Written by: Joshua Nubla, PharmD, NCODA
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Description: This PQI will discuss management strategies for oncolytic medication induced diarrhea including combinations of fluid hydration therapies, antimotility agents such as loperamide, and dose modifications.

Background: A common side effect with many oncolytic therapies is medication induced diarrhea which can result from chemotherapy or targeted therapy regimens. Medication induced diarrhea will present with increasing frequency and consistency of bowel movements and drastic changes in hydration status and electrolyte levels. Oncolytic induced diarrhea can lead to life threatening dehydration and electrolyte imbalances.

PQI Process: Identify patients who are taking an oncolytic agent with a known diarrhea side effect.

Common oral oncolytic agents that cause diarrhea

  • Tyrosine Kinase Inhibitors (TKI)
  • Multi-kinase Inhibitors
  • Phosphatidylinositol-3-kinase (PI3K) Inhibitors
  • Capecitabine
  • Everolimus
  • Fluorouracil (5FU®)
  • Irinotecan

Upon receiving a prescription of any agents that commonly cause diarrhea:

  • Counsel patient on importance of diarrhea management and risks of dehydration
  • Provide loperamide and dosing instruction (see supplemental information)
  • Counsel patient on appropriate diet (see supplemental information)
  • Schedule follow up phone call within first few days or weeks of starting therapy to asses if patient is experiencing diarrhea
    • If not controlled with loperamide change in therapy may be needed
    • If severe, may need to provide IV fluid and electrolyte replacement

Patient Centered Activities:

  • Provide Oral Chemotherapy Education (OCE) Supplemental Sheet
  • Adhere to suggested dosing and diet strategies
  • Start taking loperamide at the first onset of diarrhea
    • If taking antidiarrheal and without relief for 48 hours, then contact clinic
  • Drink plenty of fluids: 6-8 large glasses of water, clear liquids, soup per day
  • If on immunotherapy contact your clinic immediately at the first onset of diarrhea

References:

  1. Micromedex Drug Database
  2. Up To Date

Supplemental Information:

Diet

  • Avoid greasy, spicy, or fried food
  • Avoid milk, caffeine, alcohol
  • Avoid high fiber vegetables
  • Eat small meals
  • Follow B-R-A-T diet
    • Bananas, rice, apple sauce, toast/tea (decaffeinated)

Medication Therapy

  • Loperamide (OTC)
    • Mild-Moderate – Take two caplets (4 mg) by mouth at the onset of diarrhea, followed by one caplet (2 mg) every hour hours or after each loose stool
    • Persistent (12-24 hrs) – Take two caplets (4 mg) by mouth at the onset of diarrhea, followed by one caplet (2 mg) every two hours until no diarrhea for 12 hours
    • During the night, take 2 caplets (4 mg) by mouth at bed time and continue every four hours during the night until morning
    • Stop taking loperamide only after there is no sign of diarrhea for 12 hours
    • Max 16 mg per day (up to 24 mg per day for chemotherapy induced diarrhea under medical supervision)
  • Diphenoxalate/Atropine (Rx)
    • Take two tablets (5 mg) by mouth three to four times daily
    • Max 40 mg per day
    • Atropinism (dryness of the skin and mucous membranes, tachycardia, urinary retention, and hyperthemia) has been reported
    • Respiratory depression has been reported
  • Octreotide (Rx)
    • Inject 100-150 mcg subcutaneously three time daily
      • Rapidly escalate to 500 mcg subcutaneously three times daily if lower doses are not effective
    • Tincture of Opium (Rx)
      • Take 10-15 drops in water every three to four hours
    • Budesonide (Rx)
      • Take 9 mg by mouth once daily (off label)

Important notice: 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

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