# article on D



## eric (Jul 8, 1999)

This is not IBS per se but it has some good info. Anyone try sunflower seeds as a laxative? Just fyi infoDiarrhea: Causes and Self-CareTreatmentsW. Steven Pray, Ph.D., R.Ph., Professor of NonprescriptionProducts and Devices, School of Pharmacy, SouthwesternOklahoma State University, Weatherford, OKAbstractThe average person living in the United States experiences 1-2episodes of diarrhea yearly. Diarrhea is usually viewed as nomore than a minor discomfort, since it is seldom fatal indeveloped countries with adequate hygiene and sanitation.[1]However, in developing countries, people suffer from 15-20episodes yearly. In Asia, Africa and Latin America, diarrheaclaims the lives of 12,600 children every day.[1,2] [U.S.Pharmacist 25(11) 2000. ï¿½ 2000 Jobson Publishing Corp.]CausesDiarrhea is often a symptom of serious illness and is not adisorder that should always be self-treated withnonprescription antidiarrheals.[3] Experts subdivide diarrhealdiseases as acute, persistent (lasting for two weeks or longer),or chronic (persisting for longer than one month).[2] Patientswith diarrhea lasting for 48 hours or more should be referred toa physician, so that differential recognition of persistent andchronic diarrhea can be undertaken. Treatment of acutediarrhea is within the realm of self-care in some cases.Acute Infectious DiarrheaMany acute cases of diarrhea are infectious in origin,attributable to bacterial, viral, or parasitic pathogens. Cluesinclude ingestion of suspect food or drink, poor sanitation,contact with an infected individual, fever, recent travel,vomiting preceding the diarrhea, or bloody and/or mucoidstools.[2,4] However, if a food is suspected, it is difficult toidentify it with certainty since infected food usually tastesnormal.[1] Physicians must consider the use of antibiotics forpatients with acute infectious bacterial or parasitic diarrhea. Ifthe pharmacist suspects an infectious cause, it is wise to referthe patient.Reye SyndromeDiarrhea is a possible symptom of Reye syndrome in infants,especially when accompanied by fever, malaise, vomiting,upper respiratory symptoms, behavioral changes, tachypnea,and apneic episodes.[5] Use of salicylates (i.e., aspirin) may beassociated with the development of Reye syndrome in childrenor teens with influenza or chicken pox. Thus, a patient who hasingested a salicylate and is experiencing diarrhea along withthese symptoms should be immediately referred. Antibiotic-Associated Diarrhea (AAD)Oral antibiotics often cause diarrhea, with an onset rangingfrom several hours after the first dose to two months after thelast dose.[6] The pharmacist should refer the patient with AAD,since the physician must make a choice whether to test for thepresence of Clostridium difficile. The wisdom of continuingthe causal antibiotic must also be considered as to theseriousness of the underlying infection for which it wasprescribed.MedicationsPrescription or nonprescription medications other thanantibiotics may induce diarrhea.[7] The pharmacist might askabout use of antiarrhythmics, antineoplastics or prokineticagents. Antacids/laxatives containing magnesium salts (e.g.,Milk of Magnesia, Haley's M-O) are a common cause. Properuse or abuse of other medications, such as the diabetesmedication Glucophage (metformin), may also be a cause. Thepatient's physician should be informed of this reaction so that atherapeutic decision can be made.DietIngestion of fiber, bran, fructose, or fruit may also result indiarrhea. Eating a jar of sunflower seeds can provide sufficientfiber to induce laxation. In addition, excessive use of sugar-freesweeteners by diabetics (e.g., mannitol, xylitol) can causediarrhea. The patient may be advised to reduce intake belowthe level that causes symptoms.elf-Care InterventionsWhen a patient asks for a self-care recommendation fordiarrhea, the pharmacist must refer patients under the age of 3and those with fever to the physician, as well as those whosediarrhea has persisted for longer than 48 hours. However, if thepatient does not meet any of the exclusionary criteria, severalself-care products are available. The pharmacist should stressthat all of the precautions on product labels must be followedclosely.AdsorbentsThere are several mechanisms by which nonprescriptionproducts can halt episodes of diarrhea. Adsorbent