Loperamide associated necrotising enterocolitis

A Review on the Management of Acute Gastroenteritis in Children

Acute gastroenteritis represents a frequent cause of morbidity among children in Hong Kong. Despite the large number of potential etiologic agents, principles of management of gastroenteritis are uniform and aim to prevent the two major complications - dehydration and malnutrition. A review of the literature was performed. Selected articles were appraised, graded, and synthesised qualitatively. Statements on recommendations were generated. Current evidence emphasises the use of oral rehydration and the early reintroduction of age-appropriate foods. Apart from these two, important aspects of management reviewed included laboratory investigations, role of anti-diarrhoeal agents, and use of antimicrobial agents. Criteria for admission of high-risk children are also addressed.

Systematic review of loperamide: No proof of antibiotics being superior to loperamide in treatment of mild/moderate travellers' diarrhoea

Looking at the worldwide emergency of antimicrobial resistance, international travellers appear to have a central role in spreading the bacteria across the globe. Travellers' diarrhoea (TD) is the most common disease encountered by visitors to the (sub)tropics. Both TD and its treatment with antibiotics have proved significant independent risk factors of colonization by resistant intestinal bacteria while travelling. Travellers should therefore be given preventive advice regarding TD and cautioned about taking antibiotics: mild or moderate TD does not require antibiotics. Logical alternatives are medications with effects on gastrointestinal function, such as loperamide. The present review explores literature on loperamide in treating TD. Adhering to manufacturer's dosage recommendations, loperamide offers a safe and effective alternative for relieving mild and moderate symptoms. Moreover, loperamide taken singly does no predispose to contracting MDR bacteria. Most importantly, we found no proof that would show antibiotics to be significantly more effective than loperamide in treating mild/moderate TD.

Diarrhoea during military deployment: current concepts and future directions

PURPOSE OF REVIEW

Diarrhoea among military travellers deployed globally in conflict and peacekeeping activities remains one of the most important health threats. Here we review recent advances in our understanding of the epidemiology, laboratory identification, treatment and chronic health consequences of this multi-cause infection, and consider the implications for public health management and future research.

RECENT FINDINGS

The incidence of diarrhoea among deployed military personnel from industrialized countries to lesser developed countries is approximately 30% per month overall, with clinical incidence between 5 and 7% per 100 person-months. The risk appears to be higher early during deployment and is associated with poor hygienic conditions and contaminated food sources. Gaps remain in our understanding of the cause, given the lack of laboratory capability in austere conditions of deployment; however, recent advances in molecular methods of characterization hold promise in improving our detection capabilities. While there have been improvements in understanding of best treatments, more work needs to be done in transforming this knowledge into action and optimizing single-dose antibiotic treatment regimens. Finally, the under-recognized burden of chronic consequences of these infections is gaining awareness and reinforces the need to find effective preventive strategies.

SUMMARY

Our understanding of the epidemiology of diarrhoea is improving but further research is needed to fully account for acute operational-focused health impacts as well as the chronic enduring disease impacts. Improved field diagnostics would be of great value to support these efforts.

Knowledge, attitudes, and practice of travelers' diarrhea management among frontline providers

BACKGROUND

Many studies have found acute gastrointestinal infections to be among the most likely reason for clinic visits among forward deployed soldiers and are considered a significant contributor to morbidity in this population. This occurs despite the controlled food and water distribution systems under which military populations operate. Furthermore, recent studies have indicated that providers often fail to appropriately identify and treat the typical causes of these infections. To adequately address this issue, an assessment of gaps in knowledge, practice, and management of acute diarrhea in deployed troops was conducted.

METHODS

A multiple-choice survey was developed by clinical researchers with expertise in travelers' diarrhea (TD) and provided to a convenience sample of clinical providers with a broad range of training and operational experience. The survey evaluated provider's knowledge of TD along with their ability to identify etiologies of various syndromic categories of acute gastrointestinal infections. Providers were also queried on selection of treatment approaches to a variety of clinical-based scenarios.

RESULTS

A total of 117 respondents completed the survey. Most were aware of the standard definition of TD (77%); however, their knowledge about the epidemiology was lower, with less than 24% correctly answering questions on etiology of diarrhea, and 31% believing that a viral pathogen was the primary cause of watery diarrhea during deployment. Evaluation of scenario-based responses showed that 64% of providers chose not to use antibiotics to treat moderate TD. Furthermore, 19% of providers felt that severe inflammatory diarrhea was best treated with hydration only while 25% felt hydration was the therapy of choice for dysentery. Across all provider types, three practitioner characteristics appeared to be related to better scores on responses to the nine management scenarios: having a Doctor of Medicine or Doctor of Osteopathy degree, greater knowledge of TD epidemiology, and favorable attitudes toward antimotility or antibiotic therapy.

