Aliment Pharmacol Ther 2001; 15: 773±782.

Guidelines for adults on self-medication for the treatment

of acute diarrhoea
D. WIN GATE*, S. F. PH ILLIPS , S. J. LEWISà, J.-R. M ALAGELADA §, P. SPEELMAN±,
R. STEFFEN**, & G. N. J. TYTG AT  
*St Bartholomew's and the Royal London School of Medicine and Dentistry, Gastrointestinal Science Research Unit, London,
UK;  Gastroenterology Research Unit, Mayo Clinic, Rochester, Minnesota, USA; àDepartment of Internal Medicine,
University Hospital of Wales, Cardiff, UK; §Digestive Diseases, Hospital General Val d'Hebron, Autonomous University
of Barcelona, Spain; ±Department of Infectious Diseases, Tropical Medicine and AIDS, Academic Medical Centre,
Amsterdam, the Netherlands; **Division of Communicable Diseases & WHO CC for Travellers' Health, Institute of Social and
Preventive Medicine (ISPM), University of Zurich, Zurich, Switzerland; and   Department of Gastroenterology±Hepatology,
Academic Medical Centre, Amsterdam, the Netherlands
Accepted for publication 14 January 2001

diarrhoea, and confer no added bene®t for adults who

SUMMARY
Acute uncomplicated diarrhoea is commonly treated by
self-medication. Guidelines for treatment exist, 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.
In general it is recognized that treatment of acute
episodes relieves discomfort and social dysfunction.
There is no evidence that it prolongs the illness. Self-
medication in otherwise healthy adults is safe.
Oral loperamide is the treatment of choice. Older anti-
diarrhoeal drugs are also effective in the relief of
symptoms but carry the risk of unwanted adverse
effects. Oral rehydration solutions do not relieve
can maintain their ¯uid intake. Probiotic agents are,
at present, limited in ef®cacy 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 diarrhoea in the frail, the
elderly (> 75 years), persons with concurrent chronic
disease, and children. Medical intervention is also
required when there is no abatement of the symptoms
after 48 h, or when there is evidence of deterioration
such as dehydration, abdominal distension, or the onset
of dysentery (pyrexia > 38.5 °C and/or bloody stools).

ting. Consequently, medication to relieve the symptoms

INTRODUCTION
Acute diarrhoea is a common af¯iction, even among
adults. The episodes are usually brief and self-limiting,
but the symptoms can be distressing and incapacita-
Correspondence to: Professor D. Wingate, St Bartholomew's and the Royal
London School of Medicine and Dentistry, Wingate Institute, 26 Ash®eld
Street, London E1 2AJ, UK.
E-mail: D.L.Wingate@mds.qmw.ac.uk
is frequently sought and often purchased without
prescription. The choice is usually based on the
recommendation of pharmacists and nurses, which in
turn, is derived from guidelines by regulatory medical
and pharmaceutical authorities. A survey of `of®cial'
guidelines, however, revealed a wide variation in the
regimens that are recommended (Table 1). Scrutiny of
the many Web sites offering advice on the manage-
ment of acute diarrhoea, or advice to travellers,

Ó 2001 Blackwell Science Ltd 773

774 D. WINGATE et al.

Table 1. Examples of guidelines for the management of acute uncomplicated diarrhoea in adults

Option Recommendation

Diet Continue normal feeding: Suspend normal diet/clear ¯uids only:

±WHO ±Australia: Gut Foundation
±China: Of®cial Guidelines ±Canadian Pharmaceutical Association
±Netherlands: GP Standard (Therapeutic Choices)
Probiotics No proven value: Can be used:
±Greece: National Formulary, ±China: Of®cial Guidelines
±Belgium: Repertory ±Germany: Artzneimittel±Richtlinien
(Pharmacist Association)
±UK: National formulary
Loperamide Recommended: Not recommended:
±USA: American College of ±China: Of®cial Guidelines
Gastroenterology
±Netherlands: GP Standarda
As adjunct to oral rehydration
supplement (ORS):
±UK: National Formulary
WHO guidelines Extrapolated to adult diarrhoea: Philippines,
(WHO/CDD/CMT/86.1) Thailand, and Pakistan
No of®cial guidelines Italy, Portugal, Mexico, Eastern European countries, Russia
identi®ed
a
Pharmacological treatment (loperamide) is recommended only when diarrhoea imposes practical problems, such as travel by bus or plane.

