Benson, A.B., Ajani, J.A., Catalano, R.B., Engelking, C., Kornblau, S.M., Martenson, J.A., . . . Wadler, S. (2004). Recommended guidelines for the treatment of cancer treatment-induced diarrhea. Journal of Clinical Oncology, 22, 2918–2926.

PURPOSE: To update and expand on the previously published practice guidelines for the treatment of cancer treatment-induced diarrhea

 

TYPES OF PATIENTS ADDRESSED: Patients with colorectal cancer, adults, patients receiving pelvic or abdominal radiation therapy, and patients receiving therapy with fluorouracil (FU) and irinotecan (CPT-11) regimens

RESOURCE TYPE: Consensus-based guideline  

 

PROCESS OF DEVELOPMENT: Roundtable literature review and shared professional experience

 

DATABASES USED: MEDLINE

 

KEYWORDS: Radiation, chemotherapy, diarrhea, octreotide, somatostatin analog

PHASE OF CARE: Active antitumor treatment

 

APPLICATIONS: Elder care

The revised recommendations updated the decision tree for diarrhea management and included the following additions.

 

Assessment needs to be thorough and in-depth to include duration of symptoms, cluster of signs and symptoms, severity, and consistency, appearance, quantity, and volume of stools over baseline. Based on the symptoms, diarrhea is classified as either “complicated” or “uncomplicated.” This determination leads treatment. Aggressive management of complicated diarrhea involves IV fluids and octreotide at starting dose of 100–150 ug subcutaneous (SC) three times daily or IV (25–50 ug/h) if the patient is severely dehydrated, with dose escalation up to 500 ug until diarrhea is controlled and administration of antibiotics (i.e., fluoroquinolone). Severe radiation therapy-induced diarrhea may not require hospitalization if close monitoring can be done in an outpatient facility that also administers IV fluids and a high level of care. For management of uncomplicated mild-to-moderate diarrhea, the initial intervention should be dietary modification and patient education related to monitoring the number of stools along with symptoms and when the symptoms require notification of the nurse/prescriber. Loperamide is administered with a first dose of 4 mg followed by 2 mg every four hours or after every unformed stool (not to exceed 16 mg/day). If diarrhea continues for more than 24 hours, then loperamide dosing is increased to 2 mg every two hours, and oral antibiotics may be started as prophylaxis for infection. If diarrhea persists for more than 48 hours, loperamide is stopped and second-line treatment with SC octreotide (100–150 ug starting dose and escalation as needed) or second-line agents (i.e., deodorized tincture of opium or camphorated tincture of opium [paregoric]) should be considered.