CONCLUSION

Results from this survey support the need for improving knowledge and management of TD among deploying providers. The information from this study should be considered to support the establishment and dissemination of military diarrhea-management guidelines to assist in improving the health of military personnel.

Fulminant amoebic colitis following loperamide use

Toxic megacolon is a rare consequence of infection with Entamoeba histolytica. We present such a patient in whom the course of disease may have been influenced by heavy loperamide use. Loperamide and other anti-motility agents have been implicated previously in the pathogenesis of toxic megacolon in patients with infectious gastroenteritis.

Colonic toxicity of administered drugs and chemicals

Although uncommon, medication-induced colonotoxicity is important to recognize because medication cessation generally leads to prompt clinical improvement, while medication continuation results in disease exacerbation. This review categorizes the association between medications and colonotoxicity as "well-established" or "probable," according to the following criteria: total number of reported cases, number of different research groups reporting an association, experimental and pharmacologic evidence of an association, and validity of an association in each reported case. Cocaine, ergotamine, estrogen, sodium polystyrene, alosetron, amphetamines, pseudoephedrine, and vasopressin are associated with colonic ischemia. The mechanisms include vasospasm, thrombogenesis, and shunting of blood from mesenteric vessels. Narcotics, phenothiazines, vincristine, atropine, nifedipine, and tricyclic antidepressants are associated with colonic pseudo-obstruction. The mechanisms include antagonizing prokinetic neurotransmitters, stimulating antikinetic neurotransmitters, promoting dysmotility, relaxing smooth muscle, and injuring enteric neurons. Numerous antibiotics are associated with pseudomembranous colitis; ampicillin is associated with hemorrhagic colitis; chemotherapy is associated with neutropenic colitis; and deferoxamine is associated with Yersinia enterocolitis. Mechanisms of these toxicities include altering normal bowel flora, weakening immunologic defenses, promoting microorganism virulence, and mucosal injury. Gold compounds, nonsteroidal antiinflammatory drugs, alpha-methyldopa, salicylates, and sulfasalazine are associated with an inflammatory or cytotoxic colitis. The mechanisms include direct mucosal cytotoxicity, antimetabolite effects, or drug allergy. Nonsteroidal antiinflammatory drugs, cyclo 3 fort, flutamide, lansoprazole, and ticlopidine are associated with lymphocytic colitis. The mechanisms include immunologic activation or attenuated immunologic defenses. Chronic cathartic use leads to colonic hypomotility and abdominal distention. Intrarectally administered corrosive compounds can produce a toxic colitis.

Review article: over-the-counter drugs and the gastrointestinal tract

An increasing number of drugs are becoming available over-the-counter, empowering patients to treat them- selves. Although drugs presently available over-the-counter are generally safe, there are issues of safety and possible delays in diagnosis of serious conditions. Therefore it is vital that patients are made aware of the indications and limitations of over-the-counter drugs through improved communication and education. Pharmacists and drug companies will have an increasingly important role in giving information and advice to patients. This review looks at the present and future of over-the-counter medication, highlighting the safety aspects.

A multicenter randomized controlled trial of a liquid loperamide product versus placebo in the treatment of acute diarrhea in children

This randomized, double-blind, placebo-controlled trial of 48 hours' duration conducted in 13 primary care ambulatory practices in the United States and Mexico was used to compare the efficacy and safety of loperamide with placebo for the treatment of acute diarrhea in children aged 2 through 11 years. Two hundred fifty-eight children with acute nonspecific diarrhea were enrolled. Children were randomly assigned to treatment with loperamide HCl 0.5 mg/5 mL (n = 130) or placebo (n = 128). The first dose of loperamide consisted of either 1.0 mg (children 2 through 5 years of age) or 2.0 mg (children 6 through 11 years of age) of study medication under the observation of study personnel. This was followed by 1 mg after each unformed stool, with a total daily dose of up to 3.0 mg in the children 2-5 years of age, 4.0 mg in the children 6-8 years of age, and 6.0 mg in the children 9-11 years of age. The primary outcome measures were time to last unformed stool, time to first unformed stool, number of unformed stools during six consecutive 8-hour periods, and overall rating of efficacy/acceptability. Secondary outcomes included abdominal pain/cramping, vomiting, and fever. Children who received loperamide had significantly shorter time to last unformed stool (p = 0.0017) and fewer numbers of unformed stools (p = 0.0237) than children who received placebo. The end-of-study overall efficacy/acceptability rating of loperamide was significantly better than for placebo (p = 0.0107). All other clinically important outcome measures related to diarrhea relief favored loperamide. There was no significant difference in the incidence of drug-related adverse events between treatment groups, although total adverse events were reported more frequently (p = 0.048) by the loperamide group (15%) compared with the placebo group (7%). In conclusion, this controlled study provides data demonstrating that at recommend doses, loperamide is well tolerated and significantly shortens the duration and severity of symptoms of acute nonspecific diarrhea in children 2 through 11 years of age.

