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Satellite Manual

3.7.1 Rapid Hydration Document

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

Below 13 kg

  • Take 0.5 mg after the first loose bowel movement, followed by:
  • 0.5 mg every 3 hours. During the night, the patient may take 0.5 mg every 4 hours. Do not exceed 4 mg per day

13 kg to < 20 kg

  • Take 1 mg after the first loose bowel movement, followed by:
  • 1 mg every 4 hours. Do not exceed 6mg per day

20 kg to < 30 kg

  • 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 kg < 43 kg

  • 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

Over 43 kg

  • Take 4 mg after the first loose bowel movement, followed by:
  • 2 mg every 4 hours. Do not exceed 16mg 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, contact the referring tertiary centre to discuss further therapy such as octreotide and possible transfer
3.7.3 Parent Handout: Prevention and Management of Irinotean induced diarrhea
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In this Section

  • 1.1 History & Overview
  • 1.2 Acknowledgements
  • 1.3 Committees and Working Groups
  • 1.4 Satellite Manual Disclaimer
  • 2.1 Principles of Satellite Care
  • 2.2 Eligible Patients
    • 2.2.1 Children Eligible for Chemotherapy Administration in a Satellite Centre
    • 2.2.2 Children Not Eligible for Chemotherapy Administration in a Satellite Centre
    • 2.2.3 Children Eligible for the Management of Complications on a Satellite Centre
    • 2.2.4 Eligibility of Children Requiring Supportive Care
  • 2.3 Scope of Satellite Practice
    • 2.3.1 Implementation of Psychosocial Treatment Plan (Process for Communication)
    • 2.3.2 Limitations on Satellite Practice
  • 2.4 Advanced Satellite Practice
  • 3.1 Safe Handling, Administration and Disposal of Chemotherapy Agents
  • 3.2 Accidental Exposure/Spills
  • 3.3 Extravasation Management
    • 3.3.1 Sample Extravasation Documenting Tool
  • 3.4 Injecting SC Medication Via an Insuflon
  • 3.5 Chemotherapy Administration Reference List
  • 3.6 Central Venous Catheter Care
  • 3.7 Chemotherapy Quick Reference
    • 3.7.1 Rapid Hydration Document
    • 3.7.2 Provider Guide: Prevention and Management or Irinotecan induced Diarrhea
    • 3.7.3 Parent Handout: Prevention and Management of Irinotean induced diarrhea
    • 3.7.4 Capizzi Methotrexate
    • 3.7.5 Erwinia L-Asparaginase
  • 4.1 Management of Fever and Neutropenia
    • 4.1.1 Routine Order Sample Sheet
    • 4.1.2 Fever Cards (Sample)
    • 4.1.3 Criteria for low-risk designation. Risk categorization refers to risk of bacteremia and serious complications, including mortality.
  • 4.2 Pentamidine Administration
    • 4.2.1 Inhaled Pentamidine
    • 4.2.2 Intravenous Pentamidine
  • 4.3 Antiemetics
  • 4.4 Treatment of Varicella-Zoster Infections
  • 4.5 TPN Document
  • 4.6 Immunization of Children with Cancer
  • 4.7 Transfusion
  • 4.8 When to consult the Tertiary Centre
  • 5.1 Palliative Care Overview
  • 5.2 Communication
  • 5.3 Settings of Care
  • 5.4 Symptom Management
  • 5.5 End of Life
  • 5.6 When a Child Dies in the Satellite Centre
    • 5.6.1 Reconciling your grief
    • 5.6.2 Funeral arrangement checklist
    • 5.6.3 Helping Children who grieve
    • 5.6.4 Coping with the Holidays
    • 5.6.5 The grieve experience
  • 6.1 Goals and Objectives
  • 6.2 Participant Site Selection
    • 6.2.1 Tertiary Site Selection
    • 6.2.2 Community Site Selection
  • 6.3 POGO’s Roles
    • 6.3.1 PHIPA, Privacy and Research
  • 6.4 Funding
    • 6.4.1 Funding Support for Tertiary Activity
    • 6.4.2 Financial Support for Pediatric Oncology Community Activity
  • 6.5 Infrastructure and Formal Requirements
    • 6.5.1 Tertiary Partners’ Role in Provincial Pediatric Oncology Satellite Program
    • 6.5.2 Satellite Partners’ Role in Provincial Pediatric Oncology Satellite Program
  • 7.1 Preamble
  • 7.2 Investigator responsibilities
  • 7.3 Training Requirements
    • 7.3.1 General Training for Conduct of Research
    • 7.3.2 Protocol Specific Training
  • 7.4 Research Activites that may be completed in satellite centres under supervision of DSI
  • 7.5 Research Activities to be completed in Tertiary Centres Only
  • 7.6 Recognition and Reporting of Adverse Events (AEs)
  • 7.7 Data Transfer
  • 7.8 Pharmacy Drug Accountibility
  • 7.9 Site Inspections and Quality Assurance
  • 8.1 Pediatric Oncology Shared Care Initial Data Transfer Sheet
  • 8.2 Shuttle Sheet
  • 8.3 Psychosocial Communication Tool
  • 9.1 Satellite Readiness/ Preparedness Checklist
  • 9.2 Education Report for Tertiary Centres
  • 9.3 Education Report for Satellite Centres
  • 9.4 Vital Signs Report
  • 9.5 Self- Assessment
  • 9.6 Satellite Contact Form
  • 9.7 Annual Satellite Caseload Report
  • 9.8 POGO Provincial Satellite Program Annual Accounting Report
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