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PHAR 154 - Self-Care II -A > Diarrhea (Parts 1 and 2 COMBINED) > Flashcards

Diarrhea (Parts 1 and 2 COMBINED) Flashcards

2024

1
Q

Diarrhea

A

Unusually frequent excretion of watery stools
- It is associated with loss of electrolytes
- Can be defined as ≥ 3 loose or watery stools per day or a definite decrease in consistency and increase in frequency based on an individual baseline

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2
Q

Decreased fluid absorption or increased fluid secretion can lead to WHAT?

A

Dehydration
- This is bigger concern moreso for children and the elderly as this can have more severe consequences for this population (depending on the severity).

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3
Q

What are some red flags for diarrhea?

This is not an exhaustive list. There are more.

I have 9 listed but try to get at least 5 of them. :)

A
  • Blood or abnormal mucus in stool
  • Extensive abdominal cramping or pain
  • Fever > 38.5˚C
  • **Frail elderly
  • Young age (<2 y)**
  • Persistent or chronic diarrhea
  • Persistent vomiting for >4 h
  • Signs or symptoms of debilitating dehydration
  • Weight loss
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4
Q

List (5) Possible Causes to Diarrhea.

This can be associated with acute, persistent, and/or chronic diarrhea

A
  • Drug-Induced (chemo, radiation, broad-spectrum antibiotics, and other meds like metformin, etc.,)
  • Food (i.e., sensitivities or intolerances)
  • Stomach Flu (i.e., viral infections or GI infections)
  • Travel
  • **Irritable Bowel Syndrome (IBS) **

IBS will be discussed later on in its own section

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5
Q

What are some of the common causes of Sudden Diarrhea ?

We have 3 noted in this case

A
  • Food poisoning
  • Traveller’s Diarrhea
  • Stomach Flu (i.e., viral infection)
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6
Q

What are some common causes of Chronic Diarrhea?

4

A
  • Celiac Disease
  • Food sensitivities/intolerances (allergy, milk/soy protein intolerances)
  • IBS
  • Medications
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7
Q

Why is understanding the duration of diarrhea important?

A

So we can try to determine the specific etiology or cause if and when possible and treat appropriately - whether through the help of a pharmacist or an MD.
- This is one of the primary goals of therapy for diarrhea

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8
Q

When is comes to assessing diarrhea, what are the three (first) concerns we should make sure to know in case studies or assessing patients?

A
  • Age is a concern as children and elderly are ones we are more cautious about
  • Severity
  • Duration/How long have they had diarrhea for?
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9
Q

Which of the following is commonly defined as diarrhea?
a) Less than 3 loose stools per day
b) 3 or more loose stools per day
c) Less than 3 bowel movements per week
d) 3 or more hard stools per day

A

b) 3 or more loose stools per day

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10
Q

What is a possible complication of diarrhea?
a) Hypernatremia
b) Hypoglycemia
c) Hypotension
d) Hyperkalemia

A

c) Hypotension

Diarrhea can cause an imbalance in electrolytes… So should be watchful of electrolytes too in some cases. FYI: Hypokalemia is also a possible complication (not so much hyper-)

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11
Q

Depending on the etiology or cause of the diarrhea, treatment can vary a bit.

However, what are the three general treatments for many diarrhea cases?

A
  • Hydration
  • Immodium (Loperamide)
  • Pepto-Bismol (Bismuth Subsalicylate)
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12
Q

List some of the common drugs that can cause diarrhea.

I have 6 noted but there are a lot more.

A

Antibiotics
- Broad-Spectrum Antibiotics such as: penicillins, fluoroquinolones (FQs), cephalosporins and erythromycins
- Also, clindamycin, ampicillin and the cephalosporins are some antibiotics that are known to possible induce C. diff-induced diarrhea

Antihypertensives
- If diarrhea occurs, more concerns of hypotension, too.

Histamine (H2-) receptor antagonists
- Ranitidine, famotidine, etc.,

**NSAIDs **

Proton pump inhibitors (PPIs)

Selective serotonin reuptake inhibitor (SSRIs)

Antacids— Magnesium salts
- if too much magnesium is taken (as discussed before)

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13
Q

Possible Causes of Diarrhea

Drug-Induced Diarrhea accounts for what percentage of all adverse drug effects?

A

Approx. 7% of all adverse drug effects reported

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14
Q

Drug-Induced Diarrhea

Although things like antibiotics, SSRIs, H2 antagonists, NSAIDs, etc., often get attention on causing drug-induced diarrhea, there are many more drugs that are associated with the reported diarrhea-induced cases.

There are at least how many drugs out there that have reports to have caused diarrhea at one point or another?

A

More than 700 medications are known to cause diarrhea.

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15
Q

Drug-Induced Diarrhea

T/F: 20% of antibiotic users have reported to having diarrhea as an adverse effect.

