treatment
Nonpharmacologic:
Lost fluids and electrolytes can be replaced with virtually any beverage plus a source of sodium chloride
Rest the bowel by avoiding high-fiber foods, fats, milk and other dairy products, caffeine and alcohol.
A bland diet emphasizing such foods as bananas, clear soups, juice, gelatin and boiled vegetables may be helpful.
For less than severe diarrhea, an oral glucose-electrolyte solution may be given if nausea and vomiting are not severe.
Intravenous fluid therapy is necessary for the treatment of severe dehydration or diarrhea that is accompanied by severe vomiting.
Oral rehydration therapy (ORT) is the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to
moderate dehydration.
Several glucose-electrolyte or rice-based physiologic solutions (Pedialyte, Infalyte, etc.) are commercially available for children who
require ORT.
Parents should be discouraged from using nonphysiologic solutions (cola, apple juice, chicken broth and sports beverages) to treat
their children with diarrhea.
Oral Rehydration Formula Recipe
½ teaspoon salt
1 teaspoon baking soda
8 teaspoons sugar
8 ounces orange juice
Dilute to 1 liter with water
Fluids may be given at rates of 50 mL/kg/24 h to 200 mL/kg/ 24 h depending on the patient’s hydration status.
*Premixed rehydration formulas are preferred.
Certain foods may be better tolerated by children and adults with diarrhea—complex carbohydrates (rice, wheat, potatoes, bread,
cereals), lean meats, yogurt, fruits and vegetables.
Fatty foods or foods high in simple sugars (tea, juices, soft drinks) should be avoided.
The BRAT diet (bananas, rice, applesauce and toast), while tolerated, is low in protein, fat and energy.
Symptoms that suggest the need for prompt medical attention include high fever (>38.5oC), bloody diarrhea, abdominal pain,
diarrhea that does not subside after 4-5 days or dehydration.1
The goals of treatment are to:
1. Maintain hydration,
2. Treat the underlying causes
3. Relieve the symptoms of diarrhea.
Pharmacologic Treatment
The antimotility agents (e.g., loperamide), adsorbents (e.g., attapulgite) and antisecretory compounds (e.g., bismuth subsalicylate)
are not recommended for preschool patients.
Prescription Agents:
The opiate analgesics
• antimotility effect on the gastrointestinal tract.
• Agents such as paregoric (camphorated tincture of opium) and paregoric-containing products have been used for many years.
• They rely on their content of morphine, which exerts its effect by decreasing the hyperperistaltic movements of the small
intestine and colon, thereby slowing down the passage of intestinal contents.
Diphenoxylate HCl with atropine sulfate and difenoxin HCl with atropine sulfate
• Specifically indicated for the treatment of diarrhea.
• Both of these agents are chemically related to meperidine, but they lack analgesic activity.
• Difenoxin is the principal active metabolite of diphenoxylate and is effective at one fifth the dosage of diphenoxylate.
• The atropine has been added in subtherapeutic doses to discourage deliberate abuse.
• At the recommended doses, anticholinergic activity is usually not a concern.
• Diphenoxylate and difenoxin appear to provide an antidiarrheal effect by slowing intestinal motility through a local effect on
the gastrointestinal wall.
• Because of these agents’ structural relationship to traditional opiates, potential side effects include dizziness, drowsiness and
sedation in a few patients.
• Addiction to (physiological dependence on) diphenoxylate and difenoxin is theoretically possible at high doses and after
chronic use but this is rare.
• It is particularly important that these two agents not be used in the management of invasive bacterial diarrhea.
• These agents may prolong or aggravate the diarrhea associated with these organisms that penetrate the intestinal mucosa (i.
e., toxigenic E. coli, Salmonella, Shigella) or in pseudomembranous enterocolitis associated with broad-spectrum antibiotic therapy.
• Because of the opiate-related agents’ depressant effects on the central nervous system, barbiturates, tranquilizers and
alcohol should not be used concomitantly.
• Patients should be warned about the potential for causing drowsiness or dizziness and should use caution when driving or
performing other tasks requiring alertness, coordination or physical dexterity.
