Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea

MANAGEMENT OF CHEMOTHERAPY INDUCED DIARRHOEA IN ADULTS WITH CANCER

Reference Number:

405 2006

Author/Manager Responsible

Karen Skelley

First Reviewed:

November 2005

Next Review Date:

December 2008

Ratified by:

Oncology/Haematology Drugs and Therapeutic Committee December 2005

Date Ratified:

Related Policies

Cytotoxic Policy Irrinotecan induced Diarrhoea policy

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Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea INDEX Section Consultation and Ratification Schedule Policy Page 3 4 4 5 5 6 6 6 7 9 11

1. Introduction 2. Symptoms 3. Causes -

4. Objectives -

5. Initial Assessment 6. Patient Education 7. Management. 8. References -

Consultation Checklist

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Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea CONSULTATION AND RATIFICATION SCHEDULE

Name and Title of Individual Karen Skelley Caroline Gilleece Rosie Simpson

Date Consulted

Name of Committee Oncology/Haematology D&T committee

Date of Committee

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Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea POLICY 1. INTRODUCTION Anti-cancer drugs are mostly anti-proliferative agents. They are toxic to dividing cells or they prevent cells from dividing. These drugs however are also toxic to other normal proliferating tissues of the body such as the gut mucosa. Epithelial integrity is disturbed, the mucosa becomes inflamed and oedematous and the absorptive surface area is decreased. (Holmes 1990) Drug related side effects not only decrease the patients quality of life but also may necessitate dosage reductions or treatment interruptions that compromise treatment efficacy (Berg 1998). It is therefore crucial that accurate baseline data is recorded so that a basis for comparison exists and it can be determined whether any symptoms are treatment related. Good communication skills are essential during this assessment process as well as the education process of the patient. Skills of listening and observation are required in assessing each individuals needs. Diarrhoea is defined as an increase in the frequency of defaecation and/or fluidity of the faeces. Diarrhoea is not only an inconvenient side effect of cancer treatment, but also can be life-threatening if not adequately managed. The severity of diarrhoea can vary considerable but can have a dramatic impact on a patients quality of life, physical well being and emotional well being. If severe, it may manifest as faecal incontinence. Diarrhoea can have profound physiological and psychosocial consequences on a patient. Severe or extended episodes of diarrhoea may result in dehydration, electrolyte imbalance and malnutrition. Patients not only have to cope with increased frequency of bowel movement but may have abdominal pain, cramping, proctitis and anal or perianal skin breakdown. Food aversions may develop or patients may stop eating altogether as they anticipate subsequent diarrhoea following intake. Consequently this may lead to weight loss and malnutrition. Fatigue, sleep disturbances, feelings of isolation and depression are all common consequences for those experiencing diarrhoea (Hogan 1998). Patients with a stoma may also need to change their appliances more frequently and skin excoriation may occur which can exacerbate distress (Campbell & Lunn 1999). The impact of severe diarrhoea should not be underestimated. It is highly debilitating, may cause patients on long-term therapy to be non-compliant and can be a life-threatening problem (Kornblau et al. 2000). If the diarrhoea is severe large amounts of fluid consisting of ingested fluids and digestive juices together with sodium and potassium are lost in the faeces. This can rapidly result in dehydration and electrolyte imbalance, low immune function, malnutrition due to reduced absorption of nutrients and inflammation, pain and/or bleeding as a result of the increased frequency of bowel movements. Page 4 of 12

Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea 2. SYMPTOMS Diarrhoea may or may not be accompanied by abdominal pain or cramping, increased frequency of bowel sounds, urgency of defecation and a change in the colour and smell of the faeces. Symptoms of mild low sodium levels include tiredness, disorientation, headache, muscle cramps and nausea. Severely low sodium levels can lead to seizures or coma. Severely low levels of potassium can cause abnormal heart function. 3. CAUSES Diarrhoea in patients receiving chemotherapy may be related to a number of causes anxiety, a change in diet, medication, infection, surgery, radiation, tumour, obstruction and chemotherapy. The GI tract is susceptible to chemotherapy toxicity because of the rapid turnover of mucosal cells. The following chemotherapy drugs are known to have the potential to induce diarrhoea: Aclarubicin Actinomycin D Azathoprine Capecitabine Cisplatin (At High Doses) Cladribine Dacarbazine Daunorubicin Docetaxel 5 - Fluorouracil Gemcitabine Hydroxyurea Idarubicin Irinotecan 6-Mercaptopurine Methotrexate Mitomycin C Mitoxantrone Oxaliplatin Paclitaxel Procarbazine Raltitrexed Tegafur/Uracil

NB: For diarrhoea following treatment with irinotecan (CPT-11, Camptosar) see policy for irinotecaninduced diarrhoea.

