Constipation & Diarrhea Flashcards
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Constipation:
infrequent stool passage (less than 3 bowel movements per week) or difficulty in passing stools.
- straining
- lumpy/hard stools, pushing for > 10 minutes
- requiring digital evacuation of stool
- sensation of incomplete evacuation
” is the most common digestive complaint in the U.S”
When should a patient be referred to see a medical provider if they have been using OTC medications to treat constipation but still having problems?
If no improvement in 7 days with OTC Tx, patient should go see provider.
When constipation persists for several weeks or longer, and the cause is unknown, it is termed ______________
chronic idiopathic constipation (CIC)
idiopathic constipation associated with chronic or recurrent abdominal discomfort that is relieved by defecation is termed ______________
irritable bowel syndrome with constipation (IBS-C)
Medical Conditions that can cause Constipation:
- IBS (irritable bowel syndrome)- constipation predominant
- anal disorders (fissures, fistulae, rectal prolapse)
- multiple sclerosis
- cerebrovascular events
- Parkinson disease (*remember dopamine controls movement through many mechanisms throughout body)
- hypothyroidism
- diabetes
- spinal cord tumors
Non-Drug Treatment:
Non drug treatments are preferred for _________
These would include:
constipation
- increasing fluid intake (64 oz daily recommended)
- limiting caffeine
- limiting alcohol (to avoid dehydration
- increasing physical activity
- replacing refined foods with whole grains, bran, fruits and vegetables, beans and other foods high in fiber
If constipation does not improve with lifestyle measures, or if a constipating drug cannot be stopped, one or more drug treatments can be used.
Most medications are available OTC and can be tried for the initial treatment of IBS-C, CIC or opioid-induced constipation (OIC).
If constipation is NOT improved after _________________ a healthcare provider should be consulted for further evaluation and, if appropriate, prescription medication can be considered.
7 days of OTC treatment
Drug Tx Classes: OTC to Tx constipation
remember “ Large & Small Bulls Shit Often”- LSBSO
1
2
3
4
5
Most drug treatments act to stimulate the muscles of the digestive tract or soften the stool, often speeding up the time for bowel movements; thus the most common side effects are _________ and __________
1) Bulk Forming
2) Osmotics
3) Stimulants
4) Stool Softeners
5) Lubricants
diarrhea & abdominal cramping
Bulk-forming drugs:
How do they work?
(soluble fiber such as psyllium) and dietary fiber are the first-line treatments in most cases and the Treatment of CHOICE in PREGNANCY
- they absorb water in the intestine, soaking up fluid and adding bulk to the stool. This increases peristalsis and decreases stool transit time.
—– use in pregnancy AND most adults
Osmotics:
How do they work?
[polyethylene glycol (PEG)] contain large ions or molecules that are poorly absorbed.
They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis.
Examples of Osmotics:
Which Osmotics require a prescription?
Stimulants:
How do they work?
- directly stimulate neurons in the colon, causing peristaltic activity.
[patients using chronic opioids, all of which are constipating, often require a stimulant laxative, because opioids reduce peristalsis and prolong stool transit time]
—- use for opioid induced constipation
Stool Softeners:
How do they work?
- are emollients that reduce the surface tension of the stool oil-water interface, allowing more water and fat to mix with the stool. This softens the fecal mass making defecation easier.
- These can be used by patients using iron supplements, which often make the stool hard and compact.
- the stool softener docusate can be given with stimulant laxative if the stool is hard. (If the stool is NOT hard, but the patient cannot push it out “mush with no push”, a stimulant alone is the usual treatment.
- – use for iron induced or hard stools
For Fast relief needed:
Adults: Use stimulant bisacodyl suppository or Glycerin suppository
Children: glycerin suppository
Lubricants:
How do they work?
- (mineral oil) coat the bowel and stool with a waterproof film. This keeps moisture in the stool and makes defecation easier.
