High-value management of patients with chronic diarrhea

Internists can apply several high-value treatments to give patients relief from chronic diarrhea.


Chronic diarrhea is always a pain in the rear, but it doesn't have to cost an arm and a leg.

During Thursday's session “Gastroenterology: Cost-Conscious Care for Common Conditions,” ACP Member Lt. Col. Joseph Cheatham, MD, explained how internists can apply several high-value treatments to give patients relief.

Chronic diarrhea is defined as two or more loose stools a day, usually for greater than four weeks at a time, with 200 g or more of stool passed per day, said Dr. Cheatham, director of the gastroenterology fellowship program at Naval Medical Center San Diego. It falls into three main categories—watery, fatty, and inflammatory—associated with different diseases, he said.

Although inflammatory bowel disease and irritable bowel syndrome (IBS) have overlapping symptoms, such as diarrhea and lower abdominal pain, the majority of younger adults with these symptoms have IBS, said Dr. Cheatham. He added that celiac disease is four times as prevalent in the IBS patient population as the general population, “So make sure that all of your IBS patients have at some point in their lives been evaluated for it.”

In non-celiac patients with chronic diarrhea, eliminating gluten won't necessarily fix the problem. Treatments, both prescribed and over-the-counter, are available, Dr. Cheatham said. “I think it's important to realize that you only have three FDA-approved drugs for IBS, diarrhea predominant,” he said.

Two of the drugs, rifaximin and eluxadoline, were approved in 2015, whereas alosetron has been around longer. All do a very good job of decreasing watery stool and improving IBS symptoms, as well as lessening pain and bloating, Dr. Cheatham noted. “They're all generally high-cost, although alosetron now has a generic available,” he said.

Although alosetron has been available for years, physicians don't often use it because it carries a black-box warning about the risk of ischemic colitis, Dr. Cheatham said, adding that this complication was found among patients who continued to take the medication while they were constipated. “It is a very effective drug in patients who have severe IBS and failed your other therapies, and I [encourage] you to take a look at potentially adding it to your armamentarium,” he said.

Loperamide also does a great job of reducing diarrhea. However, it doesn't do much for pain, Dr. Cheatham noted. “It is the lowest-cost option that you have, and it's very safe,” he said.

Other low-cost medication options include tricyclic antidepressants, which reduce diarrhea and lessen pain, and antispasmodics and serotonin–norepinephrine reuptake inhibitors (SSNRIs), which decrease pain but not diarrhea, Dr. Cheatham said. “It is common for loperamide to be paired with an antispasmodic or an SSNRI in order to help some patients. These are cheap but effective treatments,” he said.

Dr. Cheatham also discussed several other options for therapy. “There's actually been a very good study done on Bifidobacterium infantis, the only probiotic that I recommend to my patients,” he said. The low-cost probiotic is taken once a day and decreases diarrhea, pain, and bloating, Dr. Cheatham said, noting that it is crucial to make sure enough bacteria are present in the product—”10 to the 10 is what I look for” in terms of colony-forming units.

Although not effective at reducing diarrhea, enteric-coated peppermint oil capsules are another low-cost option for decreasing pain and bloating, he said.

Finally, about 33% of individuals with IBS will respond to a diet low in fermentable oligo- di- and monosaccharides and polyols (FODMAPs), which has been shown to reduce diarrhea, pain, and bloating and is low to moderate cost, Dr. Cheatham said.

However, the diet, which restricts high-FODMAP (and omnipresent) foods such as garlic and onions, is often difficult for patients to maintain completely, he noted. Dr. Cheatham said he suggests that patients refer to educational materials online to learn which foods are high and low in FODMAPs and tailor their diets accordingly.