Self-Care of Diarrhea, Nausea, and Vomiting PDF

SELF-CARE OF DIARRHEA, NAUSEA AND VOMITING Kelly Orr, PharmD, Clinical Professor Chapters 16 & 19 Learning Objectives ◦ Understand etiology, epidemiology, and pathophysiology of diarrhea, nausea and vomiting; ◦ Identify patients not suitable for self-treatment; ◦ Describe non...

SELF-CARE OF DIARRHEA, NAUSEA AND VOMITING Kelly Orr, PharmD, Clinical Professor Chapters 16 & 19 Learning Objectives ◦ Understand etiology, epidemiology, and pathophysiology of diarrhea, nausea and vomiting; ◦ Identify patients not suitable for self-treatment; ◦ Describe non-pharmacologic and pharmacologic treatment for N/V; ◦ Discuss treatment in special populations; and ◦ Review counseling points Diarrhea ◦ Abnormal ­ stool frequency or liquidity ◦ >3 BMs per day ◦ Acute, persistent, or chronic in nature ◦ Acute: < 14 days ◦ Persistent: 14 days – 4 weeks ◦ Chronic: > 4 weeks ◦ Symptom of underlying pathology or disease ◦ Mild-moderate mostly viral ◦ More severe is likely bacterial ◦ Approximately 1.7 billion episodes of acute diarrheal illness occur world wide annually ◦ Significant contributor to morbidity & mortality, especially children < 5 years ◦ US has an annual incidence of 1 case per adult be year Etiology of Diarrhea ◦ Viral gastroenteritis ◦ Food-Borne diarrhea (Table 3) ◦ Norovirus, rotavirus ◦ Mostly sanitation issues ◦ Self-limiting ◦ Viruses > Bacteria > Protozoa ◦ Bacterial gastroenteritis ◦ Also includes Traveler’s Diarrhea ◦ 10% of cases, several species ◦ Food- Induced diarrhea responsible ◦ Intolerance to foods ◦ Mod-severe cases need ◦ Spicy, fatty, high fiber,etc antibiotics ◦ Lactose intolerance ◦ Protozoal diarrhea ◦ Medications (Table 1) ◦ No OTC, Rx ◦ Antibiotics, PPIs, Mg See Table 2 for Infectious Causes Clinical Classifications ◦ Osmotic ◦ Secretory ◦ Inflammatory ◦ Motor See Table 4 for descriptions Exclusions for Self Treatment ◦ 100.4oF [38oC] ◦ Visible blood, mucus, or pus in the stool ◦ Persistent vomiting Exclusions for Self-Treatment (cont.) ◦ High output, frequent & substantial volume of diarrhea ◦ Severe abdominal pain/distress ◦ Risk for significant complications ◦ Diabetes, severe CVD, renal disease ◦ Multiple chronic medical conditions ◦ Immunosuppressed patients (ie: cancer chemo, AIDS) ◦ Frail patients > 65 years of age ◦ Pregnancy ◦ Chronic or persistent diarrhea ◦ Suboptimal response to ORS already administered Treatment Goals for Diarrhea ◦ Prevent or correct fluid and electrolyte loss and acid-base disturbance ◦ Control symptoms ◦ Identify and treat cause ◦ Prevent acute morbidity and mortality General Treatment Approach ◦ Review Figures 16-1 & 16-2 ◦ Focus on fluid and electrolyte replenishment for mild-moderate uncomplicated diarrhea ◦ Oral Rehydration Solutions (ORS) ◦ Infectious diarrhea often self-limiting ◦ If symptoms remain or worsen after 48 hours refer to PCP ◦ Symptomatic relief (loperamide) in carefully selected patients Non-Pharmacological Measures ◦ Fluid & Electrolyte management (next slides) ◦ Dietary management ◦ Don’t withhold food for more than 24 hours ◦ Should be reintroduce once hydrated (3 – 4 hours) ◦ Include complex carbohydrate-rich foods, yogurt, lean meats, fruits, and vegetables in diet ◦ BRAT not recommended, insufficient calories ◦ Avoid: fatty, spicy, simple sugar foods, and caffeine Non-Pharmacological Measures ◦ Preventative measures ◦ Viral gastroenteritis: washing hands, sterile techniques ◦ Rotavirus vaccine ◦ Traveler’s diarrhea ◦ BSS often recommended as prophylaxis though FDA deemed insufficient data to support; ACG published guidelines to use BSS 2.1 g four times a day for up to 2 weeks unless contraindicated (reduce risk up to 60%) ◦ ACG recommends loperamide for max 48 hours; however if dysentery only use concomitantly with antibiotics ◦ Prophylactic antibiotics not currently