Which Bulk forming drugs OTC come as an chewable tablet?
calcium polycarbophil (Fibercon)
wheat dextrin (Benefiber)
Key Drugs that are Constipating:
- Antacids (aluminum and calcium containing)
- Antidiarrheals
- Clonidine
- Colesevelam
- Iron
- Non-DHP CCBs (diltiazem & verapamil)
- opioids
- Sucralfate
- [drugs with anticholinergic effects]:
antihistamines (diphenhydramine)
antispasmodics (baclofen)
phenothiazines (prochlorperazine)
TCAs (amitriptyline)
urge incontinence drugs (oxybutynin)
Metamucil
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psyllium
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: capsule, powder
Dosing: 2.5-30g/day in divided doses
Max dose:
Contraindications:
*Fecal impaction and GI obstruction (psyllium)
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
Pearls/Notes:
- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
- psyllium modestly improves cholesterol and blood glucose
Onset: 12-72 hours
Drug-Drug/Food interactions:
FiberCon
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calcium polycarbophil
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: chewable tablet, caplet
Dosing: 1250mg 1-4 times/ day
Max dose:
Contraindications:
*Fecal impaction
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
Pearls/Notes:
- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
- Calcium is a polyvalent cation; *separate calcium polycarbophil from select drugs due to a binding interaction
Onset: 12-72 hours
Drug-Drug/Food interactions:
Citrucel
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methylcellulose
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: powder, caplet
Dosing: 1-6 grams/day
Max dose:
Contraindications:
*Fecal impaction
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
Pearls/Notes:
- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
Onset: 12-72 hours
Drug-Drug/Food interactions:
Benefiber
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Wheat dextrin
class: Bulk-forming laxative
Indications: prevent constipation
MOA: drug absorbs water in the intestine, it swells up, adding bulk to the stool and this then distends the colon. This increases peristalsis and decreases stool transit time.
Dosage forms: chewable tablet, powder, tablet
Dosing: 4 grams (2 teaspoonfuls) in 4-8 oz of liquid or soft food TID
Max dose:
Contraindications:
*Fecal impaction
Warnings:
Side Effects:
* flatulence, abdominal cramping, bloating, bowel obstruction (if strictures present), choking (if powder forms are not taken with enough fluids).
Monitoring:
Pearls/Notes:
- Adequate fluids are required*; use caution if fluid restricted (heart failure), if difficulty swallowing (Parkinson disease) or it at risk for fecal impaction (intestinal ulcerations, stenosis)
Onset: 12-72 hours
Drug-Drug/Food interactions:
Milk of Magnesia
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magnesium hydroxide
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: chewable tablet, suspension
Dosing:
OTC- magnesium hydroxide: 2.4-4.8g QDHS or in divided doses
Max dose:
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
*Magnesium-containing products: Caution with renal impairment and DO NOT USE if severe renal impairment.
Pearls/Notes:
Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
magnesium citrate/magnesium sulfate
MiraLax
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polyethylene glycol 3350
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: powder
Dosing:
OTC- 17g in 4-8 oz of water daily
Contraindications:
GI obstruction
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
Pearls/Notes:
Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
GaviLax/GlycoLax
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polyethylene glycol 3350
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms:
Dosing:
Rx:
Max dose:
Contraindications:
*GI obstruction
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
Pearls/Notes:
Onset: 30min to 96 hours (oral), 5-30min (rectal)
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PediaLax
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Glycerin
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: suppository
Dosing:
OTC: PR- insert 1 daily
Max dose:
Contraindications:
*GI obstruction
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
Pearls/Notes:
*Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
Constulose
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lactulose
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms:
Dosing: solution, crystal packet
*Rx- 10-20 grams PO daily
oral solution can be diluted and administered rectally.
Max dose:
Contraindications:
low galactose diet
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
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Lactulose: used commonly for hepatic encephalopathy*
Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
Enulose
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lactulose
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: solution, crystal packet
Dosing:
*Rx- 10-20 grams PO daily
oral solution can be diluted and administered rectally.
Max dose:
Contraindications:
Low galactose diet
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
Pearls/Notes:
Lactulose: used commonly for hepatic encephalopathy*
Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
Fleet enema
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sodium phosphates
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: enema
Dosing:
PR (per rectum)- OTC: insert contents of one 4.5oz enema as a single dose
Contraindications:
*GI obstruction
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
Pearls/Notes:
Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
Pizensy
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Rx*
Drug-Drug/Food interactions:
lactitol
class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms:
Dosing:
*Rx- 20 grams in 4-8 oz of water, juice or other beverage (coffee, tea, soda) daily, preferred taken with a meal.