A

True.
- Diarrhea is a common side effect reported when taking antibiotics.

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16
Q

Drug-Induced Diarrhea

What is a rare but worser outcome than antibiotic-induced diarrhea?

A

C. difficile
- Often sounds like typical case of ABX-induced diarrhea on the surface BUT hard to assess without lab tests (but most mild cases will not get labwork done)

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17
Q

Drug-Induced Diarrhea

A 45-yo lady comes to the pharmacy for the first time and asks you to fill a prescription. When building their profile on your system, you ask patient about allergies. Patient confirms she does have an allergy to Penicillin. When you ask more information, she said she had Pen-VK prescribed to her a few years ago and experienced a few days of diarrhea and it stopped within a day or two after she stopped taking it…

Is this an allergic reaction?

A

No, it’s was an adverse effect (based on the information provided).

  • Usually ABX-induced-diarrhea isn’t usually too bad; however, it is our job as pharmacists to kindly advise patient accordingly, empathize about their discomfort in the past, and offer solutions (adding loperamide) if penicillin is introduced again and if a more suitable option to use.
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18
Q

Drug-Induced Diarrhea

Approximately what percentage of people taking antibiotics report experiencing diarrhea?
a) 2%
b) 10%
c) 20%
d) 50%

A

c) 20%

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19
Q

Drug-Induced Diarrhea

T/F: Antibiotics can induce diarrhea by altering the bacterial flora in the gut

A

True!

20
Q

Drug-Induced Diarrhea

When does drug-induced diarrhea usually occur after starting antibiotic treatment?
a) Immediately
b) 1 week after
c) 2-3 days after
d) 1 month after

A

c) 2-3 days after

21
Q

Drug-Induced Diarrhea

A patient presents with diarrhea after starting antibiotic treatment. While antibiotics can cause diarrhea, which of the following class of antibiotics is not a prevalently known culprit associated with inducing diarrhea?

a) Aminoglycosides
b) Erythromycins
c) Fluoroquinolones (FQs)
d) Penicillins
e) Cepholosporins

A

a) Aminoglycosides
- It’s possible this ABX drug class might cause diarrhea; however, it is not as commonly known to cause diarrhea.

22
Q

Drug-Induced Diarrhea

T/F: C. difficile-associated diarrhea is a common consequence of antibiotic-induced diarrhea

A

False.
- It is a uncommon, rare consequence of antibiotic-induced diarrhea.
- But if it does happen, can be serious in some cases.

We will talk more about C. diff in upper years.

23
Q

Drug-Induced Diarrhea

What are the 3 General Recommendations for Drug-Induced Diarrhea?

A

**- Discontinue the drug **
- Change the dose - likely unable to do this w/ ABXs. If needed, would need to D/C drug and switch agent instead.
- Continue current therapy but add loperamide to counteract the side effects - least likely because many don’t want to add another agent.

24
Q

Antidiarrheal medications are indicated for:

Don’t just say “diarrhea”

A

Relief of debilitating symptoms that accompany diarrheal illness.
- There are a few antidiarrheal medications that can use… VERY IMPORTANT TO BE VERY FAMILIAR WITH THEM.

25
Q

Drug-Induced Diarrhea

What anti-diarrheal agent/drug could be used for drug-induced diarrhea?

Very important to know this!

A

Imodium (Loperamide)

  • Loperamide is the ONLY anti-motility/antidiarrhea medication indicated for drug-induced diarrhea.
26
Q

Drug-Induced Diarrhea

Do we actually like loperamide for drug-induced diarrhea?

A

Yes! It is a legitimate choice to consider (but if severe diarrhea, not going to do much).

  • Slows down diarrhea and the GI motility so can recover and ultimately get back to normal stools
  • Can add loperamide while taking an ABX if necessary and depending on factors.
  • In Canada, OTC fine print indicates approved for people ages 12+ (unless advised by an MD)
27
Q

Drug-Induced Diarrhea

Mechanism of Action:
**Imodium (Loperamide) **

A

Slows down the diarrhea, slows GI motility down so body can re-stabilize and delay hopefully can result in firmer stools with less diarrhea.

Loperamide is a synthetic opioid that primarily interacts w/ mu-opioid receptors within the gastrointestinal tract.

It inhibits the release of acetylcholine and prostaglandins, thereby reducing peristalsis and increasing the tone of the anal sphincter.

= Decreased motility and delays the transit time through the intestine, leading to increased absorption of water and electrolytes and ultimately, the formation of firmer stools and reduction in diarrhea.

28
Q

What is the minimum age of indicative use for Imodium (Loperamide) in Canada?

A

12 years (and older) - unless MD approves use for younger patients.

  • USA has approved for 6+ but Canada is not there yet and being cautious.
29
Q

Drug-Induced Diarrhea

Can loperamide be used for long-term therapy?

