CH. 40: Drug Therapy for Diarrhea

Diarrhea:

an increase in liquid consistency of stool or a frequency of stools more than 3 times a day

Clinical Manifestations for Diarrhea:

• can be an acute issue or chronic; can vary from mild to severe

• acute episodes generally occur when the body tries to rid itself of infectious agents, toxins, and irritants

  • will usually resolve in 24-48 hours

  • prolonged acute diarrhea can lead to fluid and electrolyte imbalances, especially in children and older adults

Chronic Diarrhea:

can lead to malnutrition and anemia and may have remissions and exacerbations

Bowel Disorders:

irritable bowel syndrome (IBS)

Crohn’s disease

ulcerative colitis

Diverticulitis

Antibiotic-Associated Colitis:

caused when antibiotics suppress the normal flora in the colon and allow the proliferation of other bacteria

Non-pharmacological Therapy for Diarrhea

• when diarrhea is not severe treatment will include replacement of fluids lost

  • acceptable liquids during the first 24 hours include clear liquids (broth, ginger ale, gelatin, tea, or decaffeinated sodas) 2-3 Liters

  • diet should include bland foods (rice, saltine crackers, applesauce, broth based soup, bread, and baked potatoes

  • a regular diet can be resumed after 2-3 days

Drug Therapy for Diarrhea:

• the most effective agents used to treat diarrhea are opiates and opiate derivatives

  • morphine and codeine rarely used for this because of associated adverse effects

  • other non-opiate medications may be used

Opiate-Related Antidiarrheal Agents

Prototype Diphenoxylate with Atropine (Lomotil):

• works by slowing peristalsis; acts on the smooth muscles of the intestine

• schedule V controlled substance:

  • requires a prescription; use carefully in patients with a history of substance abuse

Diphenoxylate with Atropine (Lomotil):

prototype for opiate-related antidiarrheal agents

Pharmacokinetics for Opiate-Related Antidiarrheal Agents

Prototype Diphenoxylate with Atropine (Lomotil):

• well absorbed by the oral route

• metabolized in the liver

• excreted in bile and feces

What to Be Aware of in Pediatric Patients When Using Opiate-Related Antidiarrheal Agents

Prototype Diphenoxylate with Atropine (Lomotil):

• monitor for signs of nervous system depression

• children under 2 should not take; from age 2-13 use liquid preparation to ensure accurate dosing

• large doses of anticholinergics may produce paradoxical hyperexcitability

• the oral solution may contain 15% alcohol

What to Be Aware of in Older Adults When Using Opiate-Related Antidiarrheal Agents

Prototype Diphenoxylate with Atropine (Lomotil):

• diarrhea may occur from laxative abuse or bowel-cleansing procedures before surgery or test-know the cause of diarrhea

• fluid volume deficits may develop rapidly in older adults with diarrhea-check for dehydration

• cautious use is indicated to avoid inducing constipation

What to Be Aware of in Critically Ill Patients When Using Opiate-Related Antidiarrheal Agents

Prototype Diphenoxylate with Atropine (Lomotil):

• caution should be used cause patient may have renal or hepatic compromise

• watch extremely closely for fluid/electrolyte imabalance

• determine cause of diarrhea before treating

What to Be Aware of in Patients With Hepatic Impairment When Using Opiate-Related Antidiarrheal Agents

Prototype Diphenoxylate with Atropine (Lomotil):

• use of this med warrants extreme caution; hepatic coma may be precipitated

• care is also necessary in patients with abnormal liver function tests

Nursing Implications for Opiate-related Antidiarrheal Agents: Preventing Interactions

Prototype Diphenoxylate with Atropine (Lomotil):

• use of methotrimeprazine and pramlintide can result in increased levels of Lomotil

• use of acetylcholinesterase inhibitors can lead to decreased drug levels

• use of alcohol may increase central nervous system (CNS) depression

Nursing Implications for Opiate-related Antidiarrheal Agents: Medication Administration

Prototype Diphenoxylate with Atropine (Lomotil):

• administered orally

• contraindicated in diarrhea cause by toxic materials, organisms that may penetrate the intestinal mucosa, and antibiotic-associated colitis

Nursing Implications for Opiate-related Antidiarrheal Agents: Adverse Effects

Prototype Diphenoxylate with Atropine (Lomotil):

• tachycardia

• headaches

• dizziness

• flushing

• nausea

• vomiting

• urinary retention

• dry skin/mucous membranes

• with higher than ordered doses hypotension and respiratory depression can occur

Loperamide (Imodium A-D):

• acts by decreasing gastrointestinal (GI) motility

• does not cause CNS effects and no potential for abuse; available OTC

• black box warning: torsades de pointes, cardiac arrest and death have been reported in people using higher than recommended doses

  • treatment of overdose may include Naloxone (Narcan), gastric lavage and administering activated charcoal

Paregoric:

• schedule III drug alone and a schedule V when combined in small amounts with other drugs

• acts by increasing muscular tone of the intestines inhibiting normal peristalsis; also used as a cough suppressant

  • only recommended for short term use and does not produce. analgesia, dependence, or euphoria

Adjuvant Medications Used to Treat Diarrhea: Bismuth Salts

• Bismuth subsalicylate (Pepto-Bismol)

• OTC medication that acts as an antisecretory and anti-inflammatory

  • will cause tongue and/or stools to have a temporary darkening in color

  • should not be taken if the patient can not take aspirin products

Adjuvant Medications Used to Treat Diarrhea: Octreotide acetate (Sandostatin):

• decreases GI secretion and motility

• use for intestinal tumors, diarrhea associated with carcinoid syndrome or HIV, and diarrhea that is not responding to other antidiarrheal drugs

• adverse effects can include cardiac dysrhythmias, diarrhea, and headache

Adjuvant Medications Used to Treat Diarrhea: Polycarbophil (FiberCon) and psyllium

occasionally used to absorb toxins and water associated with diarrhea making the stool have a gelatin consistency

Additional Medications Used to Treat Diarrhea: Bile-Binding Agents

Cholestyramine (Questran) and colestipol (Colestid) used to treat bile salt accumulation from Crohn’s disease or surgical excision of the ileum

Additional Medications Used to Treat Diarrhea: Enzymatic Replacement:

Pancreatin or Pancrelipase (Viokase, Pancrease, Cotazym) used for pancreatic enzyme deficiency that results in malabsorption and steatorrhea

Additional Medications Used to Treat Diarrhea: Antibacterial Drugs

• Rifaximin (Xifaxan): broad spectrum antibiotic often used to treat travelers’ diarrhea

• Nitazoxanide (Alinia): an antiprotozoal drug used to treat diarrhea resulting from giardia lamblia and cryptosporidium parvum

Additional Medications Used to Treat Diarrhea: Selective 5-HT# Receptor Antagonist

• Alosetron (Lotronex): used to treat women with chronic severe diarrhea IBS that has not responded to conventional treatment

• safety and efficacy has not been determined in men

• black box warning for the developmental of obstruction, perforation, hemorrhage, and ischemic colitis