Medication/supplement | Comments |
Antidiarrheal agents |
Loperamide 2 to 4 mg as needed. Not to exceed 16 mg/day. | - Preferred initial antidiarrheal.
- Gradually titrate down to minimum required.
- Commercial liquids (1 mg/5 mL or 1 mg/7.5 mL) also available.
|
Diphenoxylate-atropine (2.5/0.025 mg). 1 to 2 tablets after each loose stool. Not to exceed 8 tablets/day. | - Each tablet contains 2.5 mg diphenoxylate (synthetic opioid).
- Atropine ingredient is to discourage abuse; causes anticholinergic effects with excess dosing.
- Commercial liquid (2.5/0.025 mg/5 mL) also available.
|
Deodorized tincture of opium 1% solution (contains 10 mg morphine per mL) 0.3 to 0.8 mL in water three times daily. | - Effective alternative in severe diarrhea with insufficient response to loperamide and diphenoxylate.
- US DEA C-II controlled substance; addictive potential.
- Avoid abrupt discontinuation, which may produce withdrawal syndrome.
- Not recommended for use in patients with a history of substance abuse.
|
Bile acid binding resins for bile acid malabsorption-associated diarrhea [cholorrhea], not fat malabsorption |
Cholestyramine 4 g once daily initially; increase gradually (eg, weekly) to 4 g three times daily. | - May reduce absorption of other drugs and supplements; administer either ≥1 hour before or 4 to 6 hours after other drugs and supplements. Refer to drug interactions database.
- Available as 4 g packets and 4 g/scoop bulk powder.
|
Colestipol: - Granules: 5 g once or twice daily; increase gradually to 5 g three times daily
- Tablets: 2 g once or twice daily; increase gradually to 2 g three times daily
| - May reduce absorption of other drugs and supplements; administer either ≥1 hour before or 4 to 6 hours after other drugs and supplements. Refer to drug interactions database.
|
Pancreatic enzymes for exocrine pancreatic insufficiency |
Pancrelipase microencapsulated, delayed-release (eg, Creon). Initially 30,000 USP units lipase (~500 USP units lipase/kg) with meals and half of that amount with snacks; adjust gradually to patient needs*. | - Use in patients with intact upper GI tract and intact gastric secretions.
|
Pancrelipase, non-microencapsulated (eg, Viokace). Initially 30,000 USP units lipase (~500 USP units lipase/kg) with meals and half of that amount with snacks; adjust gradually to patient needs*. | - Inactivated by stomach acid. Use in patients lacking acid-peptic gastric environment or administer with acid-suppressing drug.
|
Vitamins and minerals (doses for oral acute repletion cited; required maintenance doses are usually lower but vary widely)¶ |
Vitamin A 40,000 to 50,000 units (12,000 to 15,000 mcg retinol activity equivalent) twice daily. | - Periconceptional exposure to a single dose of >25,000 units or >10,000 units/day has been reported to be teratogenic, so take caution in women of child-bearing age.
|
Vitamin D3 (cholecalciferol) 10,000 to 50,000 units (250 to 1250 mcg)/day individualized according to serum 25(OH)D level. | - Patients who remain deficient on such doses will need to be treated with hydroxylated vitamin D metabolites (eg, calcitriol) because they are more readily absorbed.
|
Vitamin K (phytonadione) 2.5 to 12.5 mg/day. | - Intravenous preparation available.
|
Folic acid 1 mg/day. | |
Vitamin B12 (cyanocobalamin) 1 mg subcutaneously or intramuscular, repeat 3 times in first week. Acute oral repletion not recommended. | - Formulations are available for intramuscular/deep subcutaneous injection and oral, sublingual, and nasal administration.
- 1 mg/day orally often sufficient for maintenance of pernicious anemia.
|
Calcium carbonate 500 mg (200 mg elemental calcium) twice daily. | |
Magnesium gluconate 1 to 4 g (54 to 216 mg elemental magnesium) four times daily. | - Often exacerbates diarrhea, necessitating parenteral replacement.
|
Ferrous sulfate 325 mg (65 mg elemental iron) three times daily. | - Available as oral liquids in multiple concentrations.
- Equivalent dose mixed in 8 to 12 ounces (240 to 360 mL) of orange juice or taken with a 250 mg ascorbic acid tablet enhances bioavailability.
|