Contraindications:
GI obstruction, galactosemia (unable to fully break down galactose)
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
*Lactitol: upper respiratory tract infections, increased blood pressure, increased creatinine phosphokinase
Monitoring:
Pearls/Notes:
Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
sorbitol
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class: osmotic laxative
Indications: constipation
MOA: drug is composed of large ions or molecules that are poorly absorbed. They draw fluid into the bowel lumen through osmosis, which distends the colon and increases peristalsis (intestinal motility).
Promotes bowel evacuation by causing osmotic retention of fluid which distends the colon with increased peristaltic activity.
Dosage forms: oral solution, enema
Dosing:
OTC
- PO: 30-150mL (70% solution) as a single dose
- PR (enema): 120mL (25-30% solution)
Max dose:
Contraindications:
*Anuria
Warnings:
Side Effects:
*Electrolyte imbalance, abdominal cramping, flatulence, dehydration, rectal irritation (suppository)
Monitoring:
Pearls/Notes:
Onset: 30min to 96 hours (oral), 5-30min (rectal)
Drug-Drug/Food interactions:
Senokot
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senna
class: stimulant laxative
Indications: for fast relief of constipation, patients on opioids need
MOA: drug directly stimulates neurons/nerves in the colon, causing an increase in peristaltic contraction activity. This pushes the stool down the GI tract.
“Patients using chronic opioids, ALL of which are constipating, often require a stimulant laxative, because opioids reduce peristalsis and prolong stool transit time”.
Dosage forms: tablet, chewable tablet, liquid, syrup,
Dosing: OTC
17.2 - 50mg daily-BID
generally given at bedtime but some patients may require BID
Max dose:
Contraindications:
Warnings:
Avoid use with stomach pain, N/V or a sudden change in bowel movements that lasts > 2 weeks.
Side Effects:
abdominal cramping, electrolyte imbalance,
Pearls/Notes:
Onset of action: 6-12 hours (oral), 15-60 minutes (rectal)
Take oral products at bedtime to induce a bowel movement the following morning; can give 30 minutes after a meal to enhance peristalsis.
Chronic Opioid use often requires a stimulant laxative.
Drug-Drug/Food interactions:
Senna S, Senokot S, Senna Plus
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senna + docusate
Dulcolax
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bisacodyl
class: stimulant laxative
Indications: for fast relief of constipation, patients on opioids need
MOA: drug directly stimulates neurons in the colon, causing peristaltic activity.
“Patients using chronic opioids, ALL of which are constipating, often require a stimulant laxative, because opioids reduce peristalsis and prolong stool transit time”.
Dosage forms:
Dosing: OTC
oral: 5 - 15mg daily, Do NOT take within 1 hour of dairy products or antacids.
PR (enema, suppository): 10mg daily, cool suppository in the fridge or cold water first if too soft to insert.
Max dose:
Contraindications:
Warnings:
Avoid use with stomach pain, N/V or a sudden change in bowel movements that lasts > 2 weeks.
Side Effects:
abdominal cramping, electrolyte imbalance, rectal irritation (suppository)
Pearls/Notes:
Onset of action: 6-12 hours (oral), 15-60 minutes (rectal)
Take oral products at bedtime to induce a bowel movement the following morning; can give 30 minutes after a meal to enhance peristalsis.
Chronic Opioid use often requires a stimulant laxative.
Drug-Drug/Food interactions:
Colace
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docusate sodium
class: emollient stool softener
Indications:
MOA: drug reduces the surface tension of the stool oil-water interface, allowing more water and fat to mix with the stool. This softens the fecal mass making defecation easier.
“These can be used by patients using iron supplements, which make the stool hard and compact”.