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Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea 4. OBJECTIVES To establish prompt diagnosis, minimise diarrhoea and prompt treatment of adults with chemotherapy-induced diarrhoea. Minimise chemotherapy treatment delays, non-compliance and dose reduction. Maximise chemotherapy dose and intensity Maximise patients quality of life whilst on chemotherapy

This policy does not relate to and is not appropriate for the management of diarrhoea associated with irinotecan (CPT-11, Camptosar) chemotherapy

5. INITIAL ASSESSMENT Patient education is central to the management of chemotherapy-induced diarrhoea. Many patients will have undergone bowel surgery prior to commencement of chemotherapy. Some may have a stoma to deal with. As already stated, accurate pre- chemotherapy assessment is crucial, as follows: Record weight in kilograms. Record World Health Organisation status or Karnofsky Performance score. Record Biochemistry results and Full Blood Count. Establish usual bowel habits and record. Enquire and record patients use of bowel medications

6. PATIENT EDUCATION Before starting chemotherapy with the potential to cause diarrhoea, patients must be informed of the potential and what action to take should they experience diarrhoea. Patients will require nutritional advice and support in order to achieve a satisfactory nutritional status. Suggest a low residue diet with high fluid intake. Bulking agents may be suggested for patients with a stoma. Prior to starting treatment patients should be given the following advice: Inform their doctor/nurse of an onset in diarrhoea Continue to monitor their bowel movements and report immediately any of the following: - fever associated with diarrhoea Page 6 of 12

Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea -

abdominal cramps/pain/bloating (especially if receiving vincaalkaloids) dizziness sudden rapid or irregular heartbeat blood in the faeces inability to urinate for 12 hours or more
inability to drink an adequate amount of fluids

7. MANAGEMENT. If patients experience diarrhoea they should be given the following advice: Drink plenty of fluids (clear fluids are best, avoid milk based drinks) Eat small amounts of bland low fibre foods (eg. Bananas, rice, noodles, white bread, skinned chicken, turkey, or white fish). Avoid greasy/fried foods, raw vegetables/fruit, whole grain breads and cereals, lactose containing products, caffeine, spicy foods and gas forming foods including beans, cabbage, broccoli or carbonated drinks. Ensure anus is kept clean by regular washing of the surrounding skin Apply barrier cream, if skin becomes irritated Ensure plenty of rest and decreases normal activity

Medical and nursing management: Ensure accurate toxicity assessment with each cycle of chemotherapy. Ensure Full Blood count and Biochemistry profile are as per protocol. Eliminate other potential causes of diarrhoea such as progressive disease, infection, laxative use and other concomitant drugs, which may cause diarrhoea such as antibiotics. Explain cause of diarrhoea and provide reassurance and support. Ensure patient understands effective use of anti-diarrhoea agents. Monitor and record effects of anti-diarrhoea agents. (See pharmacological interventions). Promote patient education regarding personal hygiene. Monitor skin in peri-anal area or surrounding stoma site. Advise use of barrier creams if appropriate. Skin care is essential to prevent bacteria present in faecal matter from destroying the skin's cellular defence and causing skin damage. This is particularly important with diarrhoea since it has high levels of faecal enzymes that come easily into contact with the perianal skin (Le Lievre 2002). Encourage fluid intake of 2 3 litres per day if able to tolerate. If not, observe for signs of dehydration and electrolyte imbalance. Check biochemistry. If diarrhoea persists and electrolyte imbalance occurs, consider admission for re-hydration and monitoring. Initiate fluid balance chart, daily weight and consider antispasmodics and analgesia as required for abdominal cramps and pain. Page 7 of 12

Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea Monitor and evaluate effectiveness of interventions Reassure the patient that the diarrhoea is chemotherapy induced and will resolve

