Loperamide Toxicity Management

Introduction to Loperamide Toxicity

• The American Society of Clinical Oncology and other guideline societies recommend avoiding loperamide in patients with grade 3-4 immunotherapy-induced diarrhea/colitis, as it may pose a risk of toxic megacolon 1, 2, 3

Contraindications and Cautions

• The Infectious Diseases Society of America recommends avoiding loperamide in patients with inflammatory diarrhea or diarrhea with fever, due to the risk of toxic megacolon 4
• The European Society of Gastrointestinal Endoscopy recommends avoiding high-dose loperamide in neutropenic patients with C. difficile infection, as it may predispose to toxic dilatation 2, 3

Therapeutic Dosing and Toxicity

• The American Society of Clinical Oncology recommends a normal therapeutic dosing of 4 mg initially, then 2 mg every 2-4 hours or after unformed stool, with a maximum of 16 mg daily 1, 5, 6