Dosage forms: capsule, tablet, enema, liquid, syrup
Dosing: OTC
PO: 50-360mg daily or in divided doses
PR (enema): 283g/5mL daily - TID
Max dose:
Contraindications:
Abdominal pain, N/V, use with mineral oil, OTC use > 1 week
Side Effects:
abdominal cramping, throat irritation (liquid)
Pearls/Notes:
Onset of action: 12-72 hours (oral), 2-15min (rectum)
Preferred when straining should be avoided (postpartum, post-MI, anal fissures, hemorrhoids)
Use when stool is hard or dry
** Do NOT Take docusate and mineral oil together (it increases the absorption of the mineral oil**
Drug-Drug/Food interactions:
mineral oil
class:
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MOA:
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class: lubricant
Indications:
MOA: coats the bowel and stool with a waterproof film. This keeps moisture in the stool and makes defecation easier.
Dosage forms: oral liquid, enema
Dosing:
PO: 15-45mL daily or in divided doses
PR (enema): 118mL as a single dose
Max dose:
Contraindications:
** Age < 6 years, pregnancy, bedridden patients, elderly, use > 1 week, difficulty swallowing
Warnings:
Side Effects:
abdominal cramping, nausea, incontinence, rectal discharge
Monitoring:
Pearls/Notes:
Onset of action: 6-8 hours (oral), 2-15min (rectal)
Take a Multivitamin at a different time due to malabsorption of fat-soluble vitamins.
Generally, not recommended due to safety concerns, potential risk of aspiration (lipid pneumonitis)
Drug-Drug/Food interactions:
Do NOT take with docusate, it increases the absorption of the mineral oil
Opioid-Induced Constipation:
-
-
-
Treatment:
-Slow peristalsis
-Increase sphincter tone
-decrease fluid into small intestine
-increase water absorption in large intestine
— Stimulant laxative +/- Stool Softener
— PAMORA
There are Mu receptors all along the colon
Drugs approved for IBS-C (constipation associated with Irritable Bowel Syndrome) AND CIC (chronic idiopathic constipation include:
- lubiprostone (Amitiza)
- linaclotide (Linzess)
- plecanatide (Trulance)
Other Classes of medications that are prescription and used to treat some or all of the constipation conditions (CIC- chronic idiopathic constipation) (OIC- opioid induced constipation), (IBS-C) irritable bowel syndrome associated constipation:
*remember- “Some Constipation Gradually Persists”– SCGP- for drug classes
1) S
2) C
3) G
4) P
1) Chloride Channel Activator
- lubiprostone (Amitiza)
2) Guanylate Cyclase C Agonists
- linaclotide (Linzess)
- plecanatide (Trulance)
3) Peripherally Acting Mu-Opioid Receptor Antagonists (PAMORAs)
- alvimopan (Entereg)
- methylnaltrexone (Relistor)
- naloxegol (Movantik)
- naldemedine (Symproic)
4) Serotonin 5HT-4 receptor agonists
- prucalopride (Motegrity)
- tegaserod (Zelnorm)
Amitiza
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Indications:
MOA:
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Monitoring:
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lubiprostone
class: Chloride channel activator
Indications: CIC, IBS-C, OIC
MOA: drug acts on chloride channels in the gut, leading to increased fluid and peristalsis.
Dosage forms: capsule
Dosing:
CIC & OIC in adult women: 24mcg BID
IBS-C in adult women: 8mcg BID
decrease dose with moderate-severe liver impairment.
Contraindications:
Mechanical bowel obstruction
Side Effects:
nausea, diarrhea, abdominal distension,
Monitoring:
Pearls/Notes:
Take with food and water to decrease nausea.
Swallow whole, do not break, chew or crush capsule.
Consider alternative treatment with methadone (decreases lubiprostone effects)
Drug-Drug/Food interactions:
Linzess
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linaclotide
class: Guanylate Cyclase C agonist
Indications: CIC, IBS-C
MOA: drug increases chloride and bicarbonate secretion into the lumen of the intestines, increasing the speed of GI transit and reducing abdominal pain.
Dosage forms: capsule
Dosing:
CIC - 145mcg daily
IBS-C: 290mcg daily
Take at least 30 minutes before breakfast on an empty stomach.