• When these agents are used for acute diarrhea, clinical improvement is usually seen within 48 hours and treatment beyond
that time frame is usually not necessary.
Nonprescription Agents:
Three agents—attapulgite, polycarbophil and calcium polycarbophil—are considered safe and effective for diarrhea treatment.
Loperamide was approved by the FDA for OTC status via a new drug application (NDA) procedure which was not part of the FDA OTC
Review process.
Because of concerns regarding significant dehydration and electrolyte imbalances, OTC agents available for diarrhea must not be
used if the diarrhea has lasted for more than two days or in patients less than three years of age.
Patients who should be under a physician’s care are those who are under three years of age, are over 60 years of age with multiple
medical problems, are pregnant and those who have a history of chronic diseases, bloody stools, abdominal tenderness, fever,
dehydration, a weight loss of more than 5% of total body weight and diarrhea for longer than 48 hours.
Loperamide HCl
• Slows intestinal motility and affects water and electrolyte movement through the bowel.
• It appears to inhibit intestinal motility by a direct effect on the circular and longitudinal muscles of the intestinal wall.
• The bulk density and viscosity of a bowel movement is increased with a concomitant reduction in daily fecal volume and a
decrease in a loss of fluid and electrolytes.
• The same contraindication concerning the use of this agent in the presence of invasive bacterial diarrhea
• Indicated for control and symptomatic relief of acute nonspecific diarrhea, including traveler’s diarrhea.
• As a prescription drug, loperamide may be prescribed for the control and symptomatic relief of chronic diarrhea associated with
inflammatory or functional bowel diseases.
• It may also be used to reduce the volume of discharge from ileostomies.
Adverse effects
• Generally minor and self-limiting
• More commonly observed during the treatment of chronic diarrhea.
• CNS penetration of the drug is minimal
• Does not usually produce the CNS side effects
• Drowsiness or dizziness and patients should observe caution while driving or performing other tasks requiring alertness,
coordination or physical dexterity.
• Dry mouth, constipation, nausea and vomiting may also occur.
• For the treatment of acute diarrhea, clinical improvement is usually observed within 48 hours.
Attapulgite,
• Safe and effective for the treatment of acute diarrhea.
• Adsorbent agent and is a naturally occurring hydrous magnesium aluminum silicate that adsorbs about eight times its weight
in water.
• Not absorbed systemically, therefore side effects are minimal.
• The adsorbent effect reduces the liquidity of the stool.
• The primary problem with attapulgite is that adsorption is not selective; the systemic absorption of nutrients and other drugs
may be disrupted. Because of this effect, patients should be counseled not to take any other medications within two to three hours
of taking attapulgite.
• Patients should not use this agent for more than two days
Calcium polycarbophil
• Hydrophilic polyacrylic resin that possesses absorbent properties.
• In diarrhea when the intestinal mucosa is incapable of absorbing water at normal rates, it absorbs free fecal water, forming a
gel to aid in the production of formed stools.
• Like attapulgite, polycarbophil is not absorbed systemically so no systemic side effects are produced.
• It can absorb up to sixty times its weight in water.
• Epigastric pain and bloating may occur which may be somewhat minimized by giving smaller doses spaced more evenly
throughout the day.
• Minimal fluid intake is encouraged and the tablets should be chewed well and not swallowed whole.
• Because calcium in this product can inhibit the absorption of tetracycline, this antibiotic should not be given at the same time
as the calcium polycarbophil.
• It is indicated for acute nonspecific diarrhea or diarrhea that is associated with conditions such as irritable bowel syndrome
and diverticulosis.
Bismuth subsalicylate
• Have antisecretory and antimicrobial effects.
• Enhances the effects of oral rehydration by shortening the episodes of diarrhea.
• The salicylate portion of this agent provides the antisecretory effect
• Bismuth portion may exert antimicrobial effects.
• This agent is indicated for the control of diarrhea, including traveler’s diarrhea.
