Diarrhea is defined as 3 or more loose, watery stools a day.1,2 About 179 million cases of acute diarrhea occur in the United States each year1 and are generally caused by stomach viruses. Health care professionals can play an important role in managing patients with diarrhea by recommending OTC products for initial treatment.

DEHYDRATION SIGNS AND SYMPTOMS
Diarrhea usually resolves on its own without treatment. However, it is important to prevent dehydration, which can ultimately lead to hospitalization. Patients should be educated about the signs and symptoms of dehydration in adults and children, as it can be life-threatening if untreated. Adults may experience dark-colored urine, dizziness, dry mouth or skin, excessive thirst, fatigue, little or no urination, or weakness.3,4 Dehydration signs and symptoms in infants and children include crying without tears, drowsiness, dry mouth or tongue, fever above 102°F, irritability, lack of wet diapers for 3 or more hours, and sunken abdomen, cheeks, or eyes.4 Patients with diarrhea accompanied by bloody stools, fever, or severe abdominal pain should be seen by a health care provider immediately, as these could be signs of a serious infection.

OTC TREATMENT OPTIONS
Oral rehydration solutions, such as Gatorade for adults and Pedialyte for children and infants, should be used to replenish electrolytes lost through mild to moderate diarrhea.3 Once patients are adequately hydrated, they can resume a normal diet. Breast milk or formula should be continued throughout the diarrhea episode. Recommend that patients take oral rehydration products when they travel, especially on cruise ships, which are known for norovirus outbreaks. Norovirus can cause diarrhea and vomiting, so it is important to be prepared.

Pedialyte products include powder formulations that can dissolve in drinks, making them easy for travel. However, individuals with severe dehydration may need to be hospitalized and given intravenous fluids if OTC oral rehydration solutions are not successful.3 Loperamide (Imodium A-D) is available over the counter and may be given to healthy adults with acute watery diarrhea, but it should be avoided in patients with bloody stools and fever, as these are signs of infection with bacteria or parasites. The maximum adult OTC dose is 8 mg per day.5 Additionally, loperamide should be avoided in patients who are younger than 18.3 The FDA has received reports of individuals abusing loperamide by taking excessive dosages.5 This can lead to serious cardiac adverse events, including heart attacks, loss of consciousness, QT interval prolongation, and Torsades de Pointes or other ventricular arrhythmias. Health care professionals should educate patients about the risks of abusing loperamide. The FDA is working with manufacturers to limit the number of doses in a package to prevent its abuse.5

Probiotics (eg, Culturelle, Florajen, and Florastor) may help to prevent and treat diarrhea resulting from antibiotics.3 Advise patients to wait at least 2 hours after taking an antibiotic to use a probiotic.4 However, there is mixed evidence regarding the use of probiotics to treat diarrhea caused by stomach viruses, even though they are commonly recommended in clinical practice as there are few adverse effects. One recent double-blind, randomized study examined children aged 3 months to 4 years with acute diarrhea caused by a stomach virus.6 Study participants received a 5-day course of Lactobacillus rhamnosus GG twice a day or a placebo. The study found there was no difference between the placebo and the probiotic.6 Therefore, probiotics may not help to treat diarrhea caused by stomach viruses in children. Probiotics will continue to be looked at in future studies.



For more pharmacist-recommended OTC products, visit OTCguide.net.
 
Jennifer Gershman, PharmD, CPh, is a drug information pharmacist and Pharmacy Times® contributor who resides in South Florida.


References
  1. US Department of Health and Human Services. Diarrhea. National Institute of Diabetes and Digestive and Kidney Diseases website. niddk.nih.gov/health-information/digestive-diseases/diarrhea. Accessed March 14, 2019.
  2. Mayo Clinic. Diarrhea. mayoclinic.org/diseases-conditions/diarrhea/symptoms-causes/syc-20352241. Accessed March 14, 2019.
  3. Shane AL, Mody RK, Crump JA, et al. 2017 Infectious Diseases Society of America clinical practice guidelines for the diagnosis and management of infectious diarrhea. Clin Infect Dis. 2017;65(12):e45-e80. doi: 10.1093/cid/cix959.
  4. Gershman J. Diarrhea: causes, management, and prevention strategies. Pharmacy Times.  July 21, 2018.pharmacytimes.com/publications/issue/2018/july2018/diarrhea-causes-management-and-prevention-strategies. Accessed March 15, 2019.
  5. FDA drug safety communication: FDA limits packaging for anti-diarrhea medicine loperamide (Imodium) to encourage safe use. FDA website. fda.gov/Drugs/DrugSafety/ucm594232.htm. Updated May 15, 2018. Accessed March 14, 2019.
  6. Schnadower D, Tarr PI, Casper C, et al. PECARN Probiotics Study Group. Lactobacillus rhamnosus GG versus placebo for acute gastroenteritis in children. N Engl J Med. 2018;379(21):2002-2014. doi: 10.1056/NEJMoa1802598.