Abstract
Diarrhea is a common side effect of chemotherapy regimens, particularly fluorouracil- and irinotecan-based therapies and abdominal and pelvic radiation regimens. Diarrhea can cause depletion of fluids and electrolytes, malnutrition, dehydration, and hospitalization, all of which can lead to cardiovascular compromise and death. Therefore, diarrhea can interfere with and detract from cancer treatment by causing dosing delays or reductions. Evidence supports pharmacologic interventions such as loperamide and octreotide as recommendations for practice. Emerging evidence suggests that probiotics are likely to be effective, but more extensive research is warranted as the field evolves. Soluble fiber supplements are likely to be effective for treating chemotherapy- or radiotherapy-induced diarrhea; however, additional research is needed because the type and dose of soluble fiber most effective in treating and preventing these types of diarrhea are unknown. This article is limited to recommendations for chemotherapy- and radiotherapy-induced diarrhea. The chemotherapy regimens included in most of the studies reviewed were the commonly used regimens containing drugs such as fluorouracil, cisplatin, adriamycin, and irinotecan.
Introduction
Diarrhea is a common side effect of chemotherapy regimens, particularly fluorouracil- and irinotecan-based therapies and abdominal and pelvic radiation regimens. Chemotherapy-induced diarrhea (CID) can occur as often as 50%-80% of the time depending on the chemotherapy regimen (Benson et al., 2004; O'Brien, Kaklamani, & Benson, 2005). Patients undergoing pelvic or abdominal radiotherapy experience diarrhea at a rate of 50%, with an even higher incidence when concurrent chemotherapy is administered (Benson et al.). Diarrhea can cause depletion of fluids and electrolytes, malnutrition, dehydration, and hospitalization, all of which can lead to cardiovascular compromise and death. Therefore, diarrhea can interfere with and detract from cancer treatment by causing dosing delays or reductions. Ultimately, the delays and reductions may have an impact on survival (Ippoliti, 1998).
Because of numerous significant clinical implications, the management and treatment of diarrhea is receiving increased attention. Appropriate management requires interdisciplinary interventions. Currently, the National Comprehensive Cancer Network (NCCN) does not have guidelines available regarding cancer treatment-induced diarrhea. The purpose of this article is to present an interdisciplinary review of evidence-based interventions for the management of CID and radiotherapy-induced diarrhea (RID), as detailed in the Oncology Nursing Society (ONS) Putting Evidence Into Practice (PEP) diarrhea resource (www.ons.org/outcomes/volume4/diarrhea/pdf/ShortCard_Diarrhea.pdf). The findings address the ONS PEP question: What interventions are effective in preventing and treating diarrhea in adults with cancer receiving chemotherapy or radiation therapy?
Healthcare professionals from multiple disciplines, including nursing, palliative care, nutrition, and medicine, collaborated for this review. Because of the vast scope of the problem of diarrhea in patients with cancer, the review was focused. Specifically, the ONS PEP resource does not address diarrhea induced by graft-versus-host disease (GVHD) because of its extensive and unique etiology. In addition, the resource does not address diarrhea related to biologic therapies, such as interferon, interleukin-2, or monoclonal antibodies, or targeted therapies, such as epidermal growth factor receptor (EGFR) inhibitors or multikinase receptor inhibitors, because of the paucity of clinical trials related to diarrhea management for the therapies. Diarrhea management for tumor-induced diarrhea also was not included. The recommendations in this article are appropriate for the adult population. Application to the pediatric population is limited and was not addressed in this study.