Diarrhea is a distressing symptom which limits the quality of life in patients receiving palliative care and is associated with high morbidity and mortality. In patients with AIDS, it is a more common problem than for other entities (e.g., cancer). Loperamide is considered the first choice medication for the symptomatic treatment of diarrhea. This literature review examines the efficacy of loperamide in the symptomatic treatment of diarrhea in palliative care. Two databases (Medline and Embase) were searched through June 2012. A total of 286 studies were identified, but only 7 met the inclusion criteria (1 cohort and 6 experimental studies) in which loperamide (alone or in combination) was tested. There is a lack of significant studies which investigate the efficacy of loperamide in the symptomatic treatment of diarrhea. Two trials indicated superiority of loperamide over placebo. In comparison with octreotide, the results were contradictory. The combination of acetorphan with loperamide was more effective than acetorphan alone, but the combination of loperamide with diphenoxylate was inferior to octreotide. The identified studies revealed methodical problems. A definite recommendation for administration of loperamide can, therefore, not be derived from this work.The English full-text version of this article is available at SpringerLink (under \"Supplemental\").

Many commonly used medications have serious toxicity in children when ingested in small doses. The toxicologic characteristics of methyl salicylate, camphor, topical imidazolines, benzocaine, and diphenoxylate-atropine are striking examples. All of these medications except Lomotil are over-the-counter and therefore, are often perceived as minimally harmful when ingested. For all of these substances, however, doses as little as 1/4 teaspoon or 1/2 tablet can have serious or fatal consequences. Thus, referral to an emergency department is prudent for ingestions involving these products. Options for initial gastrointestinal (GI) decontamination are variable, depending on the estimated amount and time of the ingestion. Induction of emesis is contraindicated for significant camphor, topical imidazoline, and Lomotil ingestions. Activated charcoal should be administered in all cases. Finally, the emergency physician must recognize the potential seriousness of these ingestions, as well as their clinical presentations to provide expeditious evaluation and treatment.

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Eight pediatric accidental overdoses of diphenoxylate-atropine (Lomotil) are reported, and 28 literature cases are reviewed. This overdose is primarily an opioid intoxication, occasionally associated with atropine toxicity. Only 6 of 36 children showed signs of atropine overdose (central nervous system excitement, hypertension, fever, flushed dry skin). Contrary to popular belief, atropine effects occur before, during, or after opioid effects. Opioid overdose (central nervous system and respiratory depression with miosis) predominated or occurred without any signs of atropine toxicity in 33 cases (92%). Diphenoxylate-induced hypoxia was the major problem and was associated with slow or fast respirations, hypotonia or rigidity, cardiac arrest, and in 3 cases cerebral edema and death. Respiratory depression recurred 13 to 24 hours after the ingestion in 7 cases and was probably due to accumulation of difenoxine, an active metabolite of diphenoxylate. Recommended treatment is intravenous naloxone for depressed or inadequate respirations, followed by continuous intravenous naloxone infusion, prompt gastric lavage, repeated administration of activated charcoal, and close monitoring for 24 hours.

Many studies have shown that clindamycin may cause pseudomembranous colitis, a potentially fatal complication. At present, prevention of this complication depends on (1) prescription of the drug only for specific severe infections, (2) early investigation and discontinuation of clindamycin if diarrhea ensues, and (3) vigorous supportive therapy.