3.7.2 Provider Guide: Prevention and Management of Irinotecan-Induced Diarrhea

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Irinotecan is a generally well-tolerated chemotherapy agent with increasing indications in pediatric oncology. One of its most important and often dose-limiting toxicities is diarrhea. This guide aims to assist providers in diarrhea prevention and management.

Prevention of Diarrhea

Dietary Measures

• Avoid fatty, greasy foods, alcohol and caffeine-containing beverages.
• Limit the consumption of dairy products or consider the use of low-lactose dairy products.
• Consume “easy to digest” carbohydrates such as rice, white bread and potatoes, white meat, bananas and canned fruit.
• Drink regularly between meals to avoid dehydration.

Antibiotic Prophylaxis

• Patients who have experienced significant diarrhea, colitis, abdominal pain or vomiting with past cycles of irinotecan may benefit from prophylaxis with cefixime.
• Cefixime (8 mg/kg/day as a single daily oral dose; maximum dose 400 mg/day) should be started 5 days prior to the start of irinotecan therapy and continued until Day 21 of the cycle.
• Antibiotic prophylaxis should be started in conversation with the patient’s specialized childhood cancer program.

Treatment of Irinotecan-Associated Diarrhea

Patients and their families should have received education about the recognition and treatment of irinotecan-related diarrhea from their specialized childhood cancer program. It is important, however, that POGO Satellite Clinic providers reiterate these points with families using the Family Handout provided below.

Family Handout: Prevention and Management of Irinotecan-Induced Diarrhea

• Fillable/printable handout for family caregivers about preventing and managing diarrhea, with fields for tracking number and characteristics of child’s stools and recording weight-appropriate loperamide dosages.
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General Measures

• Ensure patient has stopped any laxative therapy.
• Ensure good perianal hygiene and regular bathing.
• Clean the perianal area with mild soap and warm water after each loose bowel movement.
• Allow skin to dry completely and let it expose to air. Apply a barrier cream such as zinc oxide ointment to skin once dried.

Early Diarrhea

• Occurs during infusion of irinotecan, or within several hours thereafter.
• Usually associated with cholinergic manifestations such as diaphoresis and abdominal cramping.
• Patients showing such symptoms should receive Atropine (0.01mg/kg; max 0.4 mg) IV.
• In patients receiving multiple days of irinotecan, it is often difficult to distinguish early vs. late diarrhea. If the patient’s symptoms do not improve with atropine, they should begin treatment with loperamide as directed for “late” diarrhea.

Late Diarrhea

• Occurs more than 8 hours after irinotecan administration.
• Should be treated with loperamide (dosing is based on body weight as per chart below).
• Family should be reminded to have loperamide on hand at home prior to beginning of irinotecan therapy and to start loperamide at the first episode of poorly formed or loose stools or earliest onset of bowel movements that are more frequent than usually expected.

Loperamide Dosing Recommendations (by Weight)

Patient Weight	First Dose	Maximum Dose	Dosing Recommendations
<13 kg	0.5 mg	4 mg/day	Take 0.5 mg after the first loose bowel movement, followed by: 0.5 mg every 3 hours. During the night, patient may take 0.5 mg every 4 hours. Do not exceed 4 mg per day.
13 to <20 kg	1 mg	6 mg/day	Take 1 mg after the first loose bowel movement, followed by: 1 mg every 4 hours. Do not exceed 6 mg per day.
20 to <30 kg	2 mg	8 mg/day	Take 2 mg after the first loose bowel movement, followed by: 1 mg every 3 hours. During the night, the patient may take 2 mg every 4 hours. Do not exceed 8 mg per day.
30 to <43 kg	2 mg	12 mg/day	Take 2 mg after the first loose bowel movement, followed by: 1 mg every 2 hours. During the night, the patient may take 2 mg every 4 hours. Do not exceed 12 mg per day.
≥43 kg	4 mg	16 mg/day	Take 4 mg after the first loose bowel movement, followed by: 2 mg every 4 hours. Do not exceed 16 mg per day.

• Once the patient has been free of diarrhea for 12 hours, loperamide may be discontinued.
• If loperamide fails to control diarrhea within 24 hours, consult the referring specialized childhood cancer program to discuss further therapy such as octreotide and possible transfer.
• Patient assessment to rule out dehydration: Consider lab workup such as electrolytes, stool samples for virology, c. difficile, and culture. IV fluids and patient admission as indicated.

This guidance document was developed by Ms. Denise Reniers, Children’s Hospital, London Health Sciences Centre, 2016. Reviewed by Ms. Kirsty Morelli, Scarborough Health Network, Centenary Hospital, Ms. Christina McCauley, POGO/The Hospital for Sick Children.

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You are welcome to download and save a local copy of this document in the Word and/or PDF formats provided. As the POGO Satellite Manual is subject to ongoing revisions and updates by POGO, we recommend you regularly check the online version posted at https://www.pogo.ca/satellite-manual/ to ensure you have the most up-to-date content. In the event of any inconsistency between the content of a local copy and the online version of the POGO Satellite Manual, the content of the online version shall be considered correct. Please see also the POGO Satellite Manual Disclaimer.

Record of Updates

Version Number	Date of Effect	Summary of Revisions
1	12/15/2021	Original version posted.