A

No, should only be used for short-term uses.

30
Q

Drug-Induced Diarrhea

SSRIs are one of the drug classes that are known to possibly cause diarrhea. In many cases, this occurs during initial therapy and/or dose increases.

Is loperamide a common add-on to counteract such side effects?

A

Not a common add-on; however, legalistically, it is okay.

  • Again, should not be used for long-term… If diarrhea doesn’t settle down after some time, might need to contact MD to modify the dose or switch to something else.
31
Q

Drug-Induced Diarrhea

Pepto-Bismol and Kaopectate are both forms of: Bismuth subsalicylate

Do we recommend for drug-induced diarrhea?

A

**No! Skip it! **

Loperamide is the only current antidiarrheal drug that is indicated for drug-induced diarrhea.

32
Q

Drug-Induced Diarrhea

When are probiotics deemed appropriate to consider for drug-induced diarrhea?

A

Only suggested/recommended for antibiotic uses.
- Replaces local bacteria destroyed by antibiotics.
- Should be used cautiously in patients who are immunosuppressed or have a badly damaged GI tract

33
Q

What is our hot take on probiotic use?

A

It’s okay to try but we are going to lower expectations. We are pretty skeptical about this one…
- We don’t know how much value it brings to the table
- We don’t even know which culture(s) and/or strain(s) to use (and the amounts of them)
- Just make sure to select the probiotics that indicates on their package that can help reduce chances of ABX-related diarrhea and go from there.

34
Q

Drug-Induced Diarrhea

List which items are okay to recommend for use in mild cases of drug-induced diarrhea.

A
  • Imodium (loperamide)
  • Probiotics (ABX only… Select the one where packaging says indicative for ABX use)

Also consider changing the dose (for non-antibiotics) OR changing the agents if possible.

35
Q

Drug-Induced Diarrhea

Can we consider the same intervention options for mild cases of drug-induced diarrhea for kids as we would with adults?

A

Not exactly. We are a bit more concerned about peds cases…

  • Imodium (loperamide) is not indicated for under 12 yo unless supervised by MD.
  • There is a Culturelle for Kids Probiotic on the shelves. Only for ABX uses, too.

We generally recommend TLC therapies (i.e. re-hydrating, replenish with electrolytes if needed, monitor what they are eating and/or drinking, changes in behaviour (red flags) and advise when it’s time to see an MD)

36
Q

Possible Causes of Diarrhea: Food-Related

Disagreeable Foods can vary and be

A

Culture-Specifics

Referring to multi-cultural factors… Not probiotics FYI LOL

37
Q

Food-Induced Diarrhea: Culture Specific/Disagreeable Foods

When we talk about food-induced diarrhea that is culture-specific, if bacteria is not the cause of concern in such cases, what are the likely culprits of this kind of diarrhea?

Disagreeable Foods

A

Irritants and/or Natural Laxatives

Not caused by bacteria in Disagreeable Foods

38
Q

Food-Induced Diarrhea

Foods that contain large amounts of what components can cause osmotic diarrhea?

A

Foods that contain large amounts of sorbitol or mannitol

39
Q

What are examples of foods that contain high amounts of either sorbitol or mannitol?

A

Prunes
Apples
Rhubarb
Butternut Squash

40
Q

Disagreeable Foods

List some of the treatment options can consider for food-induced diarrhea that is related to Disagreeable Foods.

A
  • Imodium (loperamide)
  • Pepto-Bismol (bismuth)
  • H2 antagonists (e.g., ranitine, famotidine, etc.) is also possible.
41
Q

Disagreeable Food

Among the possible treatments for diarrhea related to disagreeable foods, which is our number one or preferred choice?

A

Imodium (loperamide) is our drug of choice for incidences related to disagreeable foods.

42
Q

Disagreeable Foods

When would Pepto-Bismol or Kaopectate (bismuth) a good option or more focused for when related to disagreeable foods?

A

Over-Indulgence.

43
Q

How does bismuth (pepto-bismol or kaopectate) help with disagreeable foods when over-indulging?

2 things

A
  • Bismuth compounds can reduce the secretion of fluid and electrolytes into the gastrointestinal tract, thereby helping to alleviate symptoms of diarrhea. Basically so not as much fluid is secreted into the GI Tract.
  • Mucosal Protection: Bismuth compounds form a protective layer over the inflamed gastrointestinal mucosa, providing a barrier against irritants among other things.
  • Works as a mild antacid and tries to protect the stomach a bit
44
Q
A
45
Q

Food-Induced: Food Allergies

Where does a pharmacist fit in when it comes to addressing Food Allergies?

A

We aren’t involved in this process!
- Diarrhea is not in our radar as being related to food allergies.
- Due to proteins, no bacteria involvement

Only if dispensing Epi-Pens

PHAR 154 - Self-Care II -A (7 decks)

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