revealed a parallel degree of confusion. As an ad hoc
group of experts from different relevant disciplines, we
have reviewed the rationale for medication, and the
validity of the different treatments that are advocated,
with the intention of producing guidelines for self-
medication that are evidence-based and widely applic-
able.
Some speci®c issues were addressed at the outset. First,
we reviewed the scienti®c basis of the pervasive belief
that diarrhoea represents a form of defence mechanism
by enteric lavage. This has led to the dogma, embodied
in a number of current guidelines, that medication
intended to diminish stool output is harmful and may
delay the excretion of pathogens. Moreover, extrapola-
tion to adults of the WHO guidelines for the treatment of
acute diarrhoea in young children has reinforced the
notion that replacement of ¯uid loss with oral rehydra-
tion solutions are the only justi®able, and presumably
adequate, therapy in adults.1 Next, we considered two
broad categories of acute diarrhoea. On the one hand
are episodes that occur in the community in which the
sufferer normally lives (residents' diarrhoea) and on the
other, those acquired during the course of travel
(travellers' diarrhoea). Finally, we recognized that there
are signi®cant differences across the world in medical
and lay opinion, and in the availability, dispensing and
usage of products; we have taken these into account in
formulating our views.
It is important to emphasize that the proposed
guidelines are formulated for the self-medication of
otherwise healthy adults. They are equally applicable
to the treatment of uncomplicated diarrhoea by
physicians. Medical intervention is indicated for the
treatment of children, frail elderly people and invalids
or people with chronic disease that puts them at
increased risk of harm from an acute diarrhoeal
episode. Finally, we acknowledge the inescapable fact
that for much of the world's population who are
especially at risk because of inadequate public health
measures, self-medication is a luxury excluded by
poverty.
METHODS
Medline searches and numerous review papers on
diarrhoea were reviewed for evidence on diarrhoea as
a defence mechanism and on various treatment options
of acute diarrhoea in adults. Strikingly, statements in
reviews were frequently referenced by studies in chil-
dren only, or not referenced at all.

Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 773±782


Pharmacological and clinical studies were also
checked for dosage, schedule of administration (for
instance, as prophylaxis or acute treatment), and their
relevance to clinical ef®cacy and self-medication in
particular in adult acute diarrhoea. This screening
showed that meta-analysis, optimal for the systematic
evaluation of therapeutic agents, could not be applied
because of the numerous discrepancies in trial design.
This was particularly evident in the patient inclusion
criteria, the severity of diarrhoea before and during
study, and in the de®nitions and timings of ef®cacy
assessments. For instance, studies with antimicrobials
usually focused on bacterial causes of residential or
travellers' diarrhoea, i.e. patients with identi®ed path-
ogens, while the patient selection for loperamide studies
usually excluded dysentery, as de®ned by identi®able
symptoms `blood in stools' or `high fever'. Patients not
only differed in features of diarrhoea at inclusion
(residential, traveller's, non-infectious, exclusion or
inclusion of dysenteric symptoms), but also in associ-
ated symptoms (such as nausea or vomiting), and speed
of recovery in the placebo group, so that trials possibly
dealt with different populations of diarrhoea sufferers.
Studies that compared medications with loperamide,
which seems to function as a reference drug, usually
lacked a placebo arm as control. However, a placebo
arm appears to be essential to validate a comparable
outcome because the spontaneous resolution of acute
diarrhoea (which, as de®ned by the FDA only lasts up to
a maximum 96 h) can confound the effects of therapy,
especially if long pre-treatment periods are allowed.2
Some comparative studies reveal multiple methodologi-
cal ¯aws, such as long pre-treatment periods (beyond
48 h), administration of ®xed, and thus non-therapeutic
loperamide dosages, and late or vague ef®cacy assess-
ments (for instance after 24±48 h). In general, there
was a striking paucity of placebo-controlled data in
adults for oral rehydration solutions, adsorbents and
probiotics.
RATIONALE FOR TREATMENT
Diarrhoea is de®ned as an abnormal increase in stool
weight and/or frequency of bowel movements.3 To
the sufferer, however, acute diarrhoea means, above
all, `urgency' and `loose stools', re¯ecting its unpre-
dictable manifestations. It is a major cause of
absenteeism but, in addition, it is unpleasant because
of the associated discomfort and concomitant symp-
Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 773±782
TREATMENT OF DIARRHOEA 775
toms, inconvenience, social embarrassment and the
threatened or actual loss of faecal continence.4 In the
face of this degree of distress, it is surprising that
some physicians either delay or even refuse treat-
ment.5
As happens with other common ailments such as
colds and in¯uenza, the onset of acute diarrhoea often
leads to self-medication. According to a UK survey
(Omnimas Weeks 1998; data on ®le in 4119 adults),
two-thirds of sufferers chose to treat diarrhoea, and
within this majority, the ratio of self-medication to
medical prescription was 2:1. Because symptom sever-
ity was not a signi®cant variable, it is likely that prior
belief or advice from others in¯uenced the decision
over the use of medication. Consistent evidence-based
advice is clearly required not only over the choice of
medication, but also over whether treatment of any
kind is justi®ed. We are unanimous in the view that
there is no advantage to be gained from withholding
medication; this merely exacerbates the distress and
discomfort of the disorder.
DIARRHOEA AS A DEFENCE MECHANISM
The decision to refrain from treatment is undoubtedly
in¯uenced by the commonly held view that diarrhoea is
a defence mechanism and therefore, should not be
treated with anti-diarrhoeal drugs that reduce stool
output.5 These agents are believed to `keep toxins or
pathogens inside the body where they do more damage'
and to `prolong illness by delaying pathogen secre-
tion'.1, 5 Reports of adverse outcomes attributed to
pharmacological treatment, in some cases for bloody
diarrhoea of unknown cause, with `®xed' doses of
different anti-motility and/or with broad-spectrum
antibiotics have been cited in support of this hypothe-
sis.6±8 Other studies were generated with high constant,
prophylactic or even lethal doses of anti-diarrhoeals,
inappropriate or irrelevant to clinical practice.9±12
There is, however, one controlled study that has been
a powerful in¯uence.1, 5, 13 In this study, Lomotil
(a combination of diphenoxylate and atropine) was
given to subjects `recruited' from a male prisoner
population in the USA and deliberately infected with
Shigella.13 Close scrutiny of the report raises doubts
about its relevance to the management of adult acute
diarrhoea of unknown cause. Treatment of the subjects
was instituted `when they developed an oral tempera-
ture of 38.3 °C, passed ®ve or more unformed stools, or
776 D. WINGATE et al.
experienced dysentery (bloody mucoid stools)'. The
cohort of 25 infected subjects was divided into four
treatment groups. One group received Lomotil and
oxolinic acid (an antibacterial agent), while the other
groups had either one or other or both of the active
drugs replaced by placebo. Oxolinic acid or Lomotil
therapy decreased diarrhoea, but fever, which occurred
in 15 out of 25 of the cohort, was markedly prolonged
in two of the four febrile subjects treated with Lomotil
alone, compared to the 11 febrile subjects in the other
three treatment groups. Stool cultures were negative
within 5 days in four out of six treated with oxolinic
acid alone, but in only of one out of six receiving
oxolinic acid with Lomotil. The numbers were small
and, perhaps for that reason, no statistical treatment
was applied to the results. Moreover, there is no way of
determining whether the adverse effects of Lomotil were
due to diphenoxylate or atropine. As required by WHO,
anticholinergic agents such as atropine were added to
older antimotility agents such as Lomotil to avoid abuse
and possible consequent dependence of the morphine
type, but are not constituents of newer anti-diarrhoeal
drugs.
Even so, taking this study into account, it is clearly
prudent to exclude persons suffering from high fever,
bloody stools or both (dysentery) from the category of
those for whom self-medication can be considered safe.
That being said, the bene®ts as well as the risks of self-
medication in dysentery need to be taken into account
in the advice given to travellers intending to visit remote
regions.
The notion of diarrhoea as a defence mechanism may
seem to have at least a super®cial logic when the cause
is an enteric pathogen. Yet, it is dif®cult to see how
diarrhoea can reverse adherence of a pathogen attached
by ®mbriae, and either diminish the secretion induced
by a toxin bound to the intestinal mucosa, or in the case
of viral diarrhoea, enhance absorption by a damaged
mucosa.14 There is no evidence to support such an
effect. In AIDS patients, or experimental parasitic
infections, with an altered immune response, diarrhoea
does not eliminate the pathogen.15 Moreover, the
defence hypothesis is inappropriate to other causes of
diarrhoea, such as diabetes, stress or hyperthyroidism,
which may be unrelated to pathogens. The concept of
diarrhoea as a means of clearing pathogens is perhaps
an anachronism reminiscent of the mediaeval paradigm
for the expulsion of toxins by methods such as
phlebotomy.
TREATMENT OPTIONS
Oral rehydration solutions
Oral rehydration solutions (glucose/electrolyte mix-
tures) increase water absorption by stimulation of
sodium-glucose transport in the small intestine.1 They
are highly effective for combating dehydration and its
serious consequences, and are the treatment of choice
in infants and young children, the frail and very
elderly.1 They do not reduce the duration of diarrhoea,
nor reduce the number of stools. They do not provide
bene®ts to the adult who can maintain suf®cient ¯uid
intake during the diarrhoea episode.16
Probiotics
Probiotics are de®ned as live microbial supplements
(bacterial strains and yeasts) thought to maintain or
normalize the micro¯ora ecology of the gut and are
therefore potentially useful in the treatment of diar-
rhoea.17, 18 Probiotics include various Lactobacillus,
Bi®dobacterium and Streptococcus species and the yeast
Saccharomyces boulardii. There is, however, scant evi-
dence that treatment with probiotics in humans reduces
pathogen colonization or confers protection against
organisms such as Vibrio cholerae or E. coli.19±22
Several pharmacological effects have been attributed to
probiotics.17, 18, 23±25 These include increased disac-
charidase activity, the production of antibacterial
substances, competition for bacterial adhesion, stimu-
lation of various immune defence mechanisms and, in
the case of Saccharomyces, antisecretory/protease effects
against toxins, as well as trophic effects on the
mucosa.23 However, for the most part, these have been
demonstrated either in vitro or, if in vivo, in germ-free,
gnotobiotic or weaning animals (characterized by
immature bacterial colonization of the bowel and
immune responses), following `pre-treatment' with high
doses. The reported effects are species-speci®c, and
importantly, dependent on dose, while the rapidity of
onset and duration of ef®cacy are variable.26, 27 Some of
the effects depend on the viability of the strain and
therefore, for clinical use, the storage life of the
probiotics as well as their resistance to gastric acid
secretion may also be important.17
Controlled clinical trials support the use of some
probiotics in infantile (rotaviral) diarrhoea.24, 25 How-
ever, there is little if any evidence for bene®ts of
currently recommended doses of probiotics in acute
Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 773±782

