CID Flashcards
Risk factors for CID? (no need to memorise in detail, just roughly know)
- > 65 y/o
- Female
- ECOG performance status ≥ 2
- Bowel inflammation/ malabsorption
- Bowel malignancy
- Biliary obstruction
Others: first cycle of chemoTx, cycle duration > 3w, concomitant neutropenia, SSx like mucositis, vomiting, anorexia, anemia, direct damage and inflammation to intestine mucosa
What is the severity grading of CID? (grades 1-5)
Grade 1: ↑ of < 4 stools/day
Grade 2: ↑ of 4-6 stools/day, limits ADLs
Grade 3: ↑ of ≥ 7 stools/day, hospitalisation needed, limiting self-care
Grade 4: life-threatening, urgent intervention needed
Grade 5: death
What defines uncomplicated diarrhea?
- Grade 1 or 2
- No complicating signs/ SSx
What defines complicated diarrhea?
- Grade 3 or 4
- Grade 1 or 2 with 1 of the following:
- Cramping
- > Grade 2 nausea/ vomiting
- ↓ performance status
- Fever
- Sepsis
- Neutropenia
- Frank bleeding
- Dehydration
What are the goals of Tx from CID?
- ↓ morbidity and mortality from CID
- Improve QoL and ADL
- Improve recovery of intestinal mucosa
- ↓ hospitalisation
What is the treatment algorithm for uncomplicated diarrhea?
Hints: what do we do to current chemoTx? pharmaco and non-pharmaco? what happens if diarrhea persists still?
- If grade 2: withhold chemoTx (resume when SSx resolve/ consider dosage reduction)
- Non-pharmaco: oral hydration with 8-10 large glasses of clear liquids
- Pharmaco: Loperamide PO 4mg, then 2mg Q4H or after every loose stool until diarrhea-free for 12H
If diarrhea persists after 12-24H…
- Schedule Loperamide PO 2mg Q2H
- Start PO abx
- If progresses to severe/ complicated CID, treat as such
If diarrhea still persists as uncomplicated after 12-24H…
- Add octreotide
What is the treatment for complicated diarrhea?
- Withhold Tx (resume when SSx resolve, at decreased dosage)
- Administer octreotide 100-150mcg SUBQ/ IV with dose escalation up to 500mcg TDS
- Start IV fluid hydration
- Start IV abx (eg. ciprofloxacin x 7d)
MOA of loperamide?
Peripherally-acting opioid receptor antagonist which inhibits the SM contraction of intestine to decrease motility
ADEs of loperamide?
Constipation, abdominal pain, dizziness, rash, bloating, n/v, dry mouth, drowsiness
MOA of octreotide?
↓ hormone secretion which:
- ↓ GI motility
- ↓ secretion of fluid
- ↑ absorption of fluid and electrolytes
What are the ADEs of octreotide?
Bradycardia, arrhythmias, constipation, abdominal pain, enlarged thyroid, n/v, headache, dizziness
What is the dosing of octreotide?
100-500mcg SUBQ TDS, may ↑ by 50mcg increments after 24h to 500mcg TDS
OR
Continuous infusion 25-50mcg/h
What are the non-pharmacoTx for CID?
- Probiotics recommended to prevent CID
- Avoid caffeine, alcohol, fruit juice, foods containing lactose, foods spicy/ high in fat or fibre, dietary supplements with high osmolarity
- Avoid lactose-containing foods for ≥ 1 week after CID resolves
- Small, frequent meals
- BRAT diet (banana, rice, applesauce, toast)
- > 3L of clear fluids containing salt & sugar (electrolyte-containing fluids)
When does early and late irinotecan-associated diarrhea occur?
- Early: within 24h of administration
- Late: 24h after administration
What is the Tx for early irinotecan-associated diarrhea? (include dosing)
Atropine 0.25-1mg (max 1.2mg) SUBQ/ IV (usually SUBQ)
What is the MOA and ADE of atropine for early irinotecan-associated diarrhea?
MOA: inhibits acetylcholine at muscarinic receptor as competitive antagonist
ADEs: insomnia, dizziness, tachycardia, blurred vision, dry mouth, constipation
What is the Tx for late irinotecan-associated diarrhea? (include dosing)
Loperamide 4mg after first loose stool, then 2mg Q2H (4mg Q4H at night) until NO BOWEL MOVEMENTS for 12h
