Written by: Joshua Nubla, PharmD NCODA- Assistant Manager
Download Here

Combinations of fluid hydration therapies, antimotility agents such as loperamide, and dose modifications can be used for patients undergoing chemotherapy induced diarrhea which is problematic in numerous therapy regimens.

Background Drug-induced diarrhea, known as a common side effect from chemotherapeutic
agents can be expressed with frequent bowel movements and drastic changes in hydration
status and electrolyte levels. CID can lead to life threatening dehydration and electrolyte

Common oral chemotherapy agents that cause diarrhea

  • Tyrosine Kinase Inhibitors
  • m-Tor Inhibitors
  • Multi-kinase Inhibitors
  • Capecitabine

Dose reductions may prevent the need for diet or drug therapy


  • Avoid greasy, spicy or fried food
  • Avoid milk, caffeine, alcohol
  • Avoid high fiber vegetables
  • Eat small meals
  • B-R-A-T diet
    • Bananas, Rice, Apple Sauce, Tea (decaffeinated)/ or Toast

Drug therapy:

  • Loperamide (OTC):
    • Take two caplets (4 mg) followed by one caplet (2 mg) every two hours until you have had no diarrhea for 12
    • During the night, take two caplets (4 mg) at bed time and continue every four hour during the night until
    • Stop taking Imodium only after there is no sign of diarrhea for 12
    • Max of 16 mg per day (up to 24 mg for chemotherapy induced diarrhea under medical supervision)
  • Diphenoxalate/Atropine (RX only):
    • Take 2 tablets (5mg) three to four times daily (Max of 8 tablets per day).
    • Atropinism (dryness of the skin and mucous membranes, tachycardia, urinary retention, and hyperthermia) has been reported
    • Respiratory depression due to diphenoxalate has been reported
  • Tincture of Opium (RX only)
    • Use if other agents do not control diarrhea
    • Deodorized tincture of opium (DTO) 10 mg/ml
    • The recommended dose is 10–15 drops in water every 3–4 hours
    • The camphorated (alcohol-based) tincture is a less concentrated preparation containing the equivalent of 0.4 mg/ml morphine, leading to a dose of 5 ml (one teaspoon) every 3–4 hours

PQI process: Upon receipt of an oral chemotherapy agent with a known diarrhea side effect

  • Counsel patient on diarrhea management
  • Provide loperamide to patient
  • Keep loperamide well stocked
  • Schedule follow up phone call within first week of starting therapy to assess if patient is experiencing diarrhea
    • If loperamide not controlling diarrhea then contact prescriber for Diphenoxalate/Atropine (or another antidiarrheal)
    • If severe will need to bring in for fluid and electrolyte replacement

Patient Centered Activities:

  • If taking antidiarrheal and without relief for 48 hours then contact clinic
  • Drink plenty of fluids per day: 6-8 large glasses (water, clear liquids, soup, sports drinks)
  • Start Loperamide at the first onset of diarrhea
  • If you are taking immunotherapy (IV) then contact your clinic immediately at the first onset
Important notice: National Community Oncology Dispensing Association, Inc. (NCODA), has developed this Positive Quality Intervention platform. This platform represents a brief summary of medication uses and therapy options derived from information provided by the drug manufacturer and other resources. This platform is intended as an educational aid and does not provide individual medical advice and does not substitute for the advice of a qualified healthcare professional. This platform does not cover all existing information related to the possible uses, directions, doses, precautions, warning, interactions, adverse effects, or risks associated with the medication discussed in the platform and is not intended as a substitute for the advice of a qualified healthcare professional. The materials contained in this platform are for informational purposes only and do not constitute or imply endorsement, recommendation, or favoring of this medication by NCODA, which assumes no liability for and does not ensure the accuracy of the information presented. NCODA does not make any representations with respect to the medications whatsoever, and any and all decisions, with respect to such medications, are at the sole risk of the individual consuming the medication. All decisions related to taking this medication should be made with the guidance and under the direction of a qualified healthcare professional.

Joshua has blogged 150 posts

View all PQI