The Clinical Guide to Supportive and Palliative Care for HIV/AIDS

A Clinical Guide to Supportive and Palliative Care for HIV/AIDS • Chapter 7: Gastrointestinal SymptomsWith all of these agents, the patient must always be monitored for the development of constipationor fecal impaction, especially when fluid intake is inadequate. Octreotide (Sandostatin) isa synthetic somatostatin analog that is approved for treatment of profuse water diarrhea secondaryto26vasoactivepicasintestinal peptide tumors and carcinoid tumors. It has shown variable effectivenessin treating diarrhea in AIDS patients. Its major disadvantages are its high cost andthe fact that it needs to be administered subcutaneously on a regular basis.Intravenous fluids may be appropriate in a patient with dehydration secondary to severe acuteor chronic diarrhea. Decisions should be made on a case-by-case basis. If the dehydration is nottoo severe, oral fluid replacement may be adequate.In patients known to have a diagnosis of CMV colitis, it may be appropriate to initiate therapywith one of the approved anti-CMV therapies (ganciclovir/Cytovene, foscarnet/Foscavir, cidofovir/Vistide or valganciclovir/Valcyte). Standard induction and maintenance dosing guidelines shouldbe followed. Whereas with CMV retinitis maintenance therapy must continue indefinitely, studieshave shown that when treating extraocular CMV disease, maintenance therapy often can bediscontinued after a relatively short period of time (usually about four weeks) and the patientsimply monitored for signs and symptoms of recurrence.Dosage information for some drugs used to treat diarrhea is presented in Table 7-1.VIITable 7-1: Antidiarrheal AgentsDrug ClassAntimotility AgentsDrug and DosageLoperamide: 4 mg after first loose bowelmovement, followed by 2 mg after eachsubsequent loose bowel movement, not toexceed 16 mg in a 24-hour periodDiphenoxylate/atropine: 2.5 to 5 mg(1 to 2 tabs) up to 4 times a dayPancreatic HormonesOpioidsSomatostatin AnaloguesPancrelipase: 1 to 3 capsules before mealsand snacksTincture of opium (paregoric): 0.6 cc inwater q 4 hours (titrate to symptom control)Octreotide: 50 mcg SC 2 to 3 times a day; canbe titrated up to as high as 1500 mg dailyCONSTIPATIONAssessmentThough diarrhea is a more frequent problem among end-stage AIDS patients, constipation isalso seen. Constipation can sometimes be difficult to determine since there is a wide range ofnormal bowel habits. Constipation is usually defined as a frequency of bowel movements lessthan three times a week, but subjective symptoms such as excessive straining, lower abdominalfullness and hard stools must also be considered when making the diagnosis. 10 In the palliativecare setting, constipation is usually the result of drugs such as opiates that reduce colonic motilityand/or of reduced physical activity.U.S. Department of Health and Human Services • Health Resources and Services Administration • HIV/AIDS Bureau 159