3.7.2 Provider Guide: Prevention and Management or Irinotecan induced Diarrhea

Irinotecan is a generally well tolerated chemotherapy agent with increasing indications in pediatric oncology.  One of the most important and often dose-limiting toxicities is diarrhea.  This guide aims to assist providers in the diarrhea 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 dose; maximum daily dose 400 mg) should be started 5 days prior to the start of irinotecan therapy and continued until Day 21 of the cycle
• Alternately, if cefixime is unavailable, cefpodoxime (10 mg/kg/day, divided in two oral doses; maximum daily dose 400 mg for children < 12 years and maximum daily dose 800 mg for those ≥ 12 years) may be used. Note that cefpodoxime should be taken with food.
• Antibiotic prophylaxis should be started in conversation with the patient’s tertiary centre

Treatment of Irinotecan Associated Diarrhea
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

• Usually associated with cholinergic manifestations such as diaphoresis and abdominal cramping.
• Occurs during infusion or within several hours thereafter
• 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

• Patients and their families should have received education about the recognition and treatment of irinotecan related diarrhea from their tertiary centre. It is important, however, that satellite care givers reiterate these points with families (see Parent Handout: Prevention and Management of Irinotecan induced diarrhea).
• Caregivers should be reminded to have loperamide on hand at home prior to beginning irinotecan therapy
• Loperamide Dosing

• Once the patient has been free of diarrhea for 12 hours, loperamide may be discontinued
• If loperamide fails to control diarrhea within 24 hours, contact the referring tertiary centre to discuss further therapy such as octreotide and possible transfer