Abstract
Chemotherapy-induced diarrhea (cid) is a common side effect of cancer treatment and can cause significant morbidity and mortality. Diarrhea is frequently severe enough to require a dose reduction of, a delay in, or a discontinuation of chemotherapy. Diarrhea-associated mortality has been reported to be as high as 3.5% in clinical trials of irinotecan and bolus 5-fluorouracil in colorectal cancer. The frequency of cid and its impact on patient management are frequently under-recognized in clinical practice.A Canadian working group, consisting of medical oncologists and an oncology pharmacist, was formed in 2001 to review the optimal approach to managing cid and to identify and implement new areas of research. The recommendations that follow are the result of the group's work.Acute medical management of cid includes loperamide or diphenoxylate as first-line agents. Subcutaneous octreotide is recommended for intractable grade 2 diarrhea and may be considered for grade 1 cid that does not resolve with high-dose loperamide. Hospitalization is recommended for patients with grades 3 and 4 cid; in-hospital care includes rehydration, antibiotic therapy, and octreotide.A chemotherapy dose reduction is generally advised for patients who have experienced grade 3 or 4 diarrhea in a previous chemotherapy cycle. If a dose reduction is not desired, prophylaxis with intramuscular long-acting release octreotide may be considered.The foregoing recommendations are based on expert opinion and require validation in prospective clinical trials.
Highlights
Diarrhea is a common side effect of chemotherapy, notably those regimens that include bolus fluorouracil (5-FU) and irinotecan
Subcutaneous octreotide is recommended for intractable grade 2 diarrhea and may be considered for grade 1 chemotherapy-induced diarrhea (CID) that does not resolve with high-dose loperamide
An analysis of two trials sponsored by the U.S National Cancer Institute (NCI) reported that CID may be associated with a substantially increased risk of early mortality among patients treated with the Saltz regimen of irinotecan/ bolus 5-FU/LV (IFL)
Summary
Diarrhea is a common side effect of chemotherapy, notably those regimens that include bolus fluorouracil (5-FU) and irinotecan. An analysis of two trials sponsored by the U.S National Cancer Institute (NCI) reported that CID may be associated with a substantially increased risk of early mortality among patients treated with the Saltz regimen 23 of irinotecan/ bolus 5-FU/LV (IFL) 24. That cost exceeds the estimated cost of other toxic events associated with chemotherapy that require hospitalization, such as the cost of febrile neutropenia (CA$5871) and cardiotoxicity (CA$4626) in breast cancer patients (2004 Canadian dollars) 25. The Group’s consensus recommendations on the prevention and management of CID follow These recommendations expand upon guidelines previously developed by Wadler et al [26,27] and by Cancer Care Ontario 28, and they address the potential use of antidiarrheal prophylaxis in high-risk patients. Where level 1 evidence was lacking, the recommendations were based on expert clinical opinion
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