recommended for most travelers ◦ CDC publishes recommendation ◦ May be considered high risk patients/areas Fluid and Electrolyte Management ◦ Review Figures 16 – 1 and 16 – 2 ◦ Two Phases ◦ Rehydration over 3 – 4 hours to quickly replace water and electrolytes ◦ Maintenance to maintain normal body composition ◦ ORS preferred for mild-moderate dehydration Oral Rehydration Solutions ◦ ORS can compensate losses ◦ Slowly rehydrate the patient ◦ Common pediatric ORS products are listed in Table 16-6 ◦ WHO & UNICEF recommend ORS containing 75 mEq/L of sodium ◦ ORS in United States ◦ Rehydration solutions contain 70 – 90 mEq/L of sodium in US ◦ Maintenance ORS contain 45 – 50 mEq/L ◦ Products mostly pre-mixed, ease of use in children Household ORS ◦ Examples Listed in Table 6 ◦ Not recommended for children 6 months – 5 years old ◦ Avoid in dehydration or moderate – severe diarrhea ◦ Usually inappropriate sodium content and high carbohydrate ◦ Chicken soup has high sodium content ◦ Sports drinks can be used, can give with crackers or pretzels to replace sodium ORS Treatment (Figures 16-1 & 16-2) Dehydration Status 6 months – 5 years old > 5 years old Patient with no signs of Continue regular diet, Continue regular diet, dehydration ( 24 hours ◦ Severe abdominal pain in middle or right lower quadrant ◦ N/V with fever and/or diarrhea ◦ Severe right upper quadrant pain, esp. after fatty food ingestion ◦ Blood in vomit ◦ Yellow skin, eye discoloration, & dark urine ◦ Stiff neck, with or without headache, and sensitivity to brightness of normal light Exclusions for Self-Treatment (cont) ◦ Head injury with N/V, blurry vision, numbness or tingling ◦ Persons w/ glaucoma, BPH, COPD, or asthma ◦ N/V associated with chemotherapy, radiation, serious metabolic disorders, CNS, GI, or endocrine disorders ◦ Pregnancy (severe nausea) or lactation ◦ Drug Induced ◦ Psychogenic Induced ◦ Chronic Disease related ◦ Gastroparesis with DM, GERD Additional Exclusions for Children ◦ Review Figure 19 – 2 ◦ Previous exclusions plus accompanied by any signs or symptoms indicating ◦ High risk for dehydration*** ◦ Younger age = greater risk ◦ Suspected poisoning ◦ Meningitis/Severe headache ◦ Concussion ◦ High risk (DM, CNS disease, hernia) *** Specific examples provided in text Treatment Goals & Approach ◦ Most cases of N/V are self-limiting ◦ Provide symptomatic relief ◦ Identify and correct underlying cause ◦ Prevent and correct complications ◦ Prevent future occurrences ◦ Review Treatment Figures 1 & 2 Non-Pharmacologic Treatment ◦ To prevent motion sickness (Table 3) ◦ Avoid reading during travel ◦ Keep your line of vision straight ahead (while on boat, in car, on train) ◦ Avoid excess food or EtOH before or during travel ◦ Stay where motion is less experienced ◦ Front of car, near plane wing, mid-ship ◦ Avoid strong odors from food or tobacco ◦ Be in control of the vehicle if possible Acupressure Wristbands ◦ FDA approved for motion sickness & NVP ◦ Stimulation of Neiguan point (pericardium 6) ◦ May be worn on one or both wrists ◦ Acustimulation is only one wrist ◦ Best used prior to onset of symptoms or when symptoms first occur ◦ Can be used with antiemetic medications ◦ May be used in children as young as 2 years of age (www.sea- band.com/faqs) Non-Pharmacologic Treatment ◦ Acupressure Wristbands ◦ SeaBands® ◦ Nerve Stimulation Technology (NST) ◦ Manual pressure ◦ Data supports either finger pressure or band are effective in reducing rate of nausea ◦ Difficult to study due to placebo challenges Acupressure Point: Pericardium 6  Oral Rehydration Solutions (ORS) ◦ Dehydration often occurs ◦ ORS can compensate losses secondary to vomiting and ◦ Slowly rehydrate the patient diarrhea ◦ Commercially available ◦ ORS products contain: products: ◦ Na, Cl, K, citrate, & carbohydrates such ◦ Pedialyte, Infalyte (Pediatrics) as