Boxed Warning:
- Do NOT use in pediatric patients; high risk of dehydration that can cause death*
Contraindications:
* Age < 6 years old, mechanical GI obstruction*
Side Effects:
diarrhea, abdominal pain, flatulence
Pearls/Notes:
* Swallow Linzess capsules whole; if needed, the capsule can be opened and the contents mixed with 1 teaspoonful of applesauce or 30mL of room temperature water; the mixture must be swallowed immediately.
Linzess: protect from moisture; Original container has a desiccant.
Drug-Drug/Food interactions:
Trulance
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plecanatide
class: Guanylate Cyclase C agonist
Indications: CIC, IBS-C
MOA: drug increases chloride and bicarbonate secretion into the lumen of the intestines, increasing the speed of GI transit and reducing abdominal pain.
Dosage forms: tablet
Dosing: 3mg daily
Boxed Warning:
- Do NOT use in pediatric patients; high risk of dehydration that can cause death*
Contraindications:
* Age < 6 years old, mechanical GI obstruction*
Side Effects:
diarrhea, abdominal pain, flatulence
Pearls/Notes:
Trulance tablets can be crushed
Drug-Drug/Food interactions:
Entereg
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
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Warnings:
Side Effects:
Monitoring:
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Drug-Drug/Food interactions:
alvimopan
class: (PAMORA) Peripherally-Acting Mu-Opioid Receptor Antagonist
Indications: For hospitalized patients only, to decrease risk of post-operative ileus.
MOA:
Dosage forms: capsule
Dosing:
12mg, 30min - 5 hours prior to surgery, then 12mg BID for up to 7 days total.
Max dose: maximum 15 doses
Boxed Warning:
* Potential risk of MI with long term use
Available only for short-term inpatients use through a REMS program
Contraindications:
* Therapeutic doses of opioids for >7 consecutive days immediately prior to use*
Side Effects: dyspepsia
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Relistor
class:
Indications:
MOA:
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Dosing:
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Warnings:
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Drug-Drug/Food interactions:
methylnaltrexone
only for OIC
Movantik
class:
Indications:
MOA:
Dosage forms:
Dosing:
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Warnings:
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Drug-Drug/Food interactions:
naloxegol
only for OIC
Symproic
class:
Indications:
MOA:
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naldemedine
only for OIC
Motegrity
prucalopride
class:
Indications:
MOA:
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Zelnorm
tegaserod
Laxatives used for WHOLE BOWEL IRRIGATION:
Diarrhea:
- is an increase in the number of bowel movements or stools that are more watery and loose than normal.
- when the intestines push stools though the bowel before the water in the stool can be reabsorbed, diarrhea occurs.
The most common bacterial cause of diarrhea is ________
E. coli
Most cases of diarrhea are_____
viral
(IBS-D) irritable bowel syndrome with diarrhea:
recurrent idiopathic diarrhea associated with chronic or recurring abdominal discomfort that is relieved by defecation.
Non-drug treatment diarrhea:
management includes fluid and electrolyte replacement.
(ORS) oral rehydration solutions: Pedialyte, Enfamil Enfalyte
When to Contact Health Care provider for any of the following in diarrhea:
- patient age is less than < 6 months
- patient is pregnant
- high fever > 101 F
- severe abdominal pain
- blood in the stool
Pepto-Bismol
class:
Indications:
MOA:
Dosage forms:
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bismuth subsalicylate
class: antidiarrheal
Indications: diarrhea
MOA: has antisecretory and antimicrobial effects
Dosage forms: suspension (262mg/15mL), chewable tablet,
Dosing:
524mg every 30-60min PRN
or
1050mg every 60min PRN
Max: 4200mg/day for up to 2 days
Contraindications:
** Salicylate allergy, taking other salicylates (aspirin), GI ulcer, bleeding problems, black/bloody stool **
Warnings:
** children and teenagers who are recovering from the flu, chicken pox, or other viral infections should NOT USE this drug due to the risk of Reyes Syndrome**.
Side Effects:
** Black tongue/stool (temporary and harmless), salicylate toxicity if used excessively (tinnitus, metabolic acidosis), nausea, abdominal pain**.