agents arethought to function mainly through the adsorption of toxins andother substances that produce diarrhea. The three adsorbentingredients proven safe and effective for diarrhea self-care arebismuth subsalicylate, attapulgite, and kaolin. (Kaolin is nolonger an ingredient in any leading product marketed at thistime.)Bismuth subsalicylate is popular as Pepto-Bismolcaplets, chewables or suspension. Whichever dosage form ischosen, the patient should be cautioned not to exceed dosageson product labels. Adult dosage for bismuth subsalicylateproducts is two tablespoonsful or tablets, with the dose forchildren 9-12 being half of that. The dose for those aged 6-9 istwo teaspoonsful or two thirds of a tablet and the dose for thoseaged 3-6 is one teaspoonful or one third of a tablet. Doses arerepeated every 30-60 minutes as needed, to a maximum of eightdoses in any consecutive 24-hour period. Due to the salicylatecontent of these products, the pharmacist must cautionpurchasers against use if a child or teenager has or isrecovering from chicken pox or flu. Further, the patient maynotice tinnitus if the product is taken with aspirin. A harmlessblackening of the tongue or teeth may occur due to conversionof residual oral bismuth to a harmless black compound. Stoolsmay also darken, which is an equally harmless reaction. Thesuspension must be well agitated prior to pouring a dose.Attapulgite reduces the number of bowel movements andimproves the consistency of loose, watery bowel movements. Itis found in such popular products as Kaopectate suspension,cherry-flavored suspension, and caplets, and in Donnagelsuspension. Kaopectate products are dosed as follows:children aged 3 to under 6 should take one-half tablespoonfulof the suspension; those aged 6 to under 12 should take onetablespoonful of suspension or one caplet, and those over 12should take two tablespoonsful or two caplets. Doses may beinstituted at the first episode of diarrhea and repeated aftereach loose bowel movement to a maximum of six doses in anyconsecutive 24-hour period. Donnagel is not recommended forchildren under the age of 6 years. A maximum of seven doses isadvised in a 24-hour period. Companies marketing attapulgitevoluntarily elected to include the phrase, "Do not use ifdiarrhea is accom-panied by blood or mucus in the stool?on theproduct labels Both Donnagel and Kaopectate suspensions mustbe agitated before pouring a dose.Calcium PolycarbophilCalcium polycarbophil is a hydrophilic, polyacrylic resin thatis insoluble in water and can absorb 60 times its weight inwater. Each tablet contains the equivalent of 500 mg ofpolycarbophil. If the patient has diarrhea, polycarbophilabsorbs excess water by forming a gel that facilitates thenormalization of bowel movements. The ingredient is free oftoxic effects, being unabsorbed and pharmacologicallyinactive. Available as Equalactin and Mitrolan chewabletablets, the products carry a warning against the concurrent useof tetracycline due to chelation with the calcium. Mitrolandoses are two tablets four times daily for adults, one tabletthree times daily for children ages 6 to under 12, and one tablettwice daily for patients aged 3 to under 6 years; dailymaximums are 12, 6, and 3 tablets in 24-hours, respectively.Equalactin doses are two tablets four times daily for adults,one tablet four times daily for those 6 to under 12, and onetablet 1? times daily for those aged 3 to under 6; dailymaximums are 8, 4, and 2 tablets, respectively. Patients usingbulking agents such as polycarbophil are cautioned that taking itwithout at least 8 ounces of water can cause choking as theproduct expands in the area above the trachea. LoperamideLoperamide (Imodium A-D solution or caplets) was the subjectof an Rx to OTC switch in the late 1980s. It slows peristalsis,reducing the frequency of bowel movements. The product labelprohibits use if the patient has blood or mucus in the stool, hasa rash or other allergic reaction to loperamide, is takingantibiotics, or has a history of liver disease. Patients 12 andolder should take four teaspoonsful after the first loose bowelmovement and two after each subsequent bowel movement. Amaximum of eight teaspoonsful can be taken daily. Childrenages 6-11 should take two teaspoonsful initially, followed byone teaspoonful after each loose bowel movement, up to amaximum of six teaspoonsful daily (9-11 years old) or fourdaily (6-8 years old). Dosing for caplets is similarly tailoredfor the patient's age. The product is not to be administered tochildren under the age of 6 years without a physician'srecommendation for proper dosing. Electrolyte ProductsSeveral companies market electrolyte products that helpprevent imbalances in the patient with diarrhea. Theircompositions are included in Table 1. However, if thepharmacist is convinced that a patient requires immediatehydration, it may be more prudent to refer the patient to aphysician. There are several reasons for this. First is theserious nature of dehydration and electrolyte imbalances in thepediatric patient. Second, children may not accept theelectrolyte solutions because of the unpleasant flavor. If theproduct is purchased in liter bottles, it must be refrigeratedafter opening and discarded after 48 hours.Internet PrecautionsA tour through Internet sites giving advice for diarrheademonstrates the precautions patients should take in using thisresource. Various web sites promote such therapies fordiarrhea as relaxation (for a 4-month old infant) to counteremotional upsets a mother had while she was pregnant,grapefruit seed extract (touted as "a broad spectrum,antimicrobial, antiparasitic and natural antibiotic?, andhomeopathic arsenic and podophyllum. None of these therapieshave proven to be safe or effective for the self-treatment ofdiarrhea; therefore, they should not be a substitute for safe andeffective interventions.DurationThe bowel movements in diarrhea are not fully formed, but arepartly composed of liquid. Thus, with every loose bowelmovement, the patient is losing body water. If the water losscontinues for too long, the patient becomes dehydrated. Withthe loss of water, the patient is also losing electrolytes--vitalelements such as sodium, potassium, calcium, and magnesium.If the body loses excessive amounts of these, its function can beendangered. For instance, low potassium can produce heartproblems. For these reasons, there is a 48-hour time limit onhow long diarrhea can last before you must see a physician.Although nonprescription products provide this information,some patients interpret labels to mean that they have 48 hoursafter purchase of the product before they should see aphysician. This is incorrect and dangerous. Rather, you onlyhave 48 hours after the first bowel movement to self-treat. If thediarrhea is still present after 48 hours (following the firstbowel movement), you should call a physician. AgeAdults usually can withstand diarrhea, as long as it does notpersist too long. However, children are more prone to fluid andelectrolyte upsets. For this reason, diarrhea should not beself-treated if the patient is under the age of 3. Do not purchasea nonprescription product and simply cut the dose for a childyounger than 3 years old. The products are not known to be safefor self-treatment at those ages. You should call a pediatricianinstead.Other SituationsIf you have fever, infection may be present, and diarrhea shouldnot be self-treated regardless of how long it has lasted or theage of the patient. Some products warn against self-treatment ifthere is blood or mucus in the stool. See a physician in either ofthese cases.ElectrolytesMost pharmacies stock electrolyte products that can helpprevent deficiencies when patients have diarrhea (Infalyte,Pedialyte, KaoLectrolyte, RevitalIce). Some are ready to drink,some are frozen before use, and others must be mixed withwater before use. Electrolyte products do not treat diarrhea.They do not allow anyone to ignore the 3-year age cut-off or the48-hour time limit on self-therapy. If the patient is over the ageof three years, the diarrhea has not lasted more than 48 hours,and fever is not present, diarrhea maybe self-treatable. Severalsafe and effective nonprescription antidiarrheal agents areavailable (Pepto-Bismol, Kaopectate, Imodium A-D, Mitrolan,Equalactin). For help in choosing a product that is appropriatefor you, Consult Your Pharmacist. ------------------ http://www.ibshealth.com/ www.ibsaudioprogram.com


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## LUCIA (Nov 1, 2000)

Eric, thank you for such a great article. It was very informative. I really appreciate the info you share with all of us.------------------


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