The first international guidelines on the treatment of acute adult diarrhea, in otherwise healthy adults, were published in Alimentary Pharmacology and Therapeutics today. Although national guidelines for the management of diarrhea currently exist worldwide, they are inconsistent and sometimes contradictory. These guidelines finally dispel the widely held belief that acute adult diarrhea should be 'left to run its course' or treated only with oral rehydration therapy.

The new guidelines for self-medication of acute adult diarrhea, published in Alimentary Pharmacology and Therapeutics, is the first international attempt to address treatment for this common, but often debilitating illness. The authors intend that the guidelines be used when advising adult patients on treatment.

A group of international experts, in varying relevant disciplines, has reviewed the rationale for medication and the validity of different treatments that are advocated, in order to produce guidelines that are evidence based and widely applicable.

The Chair of the Panel, Professor David Wingate, Gastrointestinal Science Research Unit, St Bartholomew's and the Royal London School of Medicine and Dentistry, London, UK said, "These new guidelines for self medication aim to provide definitive guidance for health professionals around the world and eliminate much of the confusion over treatment that currently exists. We know that some patients choose not to treat acute adult diarrhea. However, our unanimous view is that there is no advantage to be gained from this; non-treatment merely exacerbates the distress and discomfort of the disorder."

The guidelines are for use by pharmacists, primary care physicians, nurses and agencies advising travellers. They provide guidance on residential and travel diarrhea and are equally applicable to the treatment of uncomplicated diarrhea by physicians, they cover:

• * rationale for treatment
• * criteria for self-medication
• * options for self-medication

The guidelines state that the optimal treatment for acute adult diarrhea, in otherwise healthy adults with sudden on-set of increased bowel action, is to maintain adequate fluid intake, consume solid food as guided by appetite (avoiding lactose-containing food) and, if self medicating, take loperamide as the drug of choice. Patients should seek medical advice if no improvement is seen in 48 hours, their overall condition gets worse or their symptoms exacerbate.

Acute adult diarrhea is a common affliction, episodes are usually brief and self-limiting but the symptoms can be distressing and incapacitating. The decision to refrain from treatment can be attributed to the commonly held view that diarrhea is a defence mechanism and therefore should not be treated with anti-diarrheal drugs that reduce stool output, as this will 'lock in pathogens' or 'prolong illness by delaying pathogen excretion'. However, there is no evidence to support this view, which is inappropriate to other causes of diarrhea such as diabetes or stress, which may be unrelated to pathogens.

It is estimated, on average, that in the US and Western Europe each member of the population will suffer from one bout of diarrhea each year. diarrhea is indiscriminate of epidemiological factors such as sex, race or class and can cause thousands of lost work and school days every year(2).

References

• 1. Wingate D et al. Guidelines for adults on self-medication for the treatment of acute diarrhea. Aliment Pharmacol Ther 2001;15:773-782.
• 2. Kapperud G et al. Clinical features of sporadic Campylobacter infections in Norway. Scand J Infect Dis 1992;24:741-9.

Notes:

Summary points of guidelines for the management of acute diarrhea in adults by self-medication.

• * Acute uncomplicated diarrhea is commonly treated by self-medication.
• * Guidelines for management exist world wide, but are inconsistent, sometimes contradictory, and often owe more to dogma than evidence. An ad hoc multidisciplinary group has reviewed the literature to determine best practice.
• * Treatment of acute episodes relieves discomfort and social dysfunction, and does not prolong the illness. Self-medication in otherwise healthy adults is safe.
• * Oral loperamide is the treatment of choice. Older antidiarrheal drugs are also effective in the relief of symptoms but carry the risk of unwanted adverse effects.
• * Oral rehydration solutions do not relieve diarrhea, and confer no added benefit for adults who can maintain their fluid intake.
• * Probiotic agents are, at present, limited in efficacy and availability.
• * Antimicrobial drugs, available without prescription in some countries, are not generally appropriate for self-medication, except for travellers on the basis of medical advice prior to departure.
• * Medical intervention is recommended for the management of acute diarrhea in the frail, the elderly (>75 years), persons with concurrent chronic disease, and children.
• * Medical intervention is required when there is no abatement of the symptoms after 48 hours, or when there is evidence of deterioration such as dehydration, abdominal distension, or the onset of dysentery (pyrexia >38.5oC and/or bloody stools).