Introduction

Diarrhea is generally defined by an increased

frequency of bowel movements ( >3 in 24 hrs)
& decreased stool consistency & increased stool
weight.
Diarrhea caused due to the use of
drugs/medication is called drug induced
diarrhea.
It accounts for 7% of all adverse drug effects
and over 700 drugs have been implicated in
causing diarrhea.

Drugs & their mechanism

Of causing diarrhoea
S.NO
1
2

DRUGS
Laxatives
Antibiotics

MECHANISM
Osmotic diarrhea
Bacterial proliferation

3
4
5

Anticancerous
NSAIDS
Glucosidase
inhibitors
Lipase
inhibitors
Antacids

Exudative diarrhea
Lymphocytic colitis
Osmotic diarrhea

6
7

Malabsorption of fat
Osmotic diarrhea

Antibiotic associated diarrhea

(AAD)
Can be defined as unexplained onset of diarrhea
that occurs with the administration of any antibiotic.
Usually relieved with fasting
Responsible for 25% of drug induced diarrhea.
The disease spectrum from benign diarrhea to
pseudomembranous colitis.
Most commonly caused by Penicillin, clindamycin,
tetracyclines, erythromycin, cephalosporins etc.

 Normally, the gut is filled with many different

bacteria. They keep each other in balance.
Antibiotics destroy some of the bacteria in the
gut.
This allows other bacteria to grow too much.
In some cases, antibiotics can allow a type of
bacteria called Clostridium difficile to grow too
much.
This can lead to severe, watery, and often
bloody diarrhea called pseudomembranous
colitis.

Clinical presentations
Mild diarrhoea to pseudomembranous colitis,
characterized by a watery diarrhoea
Fever
Leucocytosis
presence of pseudomembranes on endoscopic
examination
Severe complications include Toxic megacolon
Perforation
Shock

Risk factors
Drug factors
1. Antibiotics with large spectrum
2. Duration of antibiotics therapy
prolonged treatment
repeated treatment

3. Combination therapies
4. Antibiotics with high billiary excretion

Host factors1. Extreme ages of life 6 years ,65

years).
2. Underlying pathologic cause previous AAD
severe underlying disease
chronic disease of the digestive tract
Immunosuppression
3. Hospitalization
length of hospital stay
gastric intestinal surgery

Other drugs
Chemotherapy medicines used to treat cancer.
Drugs used to treat heartburn and stomach
ulcers-omeprazole, rabeprazole, cimetidine,
ranitidine & nizatidine.
Medications that suppress the immune system
(such as mycophenolate).
NSAIDs used to treat pain and arthritis, such
as ibuprofen and naproxen.
Some herbal teas contain senna or other
"natural" laxatives that can cause diarrhea.

Mechanism by which these drugs

cause diarrhoea
Disruption of protective commensal bacteria by
antibiotic therapy may result in Clostridium
difficile supra-infection -causes diarrhoea by
secreting two potent toxins that cause mucosal
damage and inflammation of the colon.
A number of drugs cause osmotic diarrhoea Antacids containing magnesium trisilicate or
hydroxide & Sorbitol, an osmotic laxative agent.

 Regulation of water and electrolyte transportNa+,K+ ATPase pump. ATPase may be inhibited by
digoxin, auranofin, colchicine.
Drugs impair fluid absorption by activating
adenylate cyclase within the enterocyte which
increases the level of cyclic AMP. This causes active
secretion of Cl and HCO3 , passive efflux of Na+,
K+ and water and inhibition of Na+ and Cl into the
enterocyte-by Bisacodyl, Misoprostol and
Chenodeoxycholic acid (used to dissolve cholesterol
gallstones).
Mucosal damage of the small and large bowel-with
Neomycin and Colchicine.

Treatment of AAD
Rehydration
Drug therapy
Probiotics

Rehydration
Can be done orally or i.v.
i.v rehydration is needed only when fluid loss
is severe i.e. > 10% body weight or patient is
losing > 10 ml/kg/hr or is unable to take
enough oral fluids due to weakness and
vomiting.
Oral rehydration therapy can be started from
beginning when fluid loss is mild or moderate.

Drug therapy
Replacement of appropriate antibiotics- drug
with lower AAD risk can be effective.
Quinolones
Co-trimoxazole
Aminoglycosides

For C.difficile diarrhoea

Antibiotic treatment, with glycopeptides
(vancomycin) or metronidazole.
Oral metronidazole (250 mg 4 times daily) or oral
vancomycin (125 mg 4 times daily)
Diarrhoea usually resolves in 2 or 3 days.
Metronidazole is the first line of treatment to
prevent the emergence of vancomycin resistant
organism.
Vancomycin should be reserved for those with
severe illness, intolerance to metronidazole, failure
to respond to metronidazole, or pregnancy.

Probiotics
Probiotics are non-pathogenic living organisms,
capable of re-establishing the bacterial
equilibrium of the intestine.
Lactobacillus acidophilus, & Enterococcus
faecium.
Saccharomyces boulardii yeast has been
shown to be a safe and effective therapy in
relapses of C. difficile colitis.

Prevention of AAD
Taking supplements containing healthy bacteria
(probiotics)
Limit antibiotic use
In the case of C difficile related diarrhoea hygiene
measures use of gloves
Handwashing etc.