Diarrhea

Diarrhea goals of self-treatment

1. Prevent or correct fluid and electrolyte loss and acid-base disturbance 2. Control Symptoms 3. Identify and treat the cause 4. Prevent acute morbidity and mortality

Bismuth salicylate is not recommended for children less than ____ years old unless recommended by PCP due to risk of Reye's syndrome

12

Bismuth Subsalicylates (Brand: Kaopectate, PeptoBismol): Duration of use

48 hours

Loperamide (Imodium) duration of use

48 hours

What are advantages and disadvantages to using "household fluids" like chicken broth, cola or ginger ale for rehydration?

A variety of common household oral solutions have also been used for oral rehydration and maintenance These solutions may be sufficient to manage mild, self-limiting diarrhea in some patients, but they should be avoided if dehydration or moderate-severe diarrhea is present. Unlike commercial ORS, these remedies are not formulated on the basis of the physiology of acute diarrhea. The inappropriately high carbohydrate content and osmolality of these solutions can worsen diarrhea, and their low sodium content can contribute to the development of hyponatremia. Sports drinks may be used in children older than 5 years and adults if additional sources of sodium, such as crackers or pretzels, are used concomitantly. Tea, another popular household remedy, is also inappropriate for children because of its low sodium content. Chicken broth is not recommended because of its inappropriately high sodium content.

Outline general concepts of patient education for each type of condition and each treatment plan. a. Nondrug measures for infants and children (6mo-5yo) b. Nondrug measures for individuals > 5 yo.

A: a. Nondrug measures for infants and children (6mo-5yo) 1. For mild-moderate diarrhea, indicated by three to five unformed bowel movements per day, give the child or infant an oral rehydration solution (ORS) at a volume of 50-100 mL/kg of body weight over 2-4 hours to replace the fluid deficit. Give additional ORS to replace ongoing losses. Continue to give the solution for the next 4-6 hours or until the child is rehydrated. 2. If the child is vomiting, give 1 teaspoon of ORS every few minutes. 3. If the child is not dehydrated, give 10 mL/kg or ½-1 cup of the ORS for each bowel movement, or 2 mL/kg for each episode of vomiting. As an alternative, to replace ongoing fluid losses, children weighing less than 10 kg should be given 60-120 mL of ORS for each episode of vomiting or diarrheal stool, and children weighing more than 10 kg should be given 120-240 mL for each episode of vomiting or diarrheal stool. 4. After the child is rehydrated, reintroduce food appropriate for the child's age, while also administering an ORS as maintenance therapy. 5. If breast-feeding an infant with diarrhea, continue the breast-feeding. If the infant is bottle-fed, consult your primary care provider or pediatrician about replacing a milk-based formula with a lactose-free formula. 6. Give children complex carbohydrate-rich foods, yogurt, lean meats, fruits, and vegetables. Do not give them fatty foods or sugary foods. Sugary foods can cause osmotic diarrhea.. 7. Do not withhold food for more than 24 hours. B: a. Nondrug measures for individuals > 5 yo. 1. For mild-moderate dehydration, indicated by a 3%-9% drop in body weight or three to five unformed stools per day, drink 2-4 liters of an ORS over 4 hours. 2. If not dehydrated, drink ½-1 cup of ORS or fluids after each unformed bowel movement. 3. If no medical conditions exist, sports drinks (with salty crackers, etc.), diluted juices, soups, and broths may be consumed until the diarrhea stops. 4. Do not withhold food for more than 24 hours.

___________ is defined as symptoms lasting less than 14 days, can generally be managed with fluid and electrolyte replacement, dietary interventions, and nonprescription drug treatment.

Acute diarrhea

Loperamide (Imodium) Adult and Peds Dosage

Adult: 4mg initially, then 2mg after each loose stool (not to exceed 8mg/day) Pediatric: • <6 years old: not recommended unless PCP consulted • 6-8 years old (48-59 lb): 2mg initially, then 1mg after each loose stool (not to exceed 4mg/day) • 9-11 years old (60-95 lbs): 2mg initially, then 1mg after each loose stool (not to exceed 6mg/day)

Digestive Enzymes (Lactase): Dose

Adult: • Dose may vary depending on degree of lactose intolerance and amt of lactase in product Peds: Lactaid not recommended in children < 4; dosage same as adult dose for older children

Bismuth Subsalicylates (Brand: Kaopectate, PeptoBismol): Dose for adult and Peds

Adult: • Tablets: 525mg every 30-60min up to 4200mg/day (not to exceed 8 doses/day • Liquid: 525mg-1025mg every 60 min up to 4200mg/day (4-8 doses/day depending on concentration used) Pediatric: • Not recommended for children <12 years old

What is the role of pharmacologic therapy in managing diarrhea?