diarrhoea in the adult, whether travelling or at home,
especially during the ®rst 24 or 48 h.27±33 Dose±
response studies and the selection of more effective
probiotic strains may eventually lead to better treatment
options.
Adsorbents
Adsorbents include charcoal, pectins, tannin albumi-
nate (plus ethacrine), clays (aluminium silicates and
kaolin) or activated clays (attapulgite, diosmectite).34
These agents are not absorbed but bind water, thereby
diminishing free stool water. They were included in
traditional anti-diarrhoeal opiate mixtures in the UK,
such as Mist. Kaolin et Morph. or `Dr Collis-Browne's
Chlorodyne Linctus', but the decline of these medicat-
ions following the removal of the opiate components
suggests that the adsorbent component was unimpor-
tant. Activated clay has been shown experimentally to
adsorb toxins, bacteria and rotavirus, to strengthen the
mucus barrier and in the absence of mucus, to
counteract disruption of the epithelial barrier, but
these effects may be negligible in the adult intestine at
therapeutic doses.35 In general, there is scant proof of
ef®cacy in acute adult diarrhoea from well-designed
placebo-controlled studies. Mild effects have been
documented in a single adult study in non-bacterial
diarrhoea and in several studies in infants.34, 36, 37
Some comparative studies of adsorbents reported
ef®cacy equal to loperamide, but lacked a placebo
group and had multiple methodological ¯aws, such as
a long pre-treatment period, late ef®cacy assessment or
use of wrong loperamide dosages.38, 39 Well-controlled
trials favour loperamide over adsorbents.40, 41 Overall,
it seems that apart from low risk, adsorbents confer
little, if any bene®t on adults suffering from acute
diarrhoea.
Drugs modifying gut motility and/or secretion
The oldest agentsÐopium, morphine and codeineÐare
effective agents for stopping diarrhoea, but they have
central effects, are habit-forming, and need prescriptions
in most countries; they will not be considered further
here.34 Diphenoxylate with atropine also requires a
prescription and is, in general, less effective than
loperamide for acute diarrhoea.42, 43
Loperamide is a peripherally acting opiate, which is
devoid of abuse potential, because it does not cross the
Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 773±782
TREATMENT OF DIARRHOEA 777
blood±brain barrier, and because it hardly reaches the
systemic circulation due to extensive hepatic extraction
and faecal excretion.34 It has multiple antisecretory
actions, some of which are not mediated by opiate
receptors.44±46 In healthy adults, a therapeutic 4-mg
dose does not signi®cantly slow orocaecal transit.47, 48
Higher or repeated doses, which increase drug concen-
tration in the enterohepatic circulation, retard jejunal
or orocaecal transit