Written by: Joshua Nubla, PharmD – NCODA
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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
  • Multi-kinase Inhibitors
  • Capecitabine, everolimus

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

  • Counsel patient on importance diarrhea management and risks of dehydration (life- threatening)
  • Provide loperamide and dosing instructions (listed below) to patient
  • Keep loperamide well stocked
  • Counsel patient on appropriate diet (listed below)
  • Schedule follow up phone call within first few days or week of starting therapy to assess if patient is experiencing diarrhea
    • If loperamide not controlling diarrhea then contact prescriber for Lomotil (or another antidiarrheal)
    • If severe will need to bring in for fluid and electrolyte replacement

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 hours
    • During the night, take two caplets (4 mg) 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 of 16 mg per day (up to 24 mg for chemotherapy induced diarrhea under medical supervision)
  • Diphenoxalate/Atropine (RX only):
    • Take two tablets (5mg) three to four times daily (Max of eight tablets per day).
    • Atropinism (dryness of the skin and mucous membranes, tachycardia, urinary retention, and hyperthemia) has been reported
    • Respiratory depression has been reported

Diet

  • 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

Patient Centered Activities:

  • Adhere to suggested dosing and diet strategies listed above
  • 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 of diarrhea

References:

  1. Micromedex Drug Database
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

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