1. LOW OSMOLARITY ORS: the advantage Dr Arati Deka Associate Professor Dept of Pediatrics, GMCH

2. Introduction Formost killer disease globally Formost killer disease globally In 1970 nearly 5 million deaths In 1970 nearly 5 million deaths --Only solution IV  In 2004 1.5 billion episodes/yr 1.5-2.5 deaths /yr 1.5-2.5 deaths /yr 8000 children/day 8000 children/day  Reduction in mortality is possible by proper management of dehydration by ORS dehydration by ORS  BMJ,The Lancet described ORS MOST MEDICAL ADVANCE OF CENTUARY MOST MEDICAL ADVANCE OF CENTUARY

3. Background/ history In 1968 researchers in Bangladesh and India discovered addition of glucose helps in sodium absorption In 1968 researchers in Bangladesh and India discovered addition of glucose helps in sodium absorption In 1971 large scale field application of ORS in 1971 war In 1971 large scale field application of ORS in 1971 war out of 3600 victims in refugees, 96% survived out of 3600 victims in refugees, 96% survived  Since then ORS mainstay of treatment

4. Electrolyte loss in acute diarrhoea EtiologyNaKCl Cholera88-10127-3086-92 Rota virus 373822 ETEC533724 Others562555 Stool electrolytes (mmoles/Litre)

5. Coupled Transport of Sodium and Glucose in Intestinal Epithelial Cells

6. Standard ORS It is the glucose based solution It is the glucose based solution Compositesmmole/L Na90 Cl80 K20 Citrate10 Glucose111 Total osmo 311

7. Conditions required for optimal absorption of ORS Osmolarity similar to or < plasma(275-295 mosm/L) Osmolarity similar to or < plasma(275-295 mosm/L) Glucose conc should not exceed 20gm/L (111mosm/L) Glucose conc should not exceed 20gm/L (111mosm/L) Sod conc sufficient to correct deficit and replace ongoing loss Sod conc sufficient to correct deficit and replace ongoing loss Molar ratio of gluc to sod 1:1 Molar ratio of gluc to sod 1:1 Potassium conc 20 osm/L Potassium conc 20 osm/L Citrate conc 10 mosm/L Citrate conc 10 mosm/L

8. Limitations of standard ORS Does not decrease stool volume Does not decrease stool volume Does not decrease frequency Does not decrease frequency Does not decrease severity Does not decrease severity Does not stop diarrhoea Does not stop diarrhoea Potential risk of hypernatremia in children with noncholera diarrhoea Potential risk of hypernatremia in children with noncholera diarrhoea May provide too much Sod to edematous children May provide too much Sod to edematous children

9. Two approaches to improve ORS 1) By modifying the amount and type of organic carriers used in ORS -rice based -rice based -aminoacid fortified -aminoacid fortified - maltodextrin ORS - maltodextrin ORS 2) By reducing the osmolarity of ORS

10. Composition of standard and reduced osmolarity ORS standard reduced osmo ORS reduced osmo ORS Glucose11111175-9075 Sod905060-7075 Chloride804060-7065 Pot20202020 Citrate1030*1010 osmolarity311251210-260245

11. Advantage of low osmolarity ORS Reduction in need for unscheduled IV therapy ( 35% in metaanalysis) Reduction in need for unscheduled IV therapy ( 35% in metaanalysis) Significant red in vomiting (30%) Significant red in vomiting (30%) Reduction in stool output (20%) Reduction in stool output (20%) Reduction in duration of diarrhoea Reduction in duration of diarrhoea No risk of hyponatremia No risk of hyponatremia 0.05%/yr in Dhaka and 0.03% /yr in Matlab, Bangladesh0.05%/yr in Dhaka and 0.03% /yr in Matlab, Bangladesh

12. Clinical relevance - low osmolarity ORS Reduction in need of IV therapy results in reduced hospitalisatin and in turn results: Reduced risk of hospital acquired infections. Reduced disruption of breastfeeding. Reduced use of needles and interventions Reduced risk of transmission of nosocomial and iatrogenic infections like HIV, Hepatitis B in already immunosupressed children. Reduced therapy cost. Reduced risk diarrheal deaths in areas where IV therapy is not readily available.

13. Clinical relevance - low osmolarity ORS By a reduction in the sodium concentration to 75 mmol/l, the glucose concentration to 75 mmol/l and the total osmolarity to 245 mmol/l the risks of the original solution can be reduced such as: 1) Hypernatremia (high plasma sodium concentration) 2) Increased stool output especially in infants and young children.

14. conclusion With the advantages of low osmolarity ORS over standard ORS, With the advantages of low osmolarity ORS over standard ORS, it is recommended to use low osmolarity ORS irrespective of the age. it is recommended to use low osmolarity ORS irrespective of the age.

15. Thank you