Pharmaco-therapeutics 2 Prince Sattam Bin AbdulAziz University College Of Pharmacy Diarrhea

Case 1 Mrs Robinson asks what you can recommend for diarrhoea. Her son David, aged 11 years, has diarrhoea and she is worried that her other two children, Natalie, aged 4 years, and Tom, aged just over 1 year, may also get it. David’s diarrhoea started yesterday; he went to the toilet about five times and was sick once, but has not been sick since. He has griping pains, but is generally well and quite lively. Yesterday he had pie and chips from the local takeaway during his lunch break at school. No one else in the family ate the same food. Mrs Robinson has not given him any medicine, but has some kaolin and morphine mixture at home and wants to know if David could take some, and also if the other children could take it if necessary.

Define Diarrhea ? Clinical definition: Alteration in a normal bowel movement characterized by an increase in the water content, volume, or frequency (more than 3/day) of stool a. Acute is generally considered less than 72 hours to 14 days in duration. b. Chronic is generally considered more than 14–30 days.

Age ? Particular care is needed in the very young and the very old. Infants(younger than 1 year) and elderly patients are especially at risk of becoming dehydrated.

Duration ? Most cases of diarrhoea will be acute and self-limiting. Because of the dangers of dehydration it would be wise to refer infants with diarrhoea of longer than 1 day’s duration to the doctor

Severity ? The degree of severity of diarrhoea is related to the nature and frequency of stools. Both these aspects are important, since misunderstandings can arise, especially in self-diagnosed complaints. Elderly patients who complain of diarrhoea may, in fact, be suffering from faecal impaction. They may pass liquid stools, but with only one or two bowel movements a day.

Symptoms ? The pharmacist should always ask about vomiting and fever in infants; both will increase the likelihood that severe dehydration will develop. Another important question to ask about diarrhoea in infants is whether the baby has been taking milk feeds and other drinks as normal. Reduced fluid intake predisposes to dehydration. The pharmacist should question the patient about food intake and also about whether other family members or friends are suffering from the same symptoms, since acute diarrhoea is often infective in origin. The presence of blood or mucus in the stools is an indication for referral

Previous history ? A previous history of diarrhoea or a prolonged change in bowel habit would warrant referral for further investigation and it is important that the pharmacist distinguish between acute and chronic conditions. Chronic diarrhoea (of more than 3 weeks’ duration) may be caused by bowel conditions such as Crohn’s disease, IBS or ulcerative colitis and requires medical advice.

Recent travel abroad ? Diarrhoea in a patient who has recently travelled abroad requires referral since it might be infective in origin. Giardiasis should be considered in travellers recently returned from South America or the Far East.

Causes ? May be classified into several major categories related to underlying cause: a. Secretory i. Secondary to enhanced secretion by intestinal mucosa. Often, large, watery volume with loss of electrolytes ii. Common causes: Bacterial or viral or bacterial enteritis, gastric hypersecretion, carcinoid, stimulant laxatives, bile acid malabsorption, celiac disease, IBD (mucosal) b. Osmotic i. Secondary to the presence of hyperosmolar gradient in the intestinal lumen ii. Common causes: Osmotic laxatives, carbohydrate malabsorption (lactase deficiency), fat malabsorption (pancreatic insufficiency), short bowel syndrome

Causes ? May be classified into several major categories related to underlying cause: c. Exudative/inflammatory i. Secondary to inflammation or infiltration/invasion of the intestinal mucosa ii. Common causes: IBD, invasive infection (C. difficile toxin, enterotoxigenic E. coli, cytomegalovirus, Shigella), ischemic colitis, radiation enterocolitis, neoplasm d. Altered motility/motor i. Secondary to autonomic nerve dysfunction ii. Common causes: Diabetic neuropathy, postvagotomy, hyperthyroidism, irritable bowel syndrome (IBS), Addison disease

Drug-induced diarrhea. May occur by a variety of mechanisms

Referral to higher level of care or further evaluation may be required for some patients. a. Immunocompromised b. Pediatrics c. Pregnancy d. Presence of fever e. Blood in the stool f. Weight loss (greater than 5%) g. Suspected invasive infection

Treatment? Removal or treatment of underlying cause(s) if possible I. Rehydration a. Intravenous fluids appropriate for hospitalized patients b. Oral rehydration appropriate for all patients if no vomiting is present Sodium and glucose are key ingredients of oral rehydration solutions because they have active uptake into the intestinal mucosa even during active diarrhea. This results in water being pulled back into circulation. Other formulations (popsicles) are also available. Gatorade may need to be diluted because it has a large amount of carbohydrates. A popsicle (Canada and the United States), freeze pop (Ireland), ice lolly (United Kingdom and Ireland), ice block (parts of Australia and New Zealand), ice pop  .. Gatorade is a brand of sports-themed beverage and food products, built around its signature line of sports drinks. Gatorade is currently manufactured by he latest from Gatorade (@Gatorade). Fueling athletic performance since 1965. #WinFromWithin. Chicago, IL.

