Diarrhea

The treatment of diarrhea can be approached in a variety of ways. Although not supported in randomized clinical trials, the use of low doses of fiber can occasionally help to reduce

TABLE 39-1. Medications for the Treatment of Pain in Irritable Bowel Syndrome

Drug

Dose

Anticholinergics/antispasmodics

Dicyclomine (Bentyl)

10 mg every 6 hours up to 40 mg every 6 hours, if tolerated

Hyoscyamine (Levsin)

0.125 to 0.25 mg orally every 4 to 6 hours

(Levsin SL,Nulev)

0.125 to 0.25 mg sublingually every 4 to 6 hours

(Levinex,Levbid)

0.375 to 0.750 mg orally every 12 hours

(IBS Stat)

1 to 2 sprays (1 to 2 mL) orally every 4 to 6 hours

Methscopolamine bromide

(Pamine)

2.5 to 5 mg every 4 to 6 hours

Glycopyrrolate (Robinul)

1 mg orally twice daily

Clidinium bromide

Chlordioxipoxide (Librax)

1 cap orally 2 to 4 times daily

Belladonna with Phenobarbital

1 to 2 tabs/caps orally 2 to 4 times daily

(Donnatal)

Extended release: 1 tab orally every 8 to 12 hours

Tricyclic compounds

Nortriptyline (Pamelor)

10 to 75 mg/day

Desipramine (Norpramin)

10 to 75 mg/day

the frequency of bowel movements. Antidiarrheal medications, such as loperamide (Imodium) and diphenoxylate hydrochloride (Lomotil) may also improve stool consistency and frequency. In refractory cases of uncontrolled diarrhea, cholestyramine may bind bile acids that may be responsible for increased colonic secretion and decreased colonic absorption of water (Sciarretta et al, 1987). (Table 39-2). In some cases, a short course of antibiotics may be tried in the hope of reducing refractory diarrhea by altering the intestinal bacterial flora (Pimental et al, 2000).

Alosetron

The 5-HT3 receptor antagonist alosetron (Lotronex) has been shown to be effective in the treatment of women with the IBS and diarrhea.

In addition to improving stool frequency, stool consistency and fecal urgency, alosetron has also been shown to significantly reduce abdominal pain (Camilleri et al, 2000). Unfortunately, adverse reactions, such as severe constipation, ischemic colitis and bowel perforation, caused temporary withdrawal of alosetron from use; however, in June 2002, the Food and Drug Administration approved restricted marketing of alosetron for "the treatment of women with severe, diarrhea-predominant IBS who have failed to respond to conventional IBS therapy (Brandt et al, 2002)." The starting dose is 1 mg QD for 4 weeks. The dose is then increased to 1 mg twice daily if the patient experiences only partial relief. only physicians experienced in treating IBS patients are permitted to prescribe alos-etron, and informed consent must be obtained from the patient before initiating therapy. Patients must be instructed to discontinue the medication and contact their physician if severe constipation or worsening abdominal pain occurs. Despite these restrictions, alosetron can be a very effective therapy in the properly chosen patient.

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