[MOL] Part 2/Chemo Toxicity/Diarrhea, Constipation, [00964] Medicine On Line

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[MOL] Part 2/Chemo Toxicity/Diarrhea, Constipation,


III.  Diarrhea
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Several anti-cancer drugs can damage the digestive tract, at times leading to diarrhea. Specific drugs particularly associated with diarrhea are 5-FU, methotrexate, cytarabine, capecitabine and irinotecan. Because it is difficult to predict which patients will develop diarrhea, prevention is not an effective management strategy and antidiarrheal therapy is the mainstay of treatment. In addition, adequate fluid intake is critical in order to prevent dehydration. Drinking water, soup or non-caffeinated beverage is adequate in mild diarrhea, and oral fluid replacement preparation (such as Gatorade) is preferable in moderate losses. Intravenous fluid support might be required in a severe case of dehydration. Diarrhea can be controlled with Lomotil or Imodium, unless the diarrhea is caused by infection.

Drug name Usual dose Side effects Cost
Water, broth, soda 8 to 10 glasses daily No coffee or caffeine-containing liquids, as they can worsen diarrhea Minimal
Rehydration formulas As indicated Well tolerated $$
Loperamide (Imodium) 2 capsules followed by 1 capsule after each loose stool, up to 8 capsules per day Sedation, drowsiness $$
Lomotil 1 or 2 tablets 3 to 4 times per day Nervousness, drowsiness $$

Diarrhea caused by irinotecan is treated in a different manner. If diarrhea occurs less than 24 hours after the infusion, atropine is given to control the symptoms. For late-onset diarrhea (more than 24 hours after infusion), the patient should take 2 caplets of loperamide (4mg) after the first episode of loose stools, followed by one caplet (2mg) every 2 hours until diarrhea-free for 12 hours. During nighttime, the patient should take 2 caplets (4mg) every 4 hours. This regimen is tailored for irinotecan-treated patients and should ot be used in others, unless indicated otherwise.

IV.  Constipation
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Constipation may be due to a number of drugs used in the management of patients with cancer, including narcotic analgesics (painkillers), "vinca" chemotherapy drugs vincristine (Oncovin), vinblastine (Velban), and vinorelbine (Navelbine), and calcium-contained antacids (Tums). Patients administered any of the above drugs should be given a bowel regimen in order to maintain normal bowel functioning.

Narcotic analgesics administered by any route (oral, topical, or injectable) may cause substantial decrease in bowel movements by inhibiting the nerves in the gastrointestinal tract. Drugs such as oral morphine (MS Contin), oral oxycodone (Oxycontin), fentanyl (Duragesic) topical patch or injectable morphine, hydrocodone (Dilaudid) have been implicated. The vinca chemotherapy drugs frequently cause constipation beginning within 7 days of therapy. Elderly patients are particularly susceptible to constipation from both narcotics and vincas.

Any patients started on these drugs should also be taking adequate fluids and fruits (prunes or raisins) to stimulate bowel functioning. In addition, a stimulant laxative such as senokot or dulcolax along with a stool softener (Colace) should be taken concurrently with narcotics. If senokot is ineffective, a prescription medication may be required such as lactulose or an over-the-counter solution of citrate of magnesia. The usual doses of medications to prevent and treat constipation are shown in the table below.

Drug name Usual dose Side effects Cost
Senokot 2 tablet twice daily until regular bowel functioning then 1 tab/day Stomach upset $
Colace 2 capsules (100mg each) twice daily None $
Dulcolax 1 or 2 tablets daily until regular bowel functioning then 1 tab/day Stomach upset $
Lactulose 15 to 30 ml two to three times daily to induce bowel functioning Diarrhea (excessive dose); flatulence $
Miralax 17 grams (1 teaspoon) per day Nausea, bloating, cramping. $
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