• If the diarrhea is accompanied by a high fever or continues for more than two days, a physician should be consulted.
• The stool may temporarily appear gray-black with use of this agent. The tongue may also be partially discolored.
Lactobacillus preparations
• Have been available for years.
• These products contain lactobacillus organisms (Lactobacillus acidophilus and Lactobacillus bulgaricus).
• They have been touted as effective in restoring normal bowel flora when diarrhea is thought to be caused by the
administration of antibiotics, but there is no solid documented evidence to support this claim.
• Milk, yogurt and buttermilk have been reported to be equally effective in re-establishing normal intestinal flora.
Kaolin-pectin
• Not proven to be effective
Activated charcoal
• Claims of anti diarrheal action
• Not proven
The American Academy of Pediatrics recommends that, as a general rule, pharmacologic agents not be used to treat acute diarrhea
in children.
Patient Counseling
Questions to ask before recommending an antidiarrheal
1. How long have you had diarrhea, and how often do the episodes occur?
2. Do you have any other symptoms in addition to diarrhea?
3. Which antidiarrheal medications have you tried, if any, and did they help?
4. What are the characteristics of your stools? Do they contain any blood or mucus?
5. Have you changed your diet (including drinking nonchlorinated water) or traveled to a foreign country recently?
6. Do others in your household have diarrhea, or can you associate the onset of the diarrhea to a particular food or drug?
7. Which medications (prescription and OTC) are you currently taking?
8. Do you have any medical conditions or chronic illnesses?
Patients with diarrhea who should be referred to a physician for a complete diagnostic evaluation:
• Infants and young children
• Elderly patients
• Patients with chronic and/or multiple medical conditions
• Patients with abdominal tenderness and cramping
• Pregnant women
• Dehydrated patients or those who have lost more than 5% of their body weight
• Patients with high fever (•101°F or 38 °C)
• Patients with stools that contain blood or mucus
Patients with severe diarrhea, or diarrhea which has lasted more than 2 days, with or without treatment
Conclusion
Diarrhea is a common, annoying and sometimes life-threatening symptom. Pharmacists are often called upon for advice on the
treatment of this disorder. Patient assessment is very important in the treatment of diarrhea; patients may present with acute or
chronic diarrhea. There are a myriad of potential causes, and by thorough and careful investigation of individual patient’s
symptomatology, pharmacists can suggest the best treatment option, whether it be an antidiarrheal, a change in diet, or referral to
a physician. It is important for pharmacists to recognize which types of diarrhea may be potentially serious and also which
populations of patients are potentially at risk for complications from diarrhea. In addition, it should be noted that stopping the
diarrhea is not necessarily the goal of treatment for all patients.
• Understand the Pathophysiology diarrhea
• Understand the main causes of the disease
• Discuss the non Pharmacologic and Pharmacologic treatments of the disease
• Patient counseling and advice
What do we need to know
• Age
Infant, child, adult, elderly
• Duration
• Severity
• Symptoms. Associated symptoms
Nausea/vomiting
Fever
Abdominal cramps
Flatulence
• Other family members affected
• Previous history
• Recent travel abroad
• Causative factors
• Medication
Medicines tried already
Other medicines being taken
When to refer
• Diarrhea of greater than 1 day’s duration in children younger than one year, 2 days in children under three and elderly
patients, 3 days in older children and adults. (these are only rough quidelines; in severe cases referral should be recommended
immediately)
• Association with severe vomiting and fever
• Suspected drug-induced reaction to prescribed medicine
• History of change in bowel habit
• Presence of blood or mucus in the stools
Definition
Diarrhea is an increase in the water content, frequency, and volume of bowel movements.
Diarrhea can be a serious problem. Mild cases disappear within a few days. Severe cases can cause serious dehydration or
nutritional problems.
Diarrhea is a common symptom that can range in severity from an acute, self-limited annoyance to a severe, life-threatening illness.
The frequency and consistency of bowel movements vary within and between individuals. Some individuals may normally defecate as
many as three times a day, while others only two to three times per week.
