Best nonspecific therapy for chronic diarrhea

What is the best nonspecific therapy for chronic diarrhea? 

Because the evaluation of chronic diarrhea may extend over several weeks and because the diagnosis is not always forthcoming, patients may need symptomatic therapy. The most effective agents are opiates. Traditional antidiarrheal agents, such as diphenoxylate and loperamide, work well in many patients but should be given on a routine schedule in patients with chronic diarrhea rather than on an as-needed basis. Typical doses of one or two tablets or capsules of these agents before meals and at bedtime will improve symptoms in most people. When this therapy is ineffective, more potent opiates, such as codeine, opium, or morphine, can be used. With the stronger agents, doses should be low at first and increased gradually, so that tolerance to the central nervous system effects can develop. Fortunately, the gut does not become tolerant to these agents; thus one can usually find a dose that will control symptoms without producing severe side effects. Other agents that are sometimes used to manage chronic diarrhea include clonidine, octreotide, and cholestyramine, but they tend to be less effective than opiates and are often less well tolerated by patients, making them second-line agents in most circumstances.

Nonspecific Therapy for Chronic Diarrhea

Drug ClassAgentDosage
Opiatesμ-Opiate receptor selective
Diphenoxylate
Loperamide
Codeine
Morphine
Opium tincture

2.5 to 5 mg qid
2 to 4 mg qid
15 to 60 mg qid
2 to 20 mg qid
2 to 20 drops qid
δ-Opiate receptor selective
Racecadotril (acetorphan)
Adrenergic agonist
Clonidine
Somatostatin analogue
Octreotide
Bile acid-binding resin
Cholestyramine

1.5 mg/kg tid *

0.1 to 0.3 mg tid

50 to 250 mcg tid (subcutaneously)

4 g qd to qid

qid, Four times daily; qd, every day; tid, three times daily.

* Not yet approved in the United States.

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