Surveillance of loperamide ingestions: an analysis of 216 poison center reports

BACKGROUND

Loperamide was approved for nonprescription use in 1988. While efficacy is well documented, there are few data on loperamide overdose and management.

METHODS

Eight poison centers participated in a prospective study enrolling 216 patients.

RESULTS

Where the amount ingested was known, it ranged from 0.03 to 0.94 mg/kg. One- to 3-year-olds were involved in 57.9% of ingestions. Ingestion was unintentional in 182 cases (84.3%), including 59 patients with therapeutic errors (27.3% of all cases). Dispensing cup errors were implicated in 23 cases; 15 patients assumed the dispensing cup was the unit of measure. No symptoms developed in 63.0%; 27.8% had related symptoms. No related symptoms were life-threatening, and no fatalities occurred. The most frequent symptoms were drowsiness (15.7%), vomiting (4.2%), and abdominal pain or burning (3.7%). The frequency of related symptoms was compared in patients receiving the most frequently utilized decontamination modalities: ipecac alone, activated charcoal alone, lavage and activated charcoal, and ipecac and activated charcoal. Compared to the 112 patients who received no decontamination, only the ipecac-treated group demonstrated a significant reduction in the frequency of related symptoms; 13.9% of patients given ipecac alone (without other gastric decontamination) had related symptoms compared to 33.0% of patients who received no decontamination. Three patients received naloxone for CNS symptoms related to loperamide; two responded and the response of the third was unknown.

CONCLUSION

Within the range of doses implicated in this study (up to 0.94 mg/kg), there were no life threatening clinical effects and no fatalities. Development of a management protocol is complicated by the absence of a predictable clinical response in each dose range. The data suggest that children over six months with single acute ingestions up to 0.4 mg/kg, and possibly higher, can be safely managed at home, without gastric decontamination.

Treatment of diarrhea of neonatal calves

Therapeutic strategies for the treatment of diarrhea of neonatal calves should be logical and should be targeted at correction of physiologic dysfunction. Appropriate, specific antimicrobial or antiprotozoal therapy should be instituted when colibacillosis, salmonellosis, or giardiasis is confirmed or suspected. All calves with diarrhea should be rehydrated if necessary, and proper nutritional support should be provided. Antisecretory agents such as flunixin meglumine and bismuth subsalicylate may be beneficial for treatment of calves with colibacillosis and salmonellosis. Adsorbants, such as attapulgite and bismuth subsalicylate, also may reduce loss of fluids. Perhaps loperamide or a similar drug will be proven effective in calves in the future. Potentially harmful drugs include several antimicrobial agents when they are administered orally, because they result in malabsorption; kaolin and pectin, which increase loss of ions during diarrhea; and motility modifiers that cause a decrease in all types of intestinal motor function. Finally, success should be measured by indicators of production such as survivability, days treated, weight gained, and net profit. Our goal should be to restore and maintain the health of the calf, not simply to alter the volume and consistency of the feces.

Necrotising colitis with perforation in diarrhoic patients treated with loperamide

Two cases of necrotising enterocolitis with perforation occurred in patients with paralytic ileus after loperamide therapy. The possible role of loperamide in the pathogenesis of the complications is suggested.

Necrotizing enterocolitis: an overlooked life-threatening complication of acute diarrhoeal illness in infants and children

A 7-month-old girl developed necrotizing enterocolitis with extensive pneumatosis intestinalis following an acute diarrhoeal illness. This was preceded by the use of an anti-motility drug and repeated attacks of paralytic ileus. It is noteworthy that all the published cases of necrotizing enterocolitis following acute diarrhoeal illness in infants and children are from tropical countries. This might be related to the use of anti-diarrhoeal drugs and associated malnutrition resulting in hypokalaemia and hypoalbuminaemia.

Double blind trial of loperamide for treating acute watery diarrhoea in expatriates in Bangladesh

To determine if loperamide is effective and safe in treating watery diarrhoea, we randomly assigned 50 adult expatriates in Bangladesh with more than three unformed stools in the previous 24 hours and illness of less than 72 hours to receive loperamide or a placebo. On entry into the five day study patients took two capsules (one loperamide capsule = 2 mg) and one after each unformed stool up to a maximum of eight per day. The groups did not significantly differ in pretreatment features or pathogens identified. Mean number of stools on study day 1 was 2.6 in the loperamide group and 4.0 in the placebo group (p = 0.035); on day 2 it was 1.3 versus 3.4 (p less than 0.001). Differences in stool frequencies during the final three study days, or proportion of patients with cramps, nausea, or vomiting on any study day, were not significant. No serious side effects occurred in either group. We conclude that loperamide, by decreasing stool frequency during the early part of illness, may have a role in the symptomatic treatment of this self-limiting disease.