Although most acute, nonspecific diarrhea in the United States is self-limiting, nonprescription antidiarrheal products may provide symptom control and will usually do no harm when used according to label instructions. Loperamide is best. No antidiarrheal drugs have been shown to significantly improve clinical outcomes of acute, nonspecific diarrhea in infants and children ages 5 years and younger.

Identify common medications associated with diarrhea (responsible for the top 100 agents).

Anti-allergy: fexofenadine, montelukast; AntidepressantsEscitalopram, fluoxetine, sertraline; Anti-infectives: amoxicillin, azithromycin, ciprofloxacin, valacyclovir; Bisphosphonate: alendronate; Cardiovascular agents: carvedilol, digoxin, enoxaparin, metoprolol, potassium chloride, spironolactone; Cholesterol-lowering agents: atorvastatin, ezetimibe, lovastatin, pravastatin; Diabetes medication: metformin; Heartburn agents: lansoprazole, omeprazole; Sedative: zolpidem

Bacteria

Bacterial pathogens cause approximately 10% of acute diarrheal illnesses each year; most cases result from food-borne transmission. Bacteria cause diarrhea through elaboration of enterotoxin, by attachment and production of localized inflammatory changes in the gut or by directly invading the mucosal epithelial cells.

Compare and contrast viral, bacterial, and protozoal classifications of diarrhea

Big chart too much info idc

______ is contraindicated in AIDS patients with acute diarrhea and also Contraindicated in pregnancy

Bismuth salicylate

ORS Approach for Mild-moderate dehydration: Maintenance Oral Rehydration

Children <6 mo.-5 years Continue for 4-6 hrs or until rehydrated Infants: resume breast-feeding, formula, or milk Children: resume age-appropriate foods Replace ongoing fluid/electrolyte losses with dextrose-electrolyte solution >5 years of age Continue ORS as needed

ORS Approach for Mild-moderate dehydration: Acute Oral Rehydration

Children <6 mo.-5 years • 50-100 mL/kg over 3-4 hrs • Give 10 mL/kg for each loose stool • Give small volumes (1-2 tsp every 1-2 mins) if child vomits to improve tolerability >5 years of age 2-4 L over 3 hrs and replace ongoing losses of body fluids/electrolytes + start symptomatic drug therapy

_________ by definition, lasts more than 4 weeks

Chronic diarrhea

Diarrhea is a symptom characterized by an abnormal increase in stool frequency, liquidity, or weight. having more than 3 bowel movements per day is considered abnormal.

Diarrhea

Protozoa

Diarrhea may also be caused by protozoa, including Giardia lamblia, Entamoeba histolytica, Isospora belli, and Cryptosporidium spp. No nonprescription therapies are available to manage diarrhea caused by these pathogens, and self-management is inappropriate.

Digestive Enzymes (Lactase): MOA

Digestive enzyme

Diarrhea Exclusion criteria

Failure to self-treat after 48 hours of ORS Symptoms remain the same or worsen after 48 hours Young age (< 6 months or weight <17.5 lbs or 8 kg) High fever (refer to fever handout) Visible blood, pus, or mucus in stool High output, including frequent and substantial volumes of diarrhea Multiple Vomiting beyond 24 hours Persistent vomiting Signs of severe dehydration o Children showing behavioral/mental changes (irritability, apathy, lethargy, unconscious) o Children who have not urinated in 8 hours o Children who have no tears when crying Severe abdominal pain/distress Suboptimal response to ORS already administered Risk for significant complications, including chronic medical conditions or concurrent illness o Diabetes, severe CVD, renal disease oImmunosuppressed patients o Frail patients ³ 65 years old Pregnancy Chronic or persistent diarrhea (lasting 14 days)

Compare and contrast food-borne, traveler's, and food-induced diarrhea.

Food-borne Recent surveillance statistics on the incidence of foodborne illnesses confirm that Salmonella and Campylobacter which caused 15.45 and 13.45 cases of illness per 100,000 population in 2012 When pathogens are identified, 59% of those infections are caused by viruses (predominantly noroviruses), 39% by bacteria, and 2% by protozoa Outbreaks of foodborne bacterial infection have been traced to poor sanitation and manufacturing practices in food production facilities and contamination of foods in various community locations, such as grocery stores and restaurants. Travelers Travelers' diarrhea is an acute, secretory diarrhea acquired mainly through ingestion of contaminated food or water. It is usually caused by bacterial enteropathogens; The causative organisms are found most often on foods such as fruits, vegetables, raw meat, seafood, and hot sauces. Pathogens may also be found in the local water, including ice cubes made from local tap water. Food-induced bacteria: Food intolerance can provoke diarrhea and may result from a food allergy or ingestion of foods that are excessively fatty or spicy or contain a high amount of dietary fiber or many seeds. Dietary carbohydrates (e.g., lactose, sucrose) are normally hydrolyzed to monosaccharides by the enzyme lactase. If not hydrolyzed, these carbohydrates pool in the lumen of the intestine and produce an osmotic imbalance. The resulting hyperosmolarity draws fluid into the intestinal lumen, causing diarrhea. Lactase activity may be reduced by infectious diarrhea; thus, acute viral diarrhea may cause temporary milk intolerance in patients of all ages.

Digestive Enzymes (Lactase): Duration of use

If lactose intolerant - take with each time dairy is ingested

When is diarrhea contagious? What can be done to prevent transmission?

Infectious diarrhea, especially acute viral gastroenteritis, often occurs in congregate living conditions such as daycare centers and nursing homes through person-to-person transmission. Isolating the individual with diarrhea, washing hands, and using sterile techniques are basic preventive measures that reduce the risk of transmission among such populations and their caregivers. Strict food handling, sanitation, and other hygienic practices help control transmission of bacteria and other infectious agents.

What probiotics may be used to manage or prevent acute uncomplicated diarrhea. (Note, since probiotics are not FDA approved pharmacists should not recommend them for the treatment or prevention of acute diarrhea per se—rather their use can be recommended for maintenance of GI function)

Lactobacillus species, Bifidobacterium lactis and Saccharomyces boulardii are effective in preventing and treating mild acute, uncomplicated diarrhea, in previously healthy infants and children, especially rotavirus diarrhea and antibiotic-associated diarrhea. Convincing evidence suggests that probiotics, including several Lactobacillus species, Bifidobacterium lactis, and Saccharomyces boulardii, are effective in preventing and treating mild acute, uncomplicated diarrhea, especially rotavirus diarrhea in children.(Note, since probiotics are not FDA approved pharmacists should not recommend them for the treatment or prevention of acute diarrhea per se—rather their use can be recommended for maintenance of GI function)

Bismuth Subsalicylates (Brand: Kaopectate, PeptoBismol): counseling points

May interfere with radiographic intestinal studies Can cause harmless black staining of stool and darkening of the tongue (can be removed by brushing the tongue with a soft-bristled brush)

How should dietary intake be adjusted when acute diarrhea occurs? What "myths" regarding dietary changes should be avoided?

Most infants and children with acute diarrhea can tolerate full-strength breast milk and cow milk. Patients (or their parents) should be advised to avoid fatty foods, foods rich in simple sugars (e.g., carbonated soft drinks, juice, gelatin desserts) that can cause osmotic diarrhea, spicy foods that may cause GI upset, and caffeine-containing beverages, which can promote fluid secretion and may worsen diarrhea. Oral intake does not worsen diarrhea, and clinically significant nutrient malabsorption is uncommon in acute diarrhea. In fact, during acute diarrhea, patients are able to absorb 80%-95% of dietary carbohydrates, 70% of fat, and 75% of the nitrogen from protein. Furthermore, early refeeding, in combination with maintenance oral rehydration, improves outcomes in children by reducing the duration of the diarrhea, reducing stool output, and improving weight gain. Current guidelines recommend withholding food no longer than 24 hours and encourage the reintroduction of a normal, age-appropriate diet once the patient has been rehydrated, which should take no longer than 3-4 hours to accomplish. Most infants and children with acute diarrhea can tolerate full-strength breast milk and cow milk. Myths: The BRAT diet (bananas, rice, applesauce, and toast) is not recommended; it provides insufficient calories, protein, and fat, especially in situations of strict or prolonged use. Patients (or their parents) should be advised to avoid fatty foods, foods rich in simple sugars (e.g., carbonated soft drinks, juice, gelatin desserts) that can cause osmotic diarrhea, spicy foods that may cause GI upset, and caffeine-containing beverages, which can promote fluid secretion and may worsen diarrhea.

Digestive Enzymes (Lactase): Contraindications

None

What are the risks and benefits of using loperamide in children 2-6 years old with acute diarrheal illness?

Nonprescription loperamide is labeled for use in children 6 years of age and older; the product information for prescription loperamide provides directions for use in children as young as 2 years of age. However, use of loperamide in children younger than 6 years is not recommended because it produces only modest, clinically insignificant effects on stool volume and duration of illness, with an unacceptably high risk of side effects, including life-threatening ileus and toxic megacolon.

What is the typical course of illness for diarrhea?

Often self-limiting, resolving within 24-72 hours without additional treatment.

Under what circumstances are oral rehydration solutions optional? When are they recommended for use?

Optional: Although ORS is generally recommended for adults with diarrhea, little evidence supports this use, and ORS may not provide any real benefit to otherwise healthy adults with mild diarrhea who can maintain an adequate fluid intake during the episode of diarrhea. Recommended: dehydration using ORS is the preferred treatment for mild-moderate diarrhea. This approach is as effective as I.V. therapy in managing fluid and electrolytes in children with mild-moderate dehydration secondary to diarrhea. Health care providers can safely recommend an ORS for mild-moderate diarrhea in patients with no exclusions to self-care.

Cereal-based ORS Pros and Cons

PROS Reduces stool volume in cholea CONS May not alter stool volume in children with noncholera acute diarrhea

ORS Powder Pros and Cons

PROS • 75 mEq/L of sodium can reduce duration of diarrhea, stool output and incidence of vomiting CONS • Improper mixing for children can lead to electrolyte complications and injury

In persistent diarrhea, symptoms last 14 days to 4 weeks

Persistent diarrhea

Loperamide (Imodium) counseling points

Potential for abuse or misuse at higher than recommended doses, encourage safe use

Types of ORS

Powder Pre-mixed Cereal based

Pre-mixed ORS Pros and Cons

Pros: • Preferred over powder for children - safe and convenient • 75 mEq/L of sodium can reduce duration of diarrhea, stool output and incidence of vomiting NO CONS

Describe how you would approach treatment of acute diarrhea in each of the following types of patients. What would you recommend to the patient for self-treatment and what would you recommend to a health care provider who asked for your advice? a. Children < 6 months of age b. Children 6 months to 5 years of age c. An otherwise healthy adult patient d. Patients greater than 65 yo e. Pregnant patient

a. Children < 6 months of age For young children (5 years and younger), self-treatment is limited to treating dehydration with ORS; antidiarrheal medications are not recommended. If diarrhea persists despite oral rehydration therapy, a primary care provider or pediatrician must be consulted. Follow ORS guidelines above. b. Children 6 months to 5 years of age For young children (5 years and younger), self-treatment is limited to treating dehydration with ORS; antidiarrheal medications are not recommended. If diarrhea persists despite oral rehydration therapy, a primary care provider or pediatrician must be consulted. Follow ORS guidelines above. c. An otherwise healthy adult patient Initial self-management for adults and children with mild-moderate, uncomplicated diarrhea should focus on fluid and electrolyte replacement by administering commercially available oral rehydration solutions (ORS) in adequate doses. Simultaneous implementation of oral rehydration and specific dietary measures is appropriate for treating mild-moderate diarrheal illness. Symptomatic control can also be achieved by using nonprescription antidiarrheal drugs, such as loperamide, in carefully selected patients d. Patients greater than 65 yo Elderly patients (65 years and older) should be strongly cautioned against self-treatment with antidiarrheal medications. Diarrhea in these patients is more likely to be severe or possibly fatal; therefore, these patients should be referred for medical evaluation. e. Pregnant patient Use of nonprescription antidiarrheals may be inappropriate during pregnancy; therefore, pregnant women should also be referred for medical evaluation before self-treating. Both loperamide and BSS are classified as Pregnancy Category C drugs. BSS-containing products are contraindicated during pregnancy because of concerns that the salicylate component may inhibit platelet function and, in the third trimester, cause premature closure of the fetal ductus arteriosus. Nursing women should generally avoid BSS.

Viral

a. Noroviruses are the most common cause of diarrhea in adults and the second most common cause in children. They cause more than 90% of epidemic viral gastroenteritis and approximately 50% of all-cause epidemic gastroenteritis worldwide. Although the virus is most often transmitted by contaminated water or food, it can also be transmitted from person to person and through contact with contaminated environmental surfaces. Outbreaks of norovirus gastroenteritis frequently occur in certain populations, such as restaurant patrons, cruise ship passengers, students on college campuses, residents of long-term care facilities and hospitals, military personnel, and immunocompromised patients. b. Rotavirus is the most common cause of severe gastroenteritis in infants and young children worldwide. In the United States, prior to widespread rotavirus vaccine administration, approximately 80% of children developed rotavirus gastroenteritis before reaching 5 years of age. Rotavirus tends to be a seasonal infection, with peaks of gastroenteritis occurring between November and February. It is spread by the fecal-oral route, can cause severe dehydration and electrolyte disturbances, and may result in death

Describe symptoms of mild-to-moderate dehydration and severe dehydration.

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Bismuth Subsalicylates (brand: Kaopectate, PeptoBismol): Indications

• Acute diarrhea including travelers' diarrhea in adults and children >12 years old • Indigestion • Adjuvant to antibiotics for treating H. pyloriassociated peptic ulcer disease

Loperamide (brand: Imodium): Indication

• Acute, nonspecific diarrhea • Travelers' diarrhea when used in combination with antibiotics • Chronic diarrhea associated with IBS and IBD • Reducing volume of high-output ileostomies

Bismuth Subsalicylates (brand: Kaopectate, PeptoBismol): Adverse effects

• Dose related mild tinnitus (discontinue if occurs - sign of salicylate toxicity) • RARE - bismuth-related neurotoxicity (slow onset tremors, postural instability, ataxia, myoclonus, poor concentration, confusion, memory impairment, seizures, visual and auditory hallucinations, psychosis, delirium, depression, death)

Bismuth Subsalicylates (brand: Kaopectate, PeptoBismol): MOA

• Forms bismuth oxychloride and salicylic acid in presence of gastric acid. Both components are biologically active • Antibacterial action • Antisecretory actions due to inhibition of prostaglandins, inhibition of intestinal secretions, stimulation of sodium and chloride reabsorption; disruption of calcium mediated ion transport • Binds enterotoxins

Loperamide (brand: Imodium): Containdications

• Invasive bacterial diarrhea (i.e. fecal leukocytes, high fever, blood or mucus in stool) or antibiotic-associated diarrhea (C. difficile) • Discontinue if abdominal distention, constipation, or ileus occurs

Digestive Enzymes (Lactase): Indications

• Lactose intolerant individuals

Bismuth Subsalicylates (brand: Kaopectate, PeptoBismol): Contraindications

• Not recommended for children <12 years old unless recommended by PCP due to risk of Reye's syndrome • Contraindicated in AIDS patients with acute diarrhea • Contraindicated in pregnancy

Loperamide (brand: Imodium): Adverse effects

• Occasional: dizziness, constipation • Infrequent: abdominal pain, abdominal distention, nausea, vomiting, dry mouth, fatigue, hypersensitivity reactions

Digestive Enzymes (Lactase): Adverse effects

• RARE- severe allergic reactions (rash; hives; difficulty breathing; tightness in the chest; swelling)

Loperamide (brand: Imodium): MOA

• Stimulates micro -opioid receptors on intestinal muscles → slowing intestinal motility and allowing for absorption of water and electrolytes • Decreases GI secretions; Disruption of mechanisms involved in peristalsis • Inhibition of calmodulin and voltage dependent calcium channels contributing to the antisecretory effect

Digestive Enzymes (Lactase): Counseling points

• Take at first bite of lactose containing food • Do not exceed recommended dose • Low lactose or soy-milk may be used to supplement calcium intake and minimize lactose intolerance • Calcium and vitamin D supplements may be used to obtain RDA for individual Pediatric: • Most patients can tolerate 100ml of milk without use of enzyme

Bismuth Subsalicylates (brand: Kaopectate, PeptoBismol): Therapeutic effect

• ↓ frequency unformed stools •↑consistency/viscosity • ↓abdominal cramps • ↓ nausea and vomiting • Antibacterial action • Antisecretory actions

Loperamide (brand: Imodium): Therapeutic effect

•↓fecal volume •↑ viscosity; •↑ bulk volume •↓ fluid and electrolyte loss

Digestive Enzymes (Lactase): Therapeutic effects

↓osmotic diarrhea associated with dairy products in lactose intolerant