When a patient asks for a self-care recommendation for diarrhea, the pharmacist must refer patients under the age of 3 and those with fever to the physician, as well as those whose diarrhea has persisted for longer than 48 hours. However, if the patient does not meet any of the exclusionary criteria, several self-care products are available. The pharmacist should stress that all of the precautions on product labels must be followed closely.
There are several mechanisms by which nonprescription products can halt episodes of diarrhea. Adsorbent agents are thought to function mainly through the adsorption of toxins and other substances that produce diarrhea. The three adsorbent ingredients proven safe and effective for diarrhea self-care are bismuth subsalicylate, attapulgite, and kaolin. (Kaolin is no longer an ingredient in any leading product marketed at this time.)Bismuth subsalicylate is popular as Pepto-Bismol caplets, chewables or suspension. Whichever dosage form is chosen, the patient should be cautioned not to exceed dosages on product labels. Adult dosage for bismuth subsalicylate products is two tablespoonsful or tablets, with the dose for children 9-12 being half of that. The dose for those aged 6-9 is two teaspoonsful or two thirds of a tablet and the dose for those aged 3-6 is one teaspoonful or one third of a tablet. Doses are repeated every 30-60 minutes as needed, to a maximum of eight doses in any consecutive 24-hour period. Due to the salicylate content of these products, the pharmacist must caution purchasers against use if a child or teenager has or is recovering from chicken pox or flu. Further, the patient may notice tinnitus if the product is taken with aspirin. A harmless blackening of the tongue or teeth may occur due to conversion of residual oral bismuth to a harmless black compound. Stools may also darken, which is an equally harmless reaction. The suspension must be well agitated prior to pouring a dose.
Attapulgite reduces the number of bowel movements and improves the consistency of loose, watery bowel movements. It is found in such popular products as Kaopectate suspension, cherry-flavored suspension, and caplets, and in Donnagel suspension. Kaopectate products are dosed as follows: children aged 3 to under 6 should take one-half tablespoonful of the suspension; those aged 6 to under 12 should take one tablespoonful of suspension or one caplet, and those over 12 should take two tablespoonsful or two caplets. Doses may be instituted at the first episode of diarrhea and repeated after each loose bowel movement to a maximum of six doses in any consecutive 24-hour period. Donnagel is not recommended for children under the age of 6 years. A maximum of seven doses is advised in a 24-hour period. Companies marketing attapulgite voluntarily elected to include the phrase, "Do not use if diarrhea is accom-panied by blood or mucus in the stool?on the product labels Both Donnagel and Kaopectate suspensions must be agitated before pouring a dose.
Calcium polycarbophil is a hydrophilic, polyacrylic resin that is insoluble in water and can absorb 60 times its weight in water. Each tablet contains the equivalent of 500 mg of polycarbophil. If the patient has diarrhea, polycarbophil absorbs excess water by forming a gel that facilitates the normalization of bowel movements. The ingredient is free of toxic effects, being unabsorbed and pharmacologically inactive. Available as Equalactin and Mitrolan chewable tablets, the products carry a warning against the concurrent use of tetracycline due to chelation with the calcium. Mitrolan doses are two tablets four times daily for adults, one tablet three times daily for children ages 6 to under 12, and one tablet twice daily for patients aged 3 to under 6 years; daily maximums are 12, 6, and 3 tablets in 24-hours, respectively. Equalactin doses are two tablets four times daily for adults, one tablet four times daily for those 6 to under 12, and one tablet 1? times daily for those aged 3 to under 6; daily maximums are 8, 4, and 2 tablets, respectively. Patients using bulking agents such as polycarbophil are cautioned that taking it without at least 8 ounces of water can cause choking as the product expands in the area above the trachea.
Loperamide (Imodium A-D solution or caplets) was the subject of an Rx to OTC switch in the late 1980s. It slows peristalsis, reducing the frequency of bowel movements. The product label prohibits use if the patient has blood or mucus in the stool, has a rash or other allergic reaction to loperamide, is taking antibiotics, or has a history of liver disease. Patients 12 and older should take four teaspoonsful after the first loose bowel movement and two after each subsequent bowel movement. A maximum of eight teaspoonsful can be taken daily. Children ages 6-11 should take two teaspoonsful initially, followed by one teaspoonful after each loose bowel movement, up to a maximum of six teaspoonsful daily (9-11 years old) or four daily (6-8 years old). Dosing for caplets is similarly tailored for the patient's age. The product is not to be administered to children under the age of 6 years without a physician's recommendation for proper dosing.
Several companies market electrolyte products that help prevent imbalances in the patient with diarrhea. Their compositions are included in TABLE 1. However, if the pharmacist is convinced that a patient requires immediate hydration, it may be more prudent to refer the patient to a physician. There are several reasons for this. First is the serious nature of dehydration and electrolyte imbalances in the pediatric patient. Second, children may not accept the electrolyte solutions because of the unpleasant flavor. If the product is purchased in liter bottles, it must be refrigerated after opening and discarded after 48 hours.
US Pharmacist. 2000;25(11) © 2000 Jobson Publishing
Cite this: Diarrhea: Causes and Self-Care Treatments - Medscape - Nov 01, 2000.