Monitoring:
Pearls/Notes:
can cause an increased risk of bleeding when used with anticoagulants, antiplatelets, or NSAIDs
Drug-Drug/Food interactions:
Imodium / Diamode
class:
Indications:
MOA:
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Dosing:
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Side Effects:
Monitoring:
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Drug-Drug/Food interactions:
loperamide
class: antidiarrheal / antimotility
Indications: diarrhea
MOA: slows intestinal motility, prolonging the time for water reabsorption
Dosage forms: capsule, tablet, liquid, suspension
Dosing:
OTC: 1 tab or 1 cap = 2mg
Rx
** 4mg PO after the first loose stool, then 2mg after each subsequent loose stool**
Max dose:
OTC Max dose: 8mg/day (self care)
*MAX dose 16mg/day (under healthcare supervision**
Boxed Warning:
* Torsades de pointes, cardiac arrest and sudden death, with doses higher than recommended; DO NOT exceed the recommended dose
- DO NOT USE in children < 2 years*
Contraindications:
*Acute dysentery (bloody diarrhea and high fever), pseudomembranous colitis (C.difficile), bacterial enterocolitis caused by invasive organisms (toxigenic E.coli, Salmonella, Shigella), abdominal pain without diarrhea,
Warnings:
Side Effects:
Constipation, abdominal cramping, nausea, QT prolongation
Monitoring:
Pearls/Notes:
Self treatment: DO NOT USE > 48 hrs
loperamide can be abused, as it causes a mild opioid-like High in large quantities.
Drug-Drug/Food interactions:
Lomotil
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
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diphenoxylate + atropine C-V
class: antidiarrheal
Indications: diarrhea
MOA: inhibits excessive GI motility and propulsion; atropine is used to discourage abuse
Dosage forms: liquid, tablet
Dosing:
diphenoxylate 5mg (two of the 2.5mg tablets) up to 4 times daily
Max dose: 20mg/day
Contraindications:
*Risk of respiratory and CNS depression in children [ DO NOT USE if < or = to 2 years of age OR less than 6 years of age for tablet], diarrhea caused by enterotoxin-producing bacteria or pseudomembranous colitis (C.difficile), obstructive jaundice.
Warnings:
Side Effects:
Monitoring:
Pearls/Notes:
- improvement is usually seen within 48 hours; if not seen within 10 days, discontinue
- **Liquid formulation is recommended in children greater than 13 years old. **
- anticholinergic effects are due to atropine [ constipation, dry mouth, sedation, tachycardia, flushing, urinary retention, blurred vision]- these are mild at recommended doses
Drug-Drug/Food interactions:
less than 6 years old - can’t use tablet
less than 13 years old- can’t use liquid
less than or equal to 2- cant use either
Bentyl
class:
Indications:
MOA:
Dosage forms:
Dosing:
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dicyclomine
class: antispasmodic
Indications: abdominal cramping/pain in diarrhea
MOA:
Dosage forms: tablet, capsule, solution, injection
Dosing: 20mg QID
Max dose: 80mg/day for less than 2 weeks. (Can increase to 40mg QID after first week, if symptoms respond.
Contraindications:
Warnings:
*Anticholinergic (Caution in patients > 65 years old, per Beers Criteria), caution in mild-moderate ulcerative colitis (can cause toxic megacolon or paralytic ileus)
Side Effects:
* dizziness, dry mouth, nausea, blurred vision, somnolence weakness*
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
Viberzi
class:
Indications:
MOA:
Dosage forms:
Dosing:
Max dose:
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Side Effects:
Monitoring:
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eluxadoline C-IV
class: peripherally acting mixed mu-opioid receptor agonist
Indications:
MOA:
Dosage forms: tablet
Dosing: 100mg PO BID, take with food
Max dose:
Contraindications:
* Patients without a gallbladder, biliary duct obstruction, sphincter of Oddi dysfunction/disease, pancreatic disease (including history of pancreatitis), alcoholism or > 3 alcoholic drinks/day, severe hepatic impairment (Child-Pugh class C), history of severe constipation, gastrointestinal obstruction*.
Warnings: CNS depression
Side Effects: constipation, nausea, abdominal pain
Monitoring:
Pearls/Notes:
Drug-Drug/Food interactions:
