OTC Nausea, Vomiting & Diarrhea: Treatments and Referral Criteria

What is the drug class and mechanism of action for Loperamide?

A synthetic opioid agonist that stimulates peripheral micro-opioid receptors on the intestinal circular muscles to slow intestinal motility.

What symptoms does Loperamide treat?

Acute non-specific diarrhea, chronic diarrhea (IBS, IBD), and is used for traveler's diarrhea prophylaxis and treatment.

Loperamide Brand Name

(Imodium)

What are the pros of using Loperamide?

Safe and well tolerated in most patient populations, including pregnant women, and is effective for managing diarrhea.

What are the cautions associated with Loperamide?

Should not be used as monotherapy for bacterial diarrhea, has a risk of toxic megacolon if used for Clostridium difficile, and can be abused at high doses.

What is a serious risk associated with high doses of Loperamide?

High doses can lead to cardiovascular complications and death.

What is the maximum prescription dose of Loperamide?

16 mg/day (8 tablets).

What are the common side effects of Loperamide?

Common side effects include constipation and potentially black hairy tongue and stool.

What is Bismuth subsalicylate used for?

Used for nausea, diarrhea, fullness, heartburn, and prevention of traveler's diarrhea.

What age group can use Bismuth subsalicylate?

Individuals aged 12 years and older.

What are the cautions when using Bismuth subsalicylate?

Can increase bleeding risk in patients on warfarin or blood thinners due to its salicylate content.

What are the contraindications for Bismuth subsalicylate?

Children/teenagers (risk of Reyes syndrome), Salicylate allergy and Pregnancy and lactation

What is the mechanism of action for Bismuth subsalicylate?

Antisecretory effects mediated by inhibition of PG synthesis that inhibits intestinal secretions through sodium and chloride GI reabsorption + Antimicrobial properties (used in combination for H. pylori treatment)

Antimicrobial properties (used in combination for H. pylori treatment)

What is the dose-related side effect of Bismuth subsalicylate?

Mild tinnitus

What is the recommendation for Loperamide use duration?

Should be limited to a maximum of 2 days of use for acute diarrhea according to FDA guidelines.

What should Loperamide not be used for?

Should not be used for treating diarrhea caused by Clostridium difficile due to the risk of toxic megacolon.

What is the risk of using high doses of Loperamide with certain drugs?

Can increase the risk of cardiovascular events when taken with other CYP450 metabolized drugs.

What is the recommended use of Loperamide for chronic conditions?

Under medical direction, Loperamide may be used longer for chronic inflammatory bowel disease and irritable bowel disease.

What are the common side effects of Phosphorated carbohydrate solution

Nausea, vomiting, diarrhea, and hyperglycemia in diabetics. (dose dependent)

What is the mechanism of action for Phosphorated carbohydrate solution?

It decreases smooth muscle contractions in the GI tract that can lead to vomiting.

What is the recommended age for using Meclizine?

Marketed for individuals aged 12 and older.

What are the pros of using Meclizine for nausea?

It has a long duration of action and is typically less sedating than other antihistamines.

What are the cons of using Dimenhydrinate?

Requires dosing every 4-6 hours and may cause sedation.

What precautions should be taken when using antihistamines for nausea?

Avoid alcohol and other sedating drugs; do not drive or perform tasks requiring mental alertness.

What are the anticholinergic side effects of antihistamines?

Dry eyes, urinary retention, dry mouth, constipation, sedation, and cognitive impairment.

What is the recommended use of Lactase supplements?

Used for lactose-induced diarrhea in individuals aged 4 and up.

What is the role of probiotics in treating diarrhea?

They recolonize intestinal flora with good bacteria but are not recommended for general patients.

What is the purpose of Oral Rehydration Solutions (ORS)?

To treat dehydration due to diarrhea or vomiting by supplying electrolyte solutes.

What should be avoided when using ORS?

Avoid sugary liquids like regular Gatorade or fruit juice that can cause osmotic diarrhea.

What are the pros of using Pedialyte for rehydration?

Comes in liquid and popsicle forms, safe for all ages, and effective for rehydration.

What is a caution regarding the sugar to sodium ratio in ORS products?

Many products may have a higher sugar to sodium ratio than recommended for rehydration.

What is the maximum dose for liquid Bismuth subsalicylate?

Max 5 doses in 1 hour.

What is the recommended age for using Dimenhydrinate?

Approved for use in children aged 2 and older.

What should patients be counseled about when taking antihistamines?

Take 30-60 minutes before motion to prevent nausea.

What are the side effects of antihistamines in older adults?

Increased risk of sedation, cognitive impairment, and paradoxical reactions.

What is the dosing for Lactase supplements?

Recommended for individuals aged 4 and up.

What is the effect of sodium citrate dihydrate chewable tablets?

Acts as a buffering agent that neutralizes HCl and increases pH.

What is the contraindication for antihistamines in breastfeeding?

Can pass to the baby, causing paradoxical effects and possibly seizures.

What is the dosing for Meclizine?

Typically dosed once daily.

What is recommended to avoid diarrhea?

Pedialyte, Gaterlyte, Liquid IV Hydration Multiplier, Gatorade G2 with 7-9g sugars in 12 oz (360 mL) fluid.

What is the effective dose of ginger for nausea?

1000-2000 mg daily in divided doses.

What are the side effects of high doses of ginger?

Increased risk of bleeding, mild GI effects (heartburn, diarrhea, mouth irritation).

How should Liquid IV hydration multiplier packets be prepared?

Mixed with 16 oz of water to achieve the right concentration.

What is the role of pyridoxine (B6) and doxylamine in treating morning sickness?

They are first-line therapy for nausea and vomiting associated with pregnancy.

What are the pros of using pyridoxine and doxylamine?

Effective for nausea and vomiting in pregnancy; available as a combination product.

What are the cons of using pyridoxine and doxylamine?

Needs to be taken multiple times a day for continuous relief.

What is the acupressure point for nausea relief?

Located 3 finger widths from the center crease of the wrist at the P6 point.

What are the pros of acupressure?

It is a non-drug option suitable for all patient populations, including pregnant women.

What are the cons of acupressure?

Efficacy is unclear due to variance in dosing regimens; electronic acupressure not recommended for patients with pacemakers.

What do H2RAs and antacids do in relation to nausea?

They reduce acid which may help reduce nausea associated with indigestion but do not directly treat vomiting.

What are the signs of moderate-severe dehydration?

Sunken eyes, severe drowsiness, dizziness, muscle pain, confusion, decreased skin turgor, dry mucous membranes, weakness, lack of urination.

What are the referral criteria for nausea and vomiting in adults?

Signs of moderate-severe dehydration, urine ketones in diabetes, suspected food poisoning, severe abdominal pain, persistent diarrhea with fever.

What are the referral criteria for nausea and vomiting in children?

Signs of severe dehydration, caregiver unable to manage at home, vomiting with each feeding, lethargy, or refusal to drink fluids.

What are the referral criteria for diarrhea?

Age

What is the recommended OTC dosing for pyridoxine and doxylamine?

25 mg B6 + 12.5 mg doxylamine (1/2 Unisom) every 8 hours.

What is the prescription dosing for the combination product of pyridoxine and doxylamine?

10 mg/10 mg: three to four times a day.

What should be considered if symptoms of nausea and vomiting do not resolve in 24-48 hours?

Referral may be necessary for IV fluids if unable to hold down fluids and showing signs of moderate dehydration.

What is the effect of ginger ale on nausea?

Ginger ale contains insignificant amounts of ginger and large amounts of sugar, which could contribute to diarrhea if consumed in large quantities.

Is ginger safe for pregnant women?

Yes, ginger in food is safe, but there is no data for supplements in pregnant women.

Loperamide and Pregnancy

Pregnant women: safe

Lactating women: likely safe for 2 days of use, but data are lacking

Bismuth subsalicylate Brand Name

(Pepto Bismol)

Bismuth subsalicylate (Pepto Bismol) Treats

Traveler's diarrhea prophylaxis and treatment and Nausea associated with indulgence of food and beverages

Meclizine Brand Name

(Bonine, Dramamine Less Drowsy)

Dimenhydrinate Brand Name

(Dramamine)

Lactase Brand Name

(Lactaid)

Lactase Treats

Lactose (food)-induced diarrhea

Probiotic supplements MOA

Recolonizes intestinal flora with good bacteria

Probiotic supplements Treat

Diarrhea

Oral rehydration solution (ORS) Brand Names

Pedialyte, Gaterlyte, Gatorade G2/Liquid IV Hydration Multiplier

Probiotic supplements Names

Bifidobacterium

Lactobacillus

Saccharomyces

Streptococcus

Ginger Brand Name

(Dramamine Natural)

OTC 25 mg B6 + 12.5mg doxylamine

(1/2 Unisom)

Lactase Brand Name

(Lactaid)

Lactase MOA

Lactase enzymes break down lactose, a disaccharide, into the monosaccharides glucose and galactose, which are absorbed

Lactase (Lactaid) Treats

Prevention of gas, diarrhea, bloating, gas pain/cramps, and nausea associated with eating dairy products