Diarrhea is defined as increased volume, fluidity, or frequency of fecal discharges compared with the patient’s normal stools.
Clinical features vary greatly depending on the cause, duration, and severity of the diarrhea, on the area of bowel affected, and on
the patient’s general health.
Etiology and Pathophysiology
While there are many causes of diarrhea, it is most often due to an enteritis (inflammation of the small intestine) of infectious or
noninfectious etiology.
Most infectious diarrheas are acquired by fecal-oral transmission via contaminated food or water.
Improperly cooked meats may also be the source of infection.
Diarrhea results from an imbalance in the absorption and secretion properties of the intestinal tract; if absorption decreases or
secretion increases beyond normal, diarrhea results.
Diarrhea may be acute or chronic.
Acute diarrhea is the abrupt onset of frequent, watery, loose stools. It may be accompanied by: flatulence, malaise and abdominal
pain.
Some clinicians consider acute diarrhea to be the passage of three or more loose stools in a 24-hour period, continuing for less than
two weeks.
Usually, acute diarrheal episodes subside within 72 hours of onset.
Common diarrhea-producing pathogens are Shigella, Salmonella, Campylobacter, Staphylococcus, Bacillus cereus, and rotaviruses.
Toxigenic Escherichia coli and S. aureus cause diarrhea through an enterotoxin, while Shigella, Salmonella, Campylobacter and
invasive E. coli directly invade the mucosal epithelial cells.
Toxin-producing pathogens usually cause a watery, large-volume diarrhea. Nausea, vomiting, cramps and fever may also occur.
Invasive organisms may invade the large intestine and produce frequent small-volume stools that may contain mucus or blood.
Pseudomembranous colitis:
Clostridium difficle is the major cause of antibiotic associated colitis and Pseudomembranous colitis. This organism produces at least
two exotoxins, A and B, which cause intestinal damage. The infection occurs most often in hospitals where the organism resides in
rooms and toilets and is transmitted by hand to the patient. If the intestinal flora disturbed by antibiotics, particularly broad
spectrum antibiotics such as clindamycin. The problem starts with inflammation covered by fibrin and debris. Diarrhea may become
profuse and watery
Diarrhea may be classified into four general types, based on the mechanism:
Diarrhea may be classified into four general types, based on the mechanism:
Osmotic diarrhea, secretory diarrhea, exudative diarrhea and motility disorder diarrhea
Osmotic diarrhea occurs when ingested solute which is not fully absorbed in the small intestine draws fluid into the intestinal lumen.
The nonabsorbed material can be a maldigested or malabsorbed nutrient or drug. Diarrhea of this type may result from disorders
such as chronic pancreatitis, bile duct obstruction, celiac disease (nontropical sprue), or Whipple’s disease.
Acute osmotic diarrhea may result from ingestion of certain fruits or candy, gum, dietetic foods, lactose or the sweeteners sorbitol or
fructose.
Secretory diarrhea occurs when the small and large bowel secrete rather than absorb electrolytes and water. Bacterial toxins,
viruses and some drugs (e.g., prostaglandins) may cause this type of diarrhea. Mucosal inflammation and ulceration caused by
inflammatory diseases and cancers may result in the outpouring (تدفق) of plasma, proteins, mucus and blood into the stool, resulting
in exudative diarrhea. Loose stools can result when intestinal contents are not exposed to the absorptive surface of the GI tract for
a sufficient amount of time.
Diarrhea due to motility disorders is caused by conditions such as diabetic neuropathy or irritable bowel syndrome.
A more common cause of osmotic diarrhea is intolerance to lactose. Lactose intolerance may cause bloating, abdominal pain or
cramps, gas, or diarrhea.
An estimated 50 million Americans experience some form of gastrointestinal discomfort shortly after consuming lactose-containing
dairy products.
Lactose intolerance is caused by a deficiency of the intestinal enzyme lactase and is more common in African-Americans, Indians and
Asians. Patients who are lactose intolerant should avoid or limit their consumption of products that contain milk, lactose, dry milk
solids, or whey.
