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Abstract & Commentary
Synopsis: Oral loperamide is the antidiarrheal treatment of choice, and self-medication with antibiotics is not generally advisable, except in travelers specifically medically advised.
Source: Wingate D, et al. Aliment Pharmacol Ther. 2001; 15:773-782.
Self-treatment of acute uncomplicated diarrhea is extremely common. However, guidelines for management of diarrhea have been confusing and contradictory. This paper is the product of an ad hoc advisory group that reviewed available evidence and reached consensus. Loperamide was deemed to be safe, effective, and less liable to produce unwanted side effects than older antidiarrheal drugs. In individuals who can successfully maintain oral fluid intake, oral rehydration solutions offer no additional advantages. Other than in certain situations related to travel and prior medical advice, the self-administration of antimicrobial drugs was not thought to be desirable. Medical intervention was urged for the frail, for severe diarrhea in the elderly (> 75 years), or the chronically ill, or for persistent diarrhea beyond 48 hours, or in situations with deterioration, distention, or dysentery (fever > 38.5° and/or bloody diarrhea).
Comment by Malcolm Robinson, MD, FACP, FACG
Guidelines for self-treatment of diarrhea in adults are extremely varied including recommendations for and against antidiarrheals, for and against probiotic treatment, and continuation of normal diet vs. use of clear liquids only. Recommendations for oral rehydration fluids in children have been extrapolated to apply to adults in the absence of any data suggesting that this approach would be at all useful. Although some physicians have refused to treat acute diarrhea, this distressing and uncomfortable symptom complex warrants intervention. There is absolutely no basis for withholding medication in acute diarrheal states. Some evidence suggests that older antidiarrheal drugs might worsen infectious dysentery, and this has been used to justify the avoidance of all antidiarrheal medication in the setting of fever and/or bloody stools. Probiotic agents have never been shown to improve acute diarrhea in adults and cannot currently be recommended. Adsorbents such as kaolin or charcoal provide minimal or no benefit and are clearly inferior to loperamide in acute diarrhea. Codeine and other opiates are excellent antidiarrheal drugs, but their abuse liability makes them less acceptable than loperamide. Bismuth subsalicylate is somewhat effective in travelers’ diarrhea caused by Escherichia coli, but this effect is probably less than loperamide. Some poorly absorbed antimicrobials have been used for travelers’ diarrhea including rifaximin. Neomycin, bacitracin, and erythromycin as sold in some Third World countries are not recognized as efficacious. Tetracycline, penicillins, and macrolides are no longer recommended due to problems with bacterial resistance. There may still be some role (albeit vanishing) for trimethoprim-sulfamethoxazole, and doxycycline also may occasionally be useful despite being a known photosensitizer (it does provide possible concomitant malaria prophylaxis). Quinolones have become increasingly popular for the treatment of acute travelers’ diarrhea since they are generally effective and well tolerated. These recommendations seem quite sound and are helpful for our own use and for recommendations to our patients.
Malcom Robinson is Medical Director, Oklahoma Foundation for Digestive Research; Clinical Professor of Medicine at University of Oklahoma College of Medicine in Oklahoma City; and Associate Editor of Internal Medicine Alert.