Diarrhea Management

Introduction

• Diarrhea management involves a comprehensive approach, including treatment options, severe diarrhea management, and chemotherapy-associated diarrhea management, as recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology 1, 2

Treatment Options

• The American Society of Clinical Oncology recommends continuing loperamide treatment until diarrhea resolves, discontinuing after a 12-hour diarrhea-free interval 1
• The European Society for Medical Oncology suggests considering octreotide 100-150 μg SC three times daily for diarrhea management, with a dose escalation up to 500 μg three times daily if needed 2, 1
• Alternative options for diarrhea management include diphenoxylate plus atropine or psyllium seeds, according to the European Society for Medical Oncology 2
• Loperamide is recommended as first-line treatment for cancer patients with therapy-associated diarrhea, at a dose of 2 mg every 2 hours and 4 mg every 4 hours at night, as recommended by the European Society for Medical Oncology 2

Severe Diarrhea Management

• The American Society of Clinical Oncology recommends considering immediate octreotide therapy along with antibiotics for severe cases of diarrhea 1
• Hospitalization may be necessary for severe dehydration or complications, as stated by the American Society of Clinical Oncology 1
• Intravenous fluids are recommended for severe dehydration, shock, altered mental status, or failure of oral rehydration therapy, as recommended by the American College of Physicians 3

Chemotherapy-Associated Diarrhea

• Loperamide is particularly effective for managing chemotherapy-associated diarrhea, according to the American Society of Clinical Oncology and the European Society for Medical Oncology 2, 4
• For bosutinib-related diarrhea, the European Society for Medical Oncology recommends starting loperamide or diphenoxylate/atropine at the first sign of symptoms 4
• For irinotecan-induced late-onset diarrhea, the European Society for Medical Oncology suggests considering adding budesonide to loperamide 2

Diagnostic Evaluation

• A complete blood count (CBC) should be performed to assess for leukocytosis, neutropenia, anemia, and hemoconcentration, which can indicate infection, risk stratification, blood loss, or dehydration, according to the American Society of Clinical Oncology 5
• Basic metabolic panel should be used to evaluate electrolytes, renal function, and evidence of dehydration, as recommended by the American Society of Clinical Oncology 5
• Stool studies, including stool culture for bacterial pathogens, C. difficile testing, and ova and parasites examination, should be performed to identify the cause of diarrhea, as suggested by the Infectious Diseases Society of America 6
• Coagulation studies should be considered if bleeding is suspected, as recommended by the American Society of Clinical Oncology 5
• Plain abdominal radiography should be used to exclude obstruction or perforation in patients with severe pain, as recommended by the American Gastroenterological Association 7
• CT scan is indicated for suspected peritonitis, intra-abdominal free air, toxic megacolon, or suspected aortitis or mycotic aneurysms in older patients with invasive infections, as recommended by the Infectious Diseases Society of America 6
• Ultrasonography can be considered as a less invasive alternative for initial assessment, as suggested by the Infectious Diseases Society of America 6

Antimicrobial Therapy

• Empiric antibiotics should be considered for patients with fever and bloody diarrhea, immunocompromised patients, or severe symptoms with systemic toxicity, as recommended by the Infectious Diseases Society of America 6
• Azithromycin is the first-line choice for antimicrobial therapy, especially in areas with high fluoroquinolone resistance, with a recommended dose of 500 mg single dose or 1-day divided dose, as recommended by the Infectious Diseases Society of America 8
• Fluoroquinolones, such as ofloxacin, ciprofloxacin, and levofloxacin, can be used when resistance is not a concern, with specific dosages and treatment durations, as recommended by the Infectious Diseases Society of America 8
• Rifaximin is recommended for non-invasive, watery diarrhea only, with a dosage of 200 mg three times daily for 3 days, as recommended by the Infectious Diseases Society of America 8

Rehydration and Nutrition

• Oral rehydration solution (ORS) is recommended for mild to moderate dehydration, with a strength of evidence rated as high, and can be prepared by mixing 3.5g NaCl, 2.5g NaHCO3 (or 2.9g Na citrate), 1.5g KCl, and 20g glucose (or equivalent sugar/carbohydrate) per liter of clean water, as recommended by the American College of Physicians and supported by the Infectious Diseases Society of America 3, 9
• The BRAT diet (Bananas, Rice, Applesauce, Toast) is recommended to manage diarrhea, as recommended by the National Comprehensive Cancer Network 10, 11
• Patients should eliminate lactose-containing products, alcohol, and high-osmolar supplements to reduce the risk of exacerbating diarrhea, as recommended by the American Society of Clinical Oncology and the European Society for Medical Oncology 1, 5, 2, 3, 12
• Eating frequent small meals rather than large ones can help manage diarrhea, as recommended by the American Society of Clinical Oncology 1
• Zinc supplementation reduces the duration of diarrhea in children 6 months to 5 years of age who reside in countries with high prevalence of zinc deficiency or who have signs of malnutrition, as recommended by the Infectious Diseases Society of America and supported by the World Health Organization 3
• Provide highly caloric nutritional supplements containing iron, folic acid, vitamin B12, vitamin D, magnesium, calcium, and trace elements, as recommended by the American Society of Clinical Oncology 5

Monitoring and Follow-up

• Continue interventions until the patient has been diarrhea-free for 24 hours, and monitor for signs of dehydration and electrolyte imbalances, particularly hypokalemia, as recommended by the American Society of Clinical Oncology 1
• Patients should be monitored for signs of dehydration, such as decreased urination, dry mouth, and dizziness, and should drink 8-10 large glasses of clear liquids daily, as recommended by the American Society of Clinical Oncology 1
• Monitoring for electrolyte imbalances, particularly hypokalemia, is crucial to prevent complications, as recommended by the American Society of Clinical Oncology 5
• Patients should be instructed to contact their healthcare provider immediately if diarrhea persists for more than 48 hours despite treatment, or if they develop fever, severe abdominal pain, blood in stool, or signs of dehydration, as recommended by the American Society of Clinical Oncology 1
• No follow-up testing is recommended in most people after resolution of diarrhea, as suggested by the Infectious Diseases Society of America 6
• Clinical and laboratory reevaluation is indicated if symptoms persist beyond 48 hours despite treatment, as recommended by the Infectious Diseases Society of America 6
• Colonoscopy should be considered for persistent symptoms (>14 days) with unidentified cause, as recommended by the Infectious Diseases Society of America 6

Supportive Care

• Implement pelvic floor and toileting exercises if radiation proctopathy is present, as recommended by the American Society of Clinical Oncology 5
• Implement skin barriers to prevent irritation and pressure ulcers in patients with fecal incontinence, as recommended by the American Society of Clinical Oncology 5
• Consider referral for psychological support, as chronic diarrhea significantly impacts quality of life, as recommended by the American Society of Clinical Oncology 5
• Neglecting nutritional status can lead to malnutrition and vitamin deficiencies that require supplementation, as recommended by the American Society of Clinical Oncology 5

Common Mistakes

• Failing to recognize overflow diarrhea from fecal impaction, especially in patients on constipating medications, is a common mistake, as noted by the European Society of Gastrointestinal Endoscopy 13
• Missing C. difficile infection in neutropenic patients, who may not develop pseudomembranes, is a common error, as noted by the European Society of Gastrointestinal Endoscopy 13
• Delaying imaging in patients with signs of complete obstruction or peritonitis can lead to poor outcomes, as noted by the European Society of Gastrointestinal Endoscopy 13