Patients should be instructed to consume one serving at a time along with solid food to help limit or offset the symptoms of lactose
intolerance.
Tablets and capsules that contain lactase (e.g., DairyEase, Lactaid) can be taken up to 30 minutes before ingestion of a milk product.
Diarrhea in infants and young children is often caused by a viral infection of the intestinal tract.
Chronic diarrhea may be caused by gastrointestinal disease, may be secondary to systemic disease, or may be psychogenic in
nature.
Pathophysiology,
Chronic diarrhea may be categorized as inflammatory diarrhea, osmotic diarrhea (malabsorption), secretory diarrhea, intestinal
dysmotility and factitious (self-induced, e.g., from laxative abuse) diarrhea.
Chronic laxative abuse can result in serious fluid and electrolyte loss, protein wasting (hypoalbuminemia) and colitis. a change in
bowel habits is one of the seven danger signals of cancer
Patient Assessment
For good assessment, the pharmacist should ascertain: the duration, onset, frequency and severity of the diarrheal episodes and
whether or not the diarrhea is accompanied by abdominal pain, vomiting, fecal overt or occult blood, steatorrhea or appetite
changes, or is associated with the consumption of certain foods or products (including dietetic food, candy or chewing gum).
It is important to determine whether the patient has recently traveled to a foreign country or has otherwise consumed
nonchlorinated water.
Treatment
Nonpharmacologic:
Lost fluids and electrolytes can be replaced with virtually any beverage plus a source of sodium chloride
Rest the bowel by avoiding high-fiber foods, fats, milk and other dairy products, caffeine and alcohol.
A bland diet emphasizing such foods as bananas, clear soups, juice, gelatin and boiled vegetables may be helpful.
For less than severe diarrhea, an oral glucose-electrolyte solution may be given if nausea and vomiting are not severe.
Intravenous fluid therapy is necessary for the treatment of severe dehydration or diarrhea that is accompanied by severe vomiting.
Oral rehydration therapy (ORT) is the preferred treatment of fluid and electrolyte losses caused by diarrhea in children with mild to
moderate dehydration.
Several glucose-electrolyte or rice-based physiologic solutions (Pedialyte, Infalyte, etc.) are commercially available for children who
require ORT.
Parents should be discouraged from using nonphysiologic solutions (cola, apple juice, chicken broth and sports beverages) to treat
their children with diarrhea.
Oral Rehydration Formula Recipe
½ teaspoon salt
1 teaspoon baking soda
8 teaspoons sugar
8 ounces orange juice
Dilute to 1 liter with water
Fluids may be given at rates of 50 mL/kg/24 h to 200 mL/kg/ 24 h depending on the patient’s hydration status.
*Premixed rehydration formulas are preferred.
Certain foods may be better tolerated by children and adults with diarrhea—complex carbohydrates (rice, wheat, potatoes, bread,
cereals), lean meats, yogurt, fruits and vegetables.
Fatty foods or foods high in simple sugars (tea, juices, soft drinks) should be avoided.
The BRAT diet (bananas, rice, applesauce and toast), while tolerated, is low in protein, fat and energy.
Symptoms that suggest the need for prompt medical attention include high fever (>38.5oC), bloody diarrhea, abdominal pain,
diarrhea that does not subside after 4-5 days or dehydration.1
The goals of treatment are to:
1. Maintain hydration,
2. Treat the underlying causes
3. Relieve the symptoms of diarrhea.
Pharmacologic Treatment
The antimotility agents (e.g., loperamide), adsorbents (e.g., attapulgite) and antisecretory compounds (e.g., bismuth subsalicylate)
are not recommended for preschool patients.
Prescription Agents:
The opiate analgesics
• antimotility effect on the gastrointestinal tract.
• Agents such as paregoric (camphorated tincture of opium) and paregoric-containing products have been used for many years.
• They rely on their content of morphine, which exerts its effect by decreasing the hyperperistaltic movements of the small
intestine and colon, thereby slowing down the passage of intestinal contents.
