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Diarrhea: Special Populations

Of special concern are infants and children and elderly or debilitated patients with diarrhea. These patient populations are at increased risk from complications from diarrhea, including dehydration and electrolyte imbalances. In addition, diarrhea may be a symptom of underlying disease in certain individuals. If diarrhea is secondary to another condition, treatment of the primary disorder is most important.

Parents of infants and young children should be educated about the signs of dehydration (thirst, dry mouth, concentrated urine, etc.) and should seek medical treatment if their child becomes dehydrated. The American Academy of Pediatrics recommends that, as a general rule, pharmacologic agents not be used to treat acute diarrhea in children.

diarrhoea

Patients with chronic diarrhea should be managed by identifying and treating the cause or supportively managing each diarrheal episode. Psyllium or another hydrophilic agent may improve stool consistency by absorbing excess water. Diphenoxylate and loperamide may be helpful in patients with mild to moderate secretory diarrhea. Other drugs, such as octreotide (e.g., Sandostatin), clonidine (e.g., Catapres), proton pump inhibitors (e.g., omeprazole [Prilosec]), H-2 receptor antagonists (e.g., ranitidine [Zantac]) and cholestyramine (Questran) may be beneficial in certain patients with certain types of diarrhea. The choice of agent should be individualized; some agents may be contraindicated in certain populations. Since chronic diarrhea may be the result of many conditions, patients should confer with their physicians as to the appropriate medication or antidiarrheal agent (if any) to use when they experience diarrheal episodes. Some patients who suffer from persistent diarrhea are aware of the cause and can manage the condition symptomatically. See Table 6 for a list of patient counseling notes.

Table 6. Patient Counseling Notes
Questions to ask before recommending an antidiarrheal:
  1. How long have you had diarrhea, and how often do the episodes occur?
  2. Do you have any other symptoms in addition to diarrhea?
  3. Which antidiarrheal medications have you tried, if any, and did they help?
  4. What are the characteristics of your stools? Do they contain any blood or mucus?
  5. Have you changed your diet (including drinking nonchlorinated water) or traveled to a foreign country recently?
  6. Do others in your household have diarrhea, or can you associate the onset of the diarrhea to a particular food or drug?
  7. Which medications (prescription and OTC) are you currently taking?
  8. Do you have any medical conditions or chronic illnesses?
Patients with diarrhea who should be referred to a physician for a complete diagnostic evaluation:
  • infants and young children
  • elderly patients
  • patients with chronic and/or multiple medical conditions
  • patients with abdominal tenderness and cramping
  • pregnant women
  • dehydrated patients or those who have lost more than 5% of their body weight
  • patients with high fever (·101°F or 38°C)
  • patients with stools that contain blood or mucus
  • patients with severe diarrhea, or diarrhea which has lasted more than 2 days, with or without treatment

Conclusion

Diarrhea is a common, annoying and sometimes life-threatening symptom. Pharmacists are often called upon for advice on the treatment of this disorder. Patient assessment is very important in the treatment of diarrhea; patients may present with acute or chronic diarrhea. There are a myriad of potential causes, and by thorough and careful investigation of individual patient’s symptomatology, pharmacists can suggest the best treatment option, whether it be an antidiarrheal, a change in diet, or referral to a physician. It is important for pharmacists to recognize which types of diarrhea may be potentially serious and also which populations of patients are potentially at risk for complications from diarrhea. In addition, it should be noted that stopping the diarrhea is not necessarily the goal of treatment for all patients.

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