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Drug Treatment of

Diarrhoea
Dr. Jatin Dhanani

Principles of Mx
Treatment of Dehydration
Maintenance of nutrition
Drug therapy

Rehydration
Intravenous

Oral

Fluid loss > 10% of BW


Dhaka fluid - Recommended

In 1 L of water
NaCl - 85mM = 5 gm
or 5D
KCl 13mM = 1 gm
NaHCO3- 48mM = 4 gm
(Na 133mM, K 13mM, Cl 98mM, HCO3 48mM)
Ringer Lactate: Na 130 mM, K 4 mM, Cl 109mM
Initial volume equal to 10% BW in 2-4 hrs

Oral rehydration
Mild (5-7%BW) to moderate (7.5-10%BW)

fluid loss
Bases of oral rehydration.
Intactness of Glucose-Na+ co-transporter
General principle
Should be iso-/hypotonic (200-310mOsm/L)
Glucose Molar ratio should be slight high(but
not >110mM)
K+ and bicarbonate/citrate should be enough

Oral Rehydration Sol.

New ORS
Na 75 mM
K 20 mM

Na+ 90 mM
K + 20 mM
Cl- 80 mM
Citrate 10 mM
Glucose 110 mM
Total osmolarity

Home based ORS


310 mOsm/L
Super ORS

Cl 65 mM
Citrate 10 mM
Glucose 75 mM
Total osmolarity

245 mOsm/L
NaCl 2.6 gm
KCl -1.5 gm
Trisod. Citrate 2.9 gm
Glucose 13.5 gm

Non diarrheal use:


Postsurgical, postburn, post-trauma maintence
of hydration and nutrition
Heat stroke
From IV to enteral nutrition change over

Zinc in pediatric
Reduce duration and severity of ac.

Diarrhoea
Continue Zn for 10-14 days prevent
diarrhoea for next 2-4 months
Zn ORS are available

Maintenance of Nutrition
Never fasting
Feeding during dirrhoea increase digestive

enz. and cell proliferation in mucosa


Give simple food breast milk, half buffalo
milk, boiled potato, rice, chicken soup,
banana, sago, etc.

Drug Therapy
Specific antimicrobial agents
Probiotics
Drug for Inflammatory Bowel Diseases(IBD)
Nonspecific antidiarrhoeal drugs

Antimicrobial Agents
Routinely used irrational
Antimicrobials of no

value in
Irritable Bowel
Syndrome (IBS)
Coeliac disease
Tropical sprue
Pancreatic enz def.
Thyrotoxicosis
Viral inf. (rotavirus)
Some bacterial inf. (S.
enterobacterius, ETEC)

Antimicrobials useful

in severe cases only

Travellers diarrhoea
EPEC
Shigella enteritis
Nontyphoid salmonella
Y. enterocolitica

Antimicrobials

regularly used in

Cholera
C. jejuni
C. defficile
Amoebiasis/giardiasis

Role of Probiotics in Diarrhoea


Live culture or lyophillised powder
Bases of use: restore and maintain the

normal gut flora


Organism commonly used
Lactobacillus sp., Bifidobacterium, S. faecalis,
Enterococcus sp., yeast Saccharomyces
boulardii

Widely used in travellers diarrhoea, acute

Infective diarrhoea, antibiotic associated


diarrhoea
Efficacy evidence is lacking

Nonspecific antidiarrhieal dugs

Absorbants and adsorbants


Colloidal bulk forming agents ispaghulla,

carboxy methyl cellulose absorbants


Absorb the water and swell modify
consistency and frequency of stool

Adsorbants - Kaolin, pectin, attapulgite

believed to adsorb the bacterial toxins and


protect the gut mucosa
Adsorbants are banned in India

Antisecretory drugs

5-ASA comp.
Bismuth Subsalicylate
Atropine
Octreotide
Racecadrotril

Racecadotril (thiorphan)
Enkephalinase inhibitor prevent
hypersecretion by blocking receptor
Use in ac. secretory diarrhoea
Others

Anti motility drugs

Codeine
Diphenoxylate
Loperamide

Opioid analogue
Acts through and receptors
prevent propulsive movement, increase
absorption and decrease secretion: increase
resistance to luminal transit and allow more
time for absorption
Codeine
Primary action peripheral in intestine and colon
Not use widely

Diphenoxylate (2.5mg) + atropine (0.025mg)


Similar to pethidine
Cross BBB abuse liability (atropine prevents)
A/E respiratory depression, paralytic ileus
and toxic megacolon in children C/I in <6yr
Loperamide
Major peripheral action very less absorbed
and cant cross BBB no abuse liability
Inhibits secretion direct acts on calmodulin
A/E rashes, abd. pain, toxic megacolon and
paralytic ileus C/I in < 4yrs
Dose: 4mg f/b 2 mg at each motion

Role of antimotility drugs


Utility limited to

Noninfective diarrhoea
Mild travellers diarrhoea
Idiopathic diarrhoea in AIDS
Chronic diarrhoea of IBS
Very mild IBD with urgency interfering with daily
work

Never use antimotility drugs in acute infective


diarrhoea

Drug for
Inflammatory Bowel Diseases
5-ASA compounds
5-ASA compounds
Corticosteroids
Sulfasalazine, mesalazine, olsalazine,
Immunosuressants
balsalazine
TNF inhibitors
M/A: 5-ASA have local antiinflammatory
action by inhibition of production of cytokine,
PAF, TNF, NFKB
Also inhibits COX and LOX

Sulfasalazine = sulfapyridine + 5-ASA


Use for mild to moderate disease
Dose: Acute condi. 3-4 gm/d and for
maintainance 1.5-2 gm/d

A/E:
b/c of sulfapyridine rashes, joint pain, fever,
hemolysis, blood dyscrasias
Others: headache, malaise, anemia, oligozoospermia,
infertility, folic acid def.

Mesalazine (mesalamine): a delayed release prep.


Less side effect fever, leucopenia, headache,
nephrotoxicity
Dose: 2.5 gm
Olsalazine: two 5-ASA compound
Balsalazine: 5-ASA linked to 4-aminobenzoyl-Balanine

Corticosteroid
For moderately sever to very severe condition
For acute exacerbation of disease
Prednisolone (40-60mg/d) effect starts
within 3-7 days and remission in 2-3 week
Hydrocortisone and methyl prednisolone for
IV inj in very severe condi. with extraintestinal
symptoms
Hydrocortisone enema for proctitis
Steroid use for short term therapy only
If not controlled immunosupressants

Immunosupressant
Azathioprine(6-MP), methotrexate, cyclosporine
Use in steroid dependent, steroid resistant,
relatively severe cases
Adverse effect should be weighed to the efficacy
TNF inhibitor
Infliximab, adalimumab
Use in severe and refractory cases.

Thank You