Treatment? Removal or treatment of underlying cause(s) if possible I. Rehydration . A popsicle (Canada and the United States), freeze pop (Ireland), ice lolly (United Kingdom and Ireland), ice block (parts of Australia and New Zealand), ice pop  .. Gatorade is a brand of sports-themed beverage and food products, built around its signature line of sports drinks. Gatorade is currently manufactured by he latest from Gatorade (@Gatorade). Fueling athletic performance since 1965. #WinFromWithin. Chicago, IL. Home-made salt and sugar solutions should not be recommended, since the accuracy of electrolyte content cannot be guaranteed, and this accuracy is essential, especially in infants, young children and elderly patients.

Treatment? Removal or treatment of underlying cause(s) if possible II. Dietary modifications a. Avoid dairy products because transient lactase deficiency may occur. b. “BRAT” diet for adults c. May need to interrupt feedings for pediatric patients III. Drug therapy for diarrhea a. Several different agents available for management of diarrhea b. Avoid antimotility agents if invasive infection is suspected. A popsicle (Canada and the United States), freeze pop (Ireland), ice lolly (United Kingdom and Ireland), ice block (parts of Australia and New Zealand), ice pop  .. Gatorade is a brand of sports-themed beverage and food products, built around its signature line of sports drinks. Gatorade is currently manufactured by he latest from Gatorade (@Gatorade). Fueling athletic performance since 1965. #WinFromWithin. Chicago, IL.  BRAT is a mnemonic for bananas, rice, apple sauce and toast

. may not be recommended for use in children under 12 years. those aged 16 years and over

Case 1 Mrs Robinson asks what you can recommend for diarrhoea. Her son David, aged 11 years, has diarrhoea and she is worried that her other two children, Natalie, aged 4 years, and Tom, aged just over 1 year, may also get it. David’s diarrhoea started yesterday; he went to the toilet about five times and was sick once, but has not been sick since. He has griping pains, but is generally well and quite lively. Yesterday he had pie and chips from the local takeaway during his lunch break at school. No one else in the family ate the same food. Mrs Robinson has not given him any medicine, but has some kaolin and morphine mixture at home and wants to know if David could take some, and also if the other children could take it if necessary.

The pharmacist’s view It sounds as if David has about of acute diarrhoea, possibly caused by the food he ate yesterday during lunchtime. He has vomited once, but now the diarrhoea is the problem. The child is otherwise well. He is 11 years old, so the best plan would be to start oral rehydration with some proprietary sachets, with advice to his mother about how they should be reconstituted. . If either or both the other children get diarrhoea, they can also be given some rehydration solution. David should see the doctor the day after tomorrow if his condition has not improved

Questions Define diarrhea ? Acute diarrhea duration ? Chronic diarrhea duration ?

Questions Age is important factor when a patient have diarrhea especially if the patient is an infant why ? It’s important to ask whether the baby has been taking milk feeds and other drinks as normal why ? Write 4 conditions for referral to higher level of care or further evaluation may be required in patient with diarrhea ?

in a diarrhea patient the presence of blood or mucus in the stools is an indication for referral (T/F) A previous history of diarrhoea or a prolonged change in bowel habit would warrant referral for further investigation (T/F) Continuing with antimotility agents if there’s antidiarrhea with invasive infection is suspected (T/F) ……………………………….. should be considered in travellers recently returned from South America or the Far East Loperamide , Diphenoxylate+ atropine should be avoided if there’s ………………… diarrhea Bismuth subsalicylate is indicated for patients >12 years old (T/F)

References Symptoms in the Pharmacy: A Guide to the Management of Common Illness, 6th Edition Alison Blenkinsopp, P. Paxton and J. Blenkinsopp © 2009 Alison Blenkinsopp Updates in Therapeutics