POSTGRADUATE SCHOOL OF MEDICINE DIARRHOEA Dr Eliyaz Ahmed and Dr Sarah Smith MDSC156: Acute Clinical Oncology A MEMBER OF THE RUSSELL GROUP CONTINUING PROFESSIONAL DEVELOPMENT

Diarrhoea Diarrhoea is a common toxicity of systemic anticancer treatment Can be quite debilitating with volume depletion, electrolyte disturbances and risk of renal failure Can interfere with treatment of malignancy due to dose delays and reductions and increased hospitalisation Assessment is crucial in decision on out-patient vs. in-patient management

Chemotherapy Induced Diarrhoea Chemotherapy Induced Diarrhoea (CID) can include drugs such as capecitabine, cisplatin, cyclophosphamide, daunorubicin, doxorubicin, docetaxel, methotrexate, oxaliplatin, and paclitaxel. Incidence can be as high as 50 -80% with drugs such as Irinotecan and 5-Flurouracil/Capecitabine Targeted therapies such as, erlotinib, sorafenib, and cetuximab, may also cause significant CID.

Aetiology of Diarrhoea in Cancer Patients Treatment related: Chemotherapy and targeted agents-most common drugs associated with diarrhoea are 5-fluorouracil/Capecitabine and Irinotecan ,Erlotinib, Gefitinib, Sorafenib, Lapatinib and Cetuximab BMT Pelvic and abdominal radiotherapy Disease related: Neuroendocrine cancers, islet cell tumours , Biliary obstruction Surgery of GI tract Whipples, intestinal resection (short bowel) Drugs: Antibiotics, laxatives, iron etc Infections : Bacterial (clostridium difficile) , fungal Dietary factors : High fibre, lactose products, laxatives

Assessment History and examination Vital signs, skin turgor Biochemistry, stool culture Complicated vs. uncomplicated Complicated diarrhoea Grade 3 and 4 Grade 1 or 2 associated with one or more of the following: nausea/vomiting, Fever and neutropenia, sepsis, bleeding, dehydration, moderate to severe abdominal cramping, declining performance status Uncomplicated Grade 1 and 2

Grading of Diarrhoea Grade Description 1 National Cancer Institute’s Common Toxicity criteria version 4.0 Grade  Description  1 Increase of <4 stools/day over baseline; mild increase in ostomy output compared with baseline 2 Increase of 4–6 stools/day over baseline; moderate increase in ostomy output compared with baseline 3 Increase of ≥7 stools/day over baseline; incontinence; hospitalization indicated; severe increase in ostomy output compared with baseline; limiting self-care ADL 4 Life-threatening consequences; urgent intervention indicated 5 Death

Management Patient education Diet Antidiarrhoeals Increased fluid intake ( up to 3 L/day) Low fibre diet, avoid milk and dairy products and caffeine containing drinks etc. Antidiarrhoeals Antimotility agents: Loperamide 4 mg, followed by 2 mg after each unformed stool with a maximum of 16 mg/day Stop chemotherapy/biologicals until complete resolution of symptoms

Management Complicated diarrhoea Hydration: IV fluids and electrolyte replacement Treat Sepsis Octroeotide : Starting dose of 100 to 150 ug SC tid or IV (25 to 50g/h) and consider increasing dose if diarrhoea is persistent

Management of Diarrhoea

Further reading http://www.oncolink.org/resources/article.cfm?id=1055 http://www.cancer.gov/cancertopics/pdq/supportivecare/gastrointestinalcomplications/HealthProfessional/page5 Richardson & Dobish, 2007 Arnold RJ, Gabrail N, Raut M, et al.: Clinical implications of chemotherapy-induced diarrhoea in patients with cancer. J Support Oncol 3 (3): 227-32, 2005 May-Jun Zidan J, Haim N, Beny A, et al.: Octreotide in the treatment of severe chemotherapy-induced diarrhea. Ann Oncol 12 (2): 227-9, 2001. Benson AB III., Ajani JA, Catalano RB, et al.Recommended Guidelines for the Treatment of Cancer Treatment-Induced Diarrhoea. J Clin Oncol 2004;22:2918-2926.

FACULTY OF HEALTH & LIFE SCIENCES – CPD Institute for Learning & Teaching Faculty of Health & Life Sciences Room 2.16A, 4th Floor Thompson Yates Building Brownlow Hill Liverpool L69 3GB www.liv.ac.uk/learning-and-teaching/cpd A MEMBER OF THE RUSSELL GROUP