Diphenoxylate HCl with atropine sulfate and difenoxin HCl with atropine sulfate
• Specifically indicated for the treatment of diarrhea.
• Both of these agents are chemically related to meperidine, but they lack analgesic activity.
• Difenoxin is the principal active metabolite of diphenoxylate and is effective at one fifth the dosage of diphenoxylate.
• The atropine has been added in subtherapeutic doses to discourage deliberate abuse.
• At the recommended doses, anticholinergic activity is usually not a concern.
• Diphenoxylate and difenoxin appear to provide an antidiarrheal effect by slowing intestinal motility through a local effect on
the gastrointestinal wall.
• Because of these agents’ structural relationship to traditional opiates, potential side effects include dizziness, drowsiness and
sedation in a few patients.
• Addiction to (physiological dependence on) diphenoxylate and difenoxin is theoretically possible at high doses and after
chronic use but this is rare.
• It is particularly important that these two agents not be used in the management of invasive bacterial diarrhea.
• These agents may prolong or aggravate the diarrhea associated with these organisms that penetrate the intestinal mucosa (i.
e., toxigenic E. coli, Salmonella, Shigella) or in pseudomembranous enterocolitis associated with broad-spectrum antibiotic therapy.
• Because of the opiate-related agents’ depressant effects on the central nervous system, barbiturates, tranquilizers and
alcohol should not be used concomitantly.
• Patients should be warned about the potential for causing drowsiness or dizziness and should use caution when driving or
performing other tasks requiring alertness, coordination or physical dexterity.
• When these agents are used for acute diarrhea, clinical improvement is usually seen within 48 hours and treatment beyond
that time frame is usually not necessary.
Nonprescription Agents:
Three agents—attapulgite, polycarbophil and calcium polycarbophil—are considered safe and effective for diarrhea treatment.
Loperamide was approved by the FDA for OTC status via a new drug application (NDA) procedure which was not part of the FDA OTC
Review process.
Because of concerns regarding significant dehydration and electrolyte imbalances, OTC agents available for diarrhea must not be
used if the diarrhea has lasted for more than two days or in patients less than three years of age.
Patients who should be under a physician’s care are those who are under three years of age, are over 60 years of age with multiple
medical problems, are pregnant and those who have a history of chronic diseases, bloody stools, abdominal tenderness, fever,
dehydration, a weight loss of more than 5% of total body weight and diarrhea for longer than 48 hours.
Loperamide HCl
• Slows intestinal motility and affects water and electrolyte movement through the bowel.
• It appears to inhibit intestinal motility by a direct effect on the circular and longitudinal muscles of the intestinal wall.
• The bulk density and viscosity of a bowel movement is increased with a concomitant reduction in daily fecal volume and a
decrease in a loss of fluid and electrolytes.
• The same contraindication concerning the use of this agent in the presence of invasive bacterial diarrhea
• Indicated for control and symptomatic relief of acute nonspecific diarrhea, including traveler’s diarrhea.
• As a prescription drug, loperamide may be prescribed for the control and symptomatic relief of chronic diarrhea associated with
inflammatory or functional bowel diseases.
• It may also be used to reduce the volume of discharge from ileostomies.
Adverse effects
• Generally minor and self-limiting
• More commonly observed during the treatment of chronic diarrhea.
• CNS penetration of the drug is minimal
• Does not usually produce the CNS side effects
• Drowsiness or dizziness and patients should observe caution while driving or performing other tasks requiring alertness,
coordination or physical dexterity.
• Dry mouth, constipation, nausea and vomiting may also occur.
• For the treatment of acute diarrhea, clinical improvement is usually observed within 48 hours.
Attapulgite,
• Safe and effective for the treatment of acute diarrhea.
• Adsorbent agent and is a naturally occurring hydrous magnesium aluminum silicate that adsorbs about eight times its weight
in water.
• Not absorbed systemically, therefore side effects are minimal.
• The adsorbent effect reduces the liquidity of the stool.
• The primary problem with attapulgite is that adsorption is not selective; the systemic absorption of nutrients and other drugs
may be disrupted. Because of this effect, patients should be counseled not to take any other medications within two to three hours
of taking attapulgite.
