Loperamide in Adult Acute Diarrhea

Introduction: Decrease in duration of diarrhea significantly reduces morbidity, loss of working days, hospital bed occupancy and use of hospital resources. Loperamide is an established treatment of acute diarrhea to decrease the duration and frequency of unformed stool with only rare adverse reactions. Methods: This is a descriptive, cross sectional, parallel group, single centre study done in odd and even days of the month for treatment and control group. The study was conducted from 1 st to 30 th September 2010 in Patan Hospital Emergency Department. Results: Out of 104 patients, 43 patients were included in Loperamide group and 63 patients were taken in supportive treatment group. Mean duration of diarrhea was 16.3 and 41.9 hours in supportive plus Loperamide group and supportive treatment only group respectively. Mean difference in duration of diarrhea was 25.6 hours 95% CI (23.9 to 27.3) (P<0.05). Similarly mean working day loss was 1.19 in group treated with Loperamide and 2.84 days in group not treated with Loperamide. Mean difference was 1.65 days CI 95% (1.45 to1.85) (P<0.05). Absolute risk of complication in Loperamide group was 6.6% Conclusion: Loperamide significantly reduces duration of diarrhea and working days lost with low rate of complications in Adult with acute non infective diarrhea.


INTRODUCTION
Diarrhea is defined as stool weight in excess of 200 grams per day. However, this definition is of little clinical value, since collecting and weighing stools is not practical in our setup. A good working definition is three or more loose or watery stools per day or a definite decrease in consistency and increase in frequency based upon an individual baseline. Diarrhea can further be classified as acute for loose stool lasting less than 14 days and persistent diarrhea if loose stool lasting more than 14 days. Diarrhea lasting more than 30 days is known as chronic diarroea. 1 Acute diarrhea is a common problem presenting to medical care. Diarrheal diseases represent one of the five leading causes of death worldwide. 2,3 It accounts for more than two million deaths annually. 4 In Nepal diarrhea is the second most common disease causing morbidity.
Outbreak of diarrhea in April-June 2009 has caused significant morbidity and mortality in western Nepal. 5 The mainstay of treatment is fluid therapy and correcting electrolyte disturbance. Antimicrobial therapy is only indicated in selected cases. 6 Anti-diarrheal agents are frequently prescribed by clinicians. According to current guidelines, they are not recommended for routine use in children with acute diarrhea, because of potential side effects and doubtful benefits. 7,8 However, in adults, their use is more liberal. There are many over-the-counter anti diarrheal agents and quite often patients request antidiarrheal drugs during their consultations. The current anti-diarrheal agent of choice is Loperamide. 9 Diarrhea has shown to cause significant morbidity, loss of working days, increase in hospital bed occupancy and use of hospital resources. To decrease this Loperamide can be used as an adjunct to the treatment along with fluids and electrolytes replacement.

METHODS
This is a single centre, descriptive, cross sectional, parallel group study conducted in Patan Hospital, Emergency Department in the month of September 2010. Patient coming on the odd days of the calendar month were given Loperamide and those patient coming on even days of month were taken given symptomatic treatment only.
Patient more than 18 years with acute watery diarrhea were included in the study and those with chronic, iatrogenic, bloody diarrhea, having received antibiotics treatment or anti diarrheal drug in last five days, history of renal or hepatic dysfunction, immunocompromise, concomitant infection, lactating mother and patient with decompensate shock were excluded from the study.
Written consent was taken from the patient. All patients in Loperamide group were informed about the medicine, its advantage and possible side effects. Time of onset of diarrhea with frequency was noted.
In this study acute diarrhea is defined as the passing of at least 3 watery stools in a minimum of 24 hours and for the duration of less than five days. Stable patient is defined as hemodyamically stable, tolerating orally and without ongoing loss. Recovery is defined as the production of 2 consecutive normal stools or no stool production for a period of 24 hours. The duration of diarrhea after treatment means the time between the Loperamide and the last loose stool. The first day of diarrhea means the 24 hours following the ER consultation, the second day means the 24 hours after the first day, and so on.
Loperamide is available as 2 mg capsule and was given 2 capsules stat and then followed by 1 capsule after each loose stool but not more than 8 capsules in a day including the stat dose.
Patients were followed up by telephone on day 3 of discharge. In the telephone interview, the intake of medications, time of the last diarrhea, and the daily frequency of diarrhea after discharge was enquired.
The primary end-points of the study are to determine significant difference in duration of diarrhea (Measured in terms of hours) following treatment in these two groups.
Secondary end-points were to determine the number of working days lost.

CONCLUSION
Loperamide reduces the duration of diarrhea and also decreases the working days lost without significant complications. People who suffer from acute diarrhea should be recommended to maintain adequate fluid intake, diet as tolerated and Loperamide as required, so that they can get on with their lives. However, a further randomized placebo controlled trials are required to verify the result in our setup as RCT's published are from the western part of the world.