glucose or dextrose ◦ Sports drinks do not include ◦ Gatorade, Poweraid recommended balance of electrolytes ◦ Sugar-to-sodium ratio Refer to Chapter 16 (Diarrhea) for ORS/Dehydration – dosing as well ORS Treatment in N/V (Ch. 16 & 19) No Signs Dehydration Mild – Moderate (3 – Severe (≥10% by body ( 5 years: Begin ORS at 2 – 4 L over 3 hours and 12 Directions Bonine Chewable Tablets Meclizine 25 mg 25-50 mg 1 hour before travel Dramamine Less Drowsy (max 50 mg/day)* Unisom Doxylamine 25 mg In pregnancy, 10 – 12.5 mg w/or without pyridoxine every 8 hours Dramamine Orange Dimenhydrinate 50 mg 50-100 mg every 4-6 hrs (max Chewable Tablets** 400 mg/day)* Benadryl** Diphenhydramine 25 mg 25-50 mg every 4 – 6 hours (max 300 mg/day)* * Take 30 – 60 minutes prior to travel for motion sickness ** Pediatric dosing limited to dimenhydrinate & diphenhydramine Antihistamine Use Contraindications Precautions ◦ Prostatic Hyperplasia ◦ Some may develop excitation ◦ Glaucoma (narrow/closed angle) especially elderly & children ◦ Dementia ◦ Asthma/COPD ◦ CV disease (angina, arrhythmia)– more ◦ Avoid alcohol sensitive to anticholinergic adverse ◦ Combination products– patients effects may “double up” ◦ Drowsiness ◦ Lactation/pregnancy Overindulgence Food & Beverages Treatments (aka “Sour Stomach”) ◦ Antacids ◦ H2 Receptor Antagonists ◦ Bismuth Subsalicylate – See interactions in Table 19 - 5 ◦ Review from Chapter 13 (Heartburn) Phosphorated Carbohydrate Solution (Emetrol®) ◦ Mixture of fructose, dextrose, and phosphoric acid ◦ Avoid in patients with DM or hereditary fructose intolerance (5 mLs = 3.74 g sugar) ◦ Indicated for nausea caused by infection, dietary indiscretion, NVP, or motion sickness ◦ MOA: direct local action on GI tract that may reduce smooth muscle contraction Emetrol® Dosing ◦ Children (5 – 12 yrs): 5 – 10 mLs at 15 minute intervals until vomiting stops ◦ Adults: 15 – 30 mLs at 15 minute intervals until vomiting stops ◦ Patient Education: ◦ Do not use for more than 1 hour and do not exceed 5 doses ◦ Do not dilute ◦ Do not consume other liquids for at least 15 minutes after taking a dose ◦ For NVP: 15 – 30 mL at rise, repeat every 3 hours if nausea threatens Special Populations: Pediatrics ◦ N/V from acute gastroenteritis, motion sickness, or dietary factors ◦ Antihistamines, phosphorated carbohydrate solution, and ORS ◦ Meclizine: > 12 yrs ◦ Diphenhydramine: > 6 yrs ◦ Dimenhydrinate: > 2 yrs ◦ Emetrol®: > 2 yrs ◦ Higher risk of dehydration, more exclusion ◦ Figure 19 – 2 Special Populations: Advanced Age ◦ Many drug interactions and side effects with current medications ◦ Anticholinergic effects ◦ Cognitive function, BPH, glaucoma ◦ Increased drowsiness related to falls ◦ Drug interactions ◦ BSS, cimetidine, antihistamines ◦ Emetrol and acupressure may be safely used ◦ Not with DM ◦ Caution electrical devices with pacemakers Special Populations: NV in Pregnancy ◦ Fresh air in the room where you sleep and where meals are prepared and eaten ◦ Before getting out of bed, eat several dry crackers and relax for 10 – 15 minutes ◦ Get out of bed slowly ◦ Eat 4 – 5 small meals per day instead of 3 large meals, do not overeat ◦ Cold food is better tolerated than hot ◦ Eat dry, bland, high protein food ◦ Take small sips of carbonated beverages ◦ Vitamin B6 ◦ Pyridoxine (A) ◦ 25-50mg three times per day ◦ 1st line with or without doxylamine Complementary Therapies ◦ Ginger ◦ Motion sickness: Two 500 mg capsules 30 minutes prior to travel, followed by 1 – 2 capsules every 4 hours as needed ◦ Maximum of 4 g per day ◦ Cannabinoids (CBD) ◦ Cannabidiol oil is < 0.3% THC, regulatory issues with good manufacturing processes and the lawful marketing of this product ◦ CBD has perceived benefits, evidence to support is overall lacking ◦ Adverse effects and drug interactions concerns not fully characterized