• Patients should not use this agent for more than two days
Calcium polycarbophil
• Hydrophilic polyacrylic resin that possesses absorbent properties.
• In diarrhea when the intestinal mucosa is incapable of absorbing water at normal rates, it absorbs free fecal water, forming a
gel to aid in the production of formed stools.
• Like attapulgite, polycarbophil is not absorbed systemically so no systemic side effects are produced.
• It can absorb up to sixty times its weight in water.
• Epigastric pain and bloating may occur which may be somewhat minimized by giving smaller doses spaced more evenly
throughout the day.
• Minimal fluid intake is encouraged and the tablets should be chewed well and not swallowed whole.
• Because calcium in this product can inhibit the absorption of tetracycline, this antibiotic should not be given at the same time
as the calcium polycarbophil.
• It is indicated for acute nonspecific diarrhea or diarrhea that is associated with conditions such as irritable bowel syndrome
and diverticulosis.
Bismuth subsalicylate
• Have antisecretory and antimicrobial effects.
• Enhances the effects of oral rehydration by shortening the episodes of diarrhea.
• The salicylate portion of this agent provides the antisecretory effect
• Bismuth portion may exert antimicrobial effects.
• This agent is indicated for the control of diarrhea, including traveler’s diarrhea.
• If the diarrhea is accompanied by a high fever or continues for more than two days, a physician should be consulted.
• The stool may temporarily appear gray-black with use of this agent. The tongue may also be partially discolored.
Lactobacillus preparations
• Have been available for years.
• These products contain lactobacillus organisms (Lactobacillus acidophilus and Lactobacillus bulgaricus).
• They have been touted as effective in restoring normal bowel flora when diarrhea is thought to be caused by the
administration of antibiotics, but there is no solid documented evidence to support this claim.
• Milk, yogurt and buttermilk have been reported to be equally effective in re-establishing normal intestinal flora.
Kaolin-pectin
• Not proven to be effective
Activated charcoal
• Claims of anti diarrheal action
• Not proven
The American Academy of Pediatrics recommends that, as a general rule, pharmacologic agents not be used to treat acute diarrhea
in children.
Patient Counseling
Questions to ask before recommending an antidiarrheal
1. How long have you had diarrhea, and how often do the episodes occur?
2. Do you have any other symptoms in addition to diarrhea?
3. Which antidiarrheal medications have you tried, if any, and did they help?
4. What are the characteristics of your stools? Do they contain any blood or mucus?
5. Have you changed your diet (including drinking nonchlorinated water) or traveled to a foreign country recently?
6. Do others in your household have diarrhea, or can you associate the onset of the diarrhea to a particular food or drug?
7. Which medications (prescription and OTC) are you currently taking?
8. Do you have any medical conditions or chronic illnesses?
Patients with diarrhea who should be referred to a physician for a complete diagnostic evaluation:
• Infants and young children
• Elderly patients
• Patients with chronic and/or multiple medical conditions
• Patients with abdominal tenderness and cramping
• Pregnant women
• Dehydrated patients or those who have lost more than 5% of their body weight
• Patients with high fever (•101°F or 38 °C)
• Patients with stools that contain blood or mucus
Patients with severe diarrhea, or diarrhea which has lasted more than 2 days, with or without treatment
Conclusion
Diarrhea is a common, annoying and sometimes life-threatening symptom. Pharmacists are often called upon for advice on the
treatment of this disorder. Patient assessment is very important in the treatment of diarrhea; patients may present with acute or
chronic diarrhea. There are a myriad of potential causes, and by thorough and careful investigation of individual patient’s
symptomatology, pharmacists can suggest the best treatment option, whether it be an antidiarrheal, a change in diet, or referral to
a physician. It is important for pharmacists to recognize which types of diarrhea may be potentially serious and also which
populations of patients are potentially at risk for complications from diarrhea. In addition, it should be noted that stopping the
diarrhea is not necessarily the goal of treatment for all patients.