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Antimotility agents used for high-output fistulas

Drug	Initial dose	Route	Frequency	Titration	Max dose	Cost*	Special considerations
Loperamide	4 mg	PO	Three times daily with meals or every 6 hours with enteral nutrition	By 2 mg	16 mg/day	$	Avoid liquid due to propylene glycol content
Diphenoxylate/atropine	2.5 mg/0.025 mg (1 tablet)	PO	Three times daily with meals or every 6 hours with enteral nutrition	By 1 tablet	2 tablets four times daily (20 mg diphenoxylate)	$$	Avoid liquid formulation due to sorbitol content
Pantoprazole	40 mg	IV	Twice daily	None	40 mg twice daily	$$$	Discontinue as soon as feasible
Codeine	15 mg	PO	Three times daily with meals, up to four times daily	By 15 mg	45 mg four times daily	$$	Monitor for CNS effects
Octreotide	100 mcg	SC	Three times daily	None	None	$$$	Discontinue if output not decreased after 3 to 5 days
Clonidine	0.3 mg	Transdermal	Every 7 days	None	0.3 mg every 7 days	$$$$	Monitor HR and BP

PO: oral; IV: intravenous; CNS: central nervous system; SC: subcutaneous; HR: heart rate; BP: blood pressure.
* Prices estimated based on approximate inpatient acquisition cost:

$: less than $1 per day
$$: more than $1 per day
$$$: more than $5 per day
$$$$: more than $10 per day

Reproduced from: Parli SE, Pfeifer C, Oyler DR, et al. Redefining "bowel regimen": Pharmacologic strategies and nutritional considerations in the management of small bowel fistulas. Am J Surg 2018; 216:351. Table used with the permission of Elsevier Inc. All rights reserved.

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