Diarrhea%20in%20adults%20-%20chronic Treatment

Treatment Trial

• In some cases, treatment may include stopping a food or drug
  
  • Lactose-containing foods or drinks
  • Sugar-free products with sorbitol and foods made with fat replacements
  • Drugs such as laxatives and antacids
• Resolution of diarrhea after a 72-hour fast indicates a diet-related cause for osmotic chronic diarrhea 
• Patients with functional diarrhea whose symptoms improve with a modified diet low in fermentable carbohydrates are likely to have IBS than celiac disease

Indications for Empiric Therapy

• Initial treatment before diagnostic testing
• When a diagnosis is strongly suspected and follow-up is available
• When there is no confirmed diagnosis after testing
• When a diagnosis has been established but specific treatment is either unavailable or has proven ineffective
• When comorbidities limit diagnostic investigation
• When resources are limited

Antidiarrheals

• Symptomatic treatment may be needed in patients because specific treatment may not be available
• Antidiarrheals can decrease stool frequency and stool weight along with associated symptoms (eg abdominal cramps)

Antipropulsives

• Include natural opioids (eg Codeine, Opium, Morphine) and synthetic opioids (eg Diphenoxylate, Loperamide)
• The natural opiates are highly potent remedies for diarrhea
  
  • Patients need to be informed about the abuse potential of these drugs; though in practice, these substances are rarely abused by chronic diarrhea sufferers
• Synthetic opioids are less potent but usually are adequate to control less severe diarrhea and should be used first prior to more potent agents
• Dose should be started at a low level and titrated up as needed to achieve effectiveness
• Use of these drugs should be monitored closely

Bismuth Preparations

• Shown to be effective in acute traveler’s diarrhea but effectiveness in chronic diarrhea has not yet been proven
• Bismuth subsalicylate has antisecretory, antibacterial and anti-inflammatory effects

Other Antidiarrheal Agents

• Intestinal Adsorbents
  
  • Include Attapulgite, Activated charcoal, Kaolin, Pectin, Dioctahedral smectite
    
    • Few controlled studies of these agents in chronic diarrhea and results have been inconclusive

• Bile Acid Sequestrant
  
  • Eg Cholestyramine
  • Effective for short-term treatment of diarrhea secondary to bile acid malabsorption 

Nonspecific Agents for Diarrhea

Bulk-Producing Laxatives

• Eg Psyllium
  
  • Psyllium may alter stool consistency, changing watery stools to semi-formed ones

Clonidine

• An alpha-adrenergic agonist, decreases gut motility and intestinal transport
• Antihypertensive effect limits its use in most patients but could be useful in diabetics

Octreotide

• A somatostatin analogue that may improve endocrine diarrhea, dumping syndrome and AIDS diarrhea
• Usually considered a 2nd-line agent compared to opiates because of its administration by injection and cost

Probiotics

• May stimulate local immunity by modifying colonic flora and may be useful for antibiotic-associated diarrhea

Other Empiric Therapies

Pancreatic Enzyme Supplementation

• A therapeutic supplementation trial is occasionally given in patients suspected of having pancreatic exocrine insufficiency

Conjugated Bile Acid Supplementation

• Reduction of steatorrhea through empiric supplementation may be used to confirm the diagnosis of bile acid deficiency

• Administer fluids and electrolytes to manage dehydration and maintain hydration
  
  • Oral rehydration solution may be given; consider giving IV fluids if patient cannot tolerate oral therapy or is markedly dehydrated 
  • Please see Diarrhea in Adults - Infectious disease management chart for specific therapy
• Cereal-based solutions increase salt and water absorption but diarrhea may worsen with their use
  • Can be lifesaving in dehydrating acute secretory diarrheas (eg cholera) but use in chronic diarrhea has not been well studied
• Patients with chronic diarrhea should be given adequate nutritional support¹ 
  • Provide patients with appropriate dietary recommendations and calorie requirement

¹Various appetite enhancers and enteral nutritional products are available. Please see the latest MIMS for specific formulations and prescribing information

• Institute specific therapy once the cause of chronic diarrhea is established
• Please see the following disease management charts for further information:
  
  • Clostridioides difficile Infection
  • Diarrhea in Adults - Infectious
  • Inflammatory Bowel Disease 
  • Irritable Bowel Syndrome 
  • Pancreatitis - Chronic
  • Parasitic Infections
  • Primary Biliary Cholangitis
  • Zollinger-Ellison Syndrome