Monitoring of patients experiencing chemotherapy-induced diarrhoea Record severity using the following toxicity scale: National Cancer Institute Common Toxicity Criteria for Diarrhoea Grade 1 Grade 2 Grade 3 Grade 4 Grade 5 Increase of less than 4 stools/day over baseline Increase of 4-6 stools/day over baseline Increase of greater than 7 stools/day over baseline, incontinence Life-threatening consequences including extremely low blood pressure as a result of severe dehydration Death

Pharmacological measures In Grade 1 2 diarrhoea, prescribe Loperamide (Imodium) 4mg initially, taking 2mg after each subsequent bowel movement, to a maximum of 8mg in 24 hours. In grade 3 or above and where the patient has a colostomy or ileostomy loperamide can be prescribed to be taken on a regular basis until the diarrhoea is under control. Seek advice from the stoma nurse. Codeine phosphate 30mg QDS can be prescribed instead of loperamide or added to loperamide when control is not achieved with loperamide alone. Avoid antacids that contain magnesium as they can increase diarrhoea Caution is required were patients are taking with metaclopramide because of its pro-motility properties. An alternative antiemetic may be required. Seek pharmacists advice for review of medication if patient is taking other medication. Consider dose modification of cytotoxic drug, if diarrhoea severe, in accordance with ASWCS chemotherapy protocols. If patient is receiving ongoing chemotherapy (eg infusional 5FU, capecitabine orally) and experiences grade 2 or greater toxicity, discuss whether chemotherapy is discontinued. Capecitabine therapy would normally be interrupted as recommended within ASWCS chemotherapy protocol.

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Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea 8. REFERENCES

Bush, N.J. (2004) Chemotherapy Induced Diarrhea. Oncology Nursing Forum Vol.31, No.5, pp.889 892, 2004. Basch, A. (1987) Symptom distress changes in elimination. Semin Oncol Nurs, 3(4), 287-92. Campbell, T. & Lunn, D. (1999) Colorectal cancer. Part 3 patient care. Prof Nurse, 15(2), 117-21. Hogan, C.M. (1998) The nurse's role in diarrhoea management. Oncol Nurs Forum, 25(5), 879-86. Holmes, S. (1991) The Oral Complications Of Specific Anticancer Therapy. International Journal of Nursing Studies. 28(4) 343-360. Kornblau, A., Benson, R., Catalano, S. et al. (2000) Management of cancer treatment-related diarrhea: issues and therapeutic strategies. J Pain Symptom Manage, 19(2), 118-29. Le Lievre, S. (2002) An overview of skin care and faecal incontinence. Nurs Times (NT Plus), 98(4), 58-9. NCI (National Cancer Institute) Common Toxicity Criteria Version 2. Nevidjon, B Sowers, K. (2000) A Nurses Guide to Cancer Care. Philadelphia. Lippincott. Viele C.S, Vogel W & Stern J. (2004) Cancer Treatment-Induced Diarrhoea: Interventions to Minimize the Roller Coaster Ride. Spotlight on symposia: from the ONS 29th Annual Congress in Anaheim, Ca. Supplement to the ONS News, Vol.19, Number 9, 2004

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Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea 9. CONSULTATION CHECKLIST Author, please attach this to each copy of the policy being sent to a meeting for comments. Dear Chairman, please would you review this policy at your committee and return any amendments / comments to ____________________________ by _____ / _____ / _____ Title of meeting Date of meeting Name of policy cancer patients Name of author _Oncology /Haematology Drugs and Therapeutic Committee ______24th November 2004_ _Management of chemotherapy induced Diarrhoea in adult

________Karen Skelley/Maggie Crowe ___ Yes No N/A

Are there any elements of this policy which present operational issues that require further discussion? If yes, please provide a contact name for the author. ___________________________________ Is the policy referenced? Does the policy include a training plan? If you are the appropriate forum, have the necessary resources been agreed to implement this policy? Is there a plan for policy implementation? Does your meeting recommend further consultation with groups or staff other than listed at the front of the policy? Other comments from meeting.

Policy accepted without further comment. (Please circle) Policy needs further amendment. (Please circle) Name of Chair __________________________ Signature ______________________________ For Human Resources Policies only Page 11 of 12

Yes / No Yes / No

Date _____ / _____ / _____

Royal United Hospital Bath NHS Trust Management of Chemotherapy Induced Diarrhoea Name of Staff Side ______________________ Signature ______________________________ Date _____ / _____ / _____

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