Treatment of diarrhea and constipation

Treatment of diarrhea and constipation Treatment of acute non-inflammatory diarrhea - 1. rehydration + BRAT diet 2. medications as needed -loperamide (imodium) -diphenoxylate + atropine (lomotil) -bismuth subsalicylate (pepto-bismol) What is first line treatment for acute non-inflammatory diarrhea - Loperamide MOA of loperamide - Mu-opioid receptor agonist. Prevents peristalsis and increase transit time Call in 48 hours if no benefit MOA of diphenoxylate/atropine - inhibits excessive GI motility and GI peristalsis ADRs of diphenoxylate/atropine - avoid alcohol, additive CNS depression When is bismuth subsalicylate used - mild nonspecific diarrhea and traveler's diarrhea MoA of bismuth subsalicylate - salicylate: antisecretory, anti-inflammatory bismuth: antimicrobial ADRs of bismuth subsalicylate - grayish black stools (important - can look like bleed) hearing loss tinnitus confusion dizziness contraindication of bismuth subsalicylate - influenza or chicken pox (reyes syndrome) What is acute inflammatory diarrhea - Fever and or blood in stool colonic tissue damage (shigellosis, salmonellosis, campylobacter) Treatment for acute inflammatory diarrhea - Empiric antibiotic therapy Rehydration Diet Loperamide (not used more than 48 hours) If C. diff its treated different empiric antibiotics used for acute inflammatory diarrhea - Travelers diarrhea: > 8 stools daily, volume depleted, diarrhea > 1 week, hospitalized, immunocompromised -3-5 days with fluroquinolone Cipro, Levofloxacin -Can use Bactrim or Doxycycline if resistant to fluoroquinolone Treatment for C. diff - metronidazole or oral vancomycin Treatment of chronic diarrhea - -loperamide -diphenoxylate/atropine -bismuth subsalicylate -OTC psyllium (Metamucil) -anticholinergics: dicyclomine (bentyl) When are anticholinergics not recommended for diarrhea - if it is caused by E. coli, Shigella, Salmonella, C. diff, pseudomembranous colitis, fever/recent abx/fecal leukocytes/mucus or pus in stool these meds will keep the infection in the gut longer - bad what is OTC psyllium (Metamucil) used to treat? - Really watery non-infectious diarrhea (niche) MoA of OTC psyllium (Metamucil) - aborbs water in intestine to form a viscous liquid to promote peristalsis and reduce transit time ADRs of OTC psyllium (Metamucil) - abdominal cramps, constipation, diarrhea, esophageal or bowel obstruction when is OTC psyllium (Metamucil) CI - fecal impaction or GI obstruction Dosing of OTC psyllium (Metamucil) - take 2-3 days for full results -onset of action is 12-72 hours take with plenty of fluid separated doses by at least 2 hours of other products Education regarding constipation - increase fluid and fiber intake First line tx for constipation - Bulk forming laxatives what are the bulk forming laxatives - -Psyllium seed (Metamucil) (more effective) -mtheylcellulose -calcium polycarbophil wheat dextrin (benefiber) ---take with full glass of water to avoid GI obstruction (also treat watery diarrhea) What to give a patient straining during BM or has hemorrhoids w pain upon BM - Surfactant laxatives (stool softeners) -Docusate sodium (colace) What are the osmotic laxatives? - magnesium oxide/citrate -polyethylene glycol (PEG) (miralax) -lactulose -sodium phosphate When are osmotic laxatives used? - to evaluate the bowel prior to surgery or diagnostic exam When should stimulant laxatives be taken? - more acute issue, not chronic what are the stimulant laxatives - Senna Bisacodyl (dulcolax) Mao of stimulant laxatives - stimulate peristalsis - why abdominal cramping is an ADR, it means the med is working if a patient has significant constipation/chronic idiopathic , what can you prescribe - Linacoltide (linzess) Plecanatide (trulance) adr is diarrhea if a patient has IBS-c what can you prescribe - Lubiprostone (Amitiza) adr is nausea and diarrhea Treatment algorithm for constipatin - 1st line: bulk forming laxatives 2nd line: laxatives (PEG, MOM, bisacodyl) 3rd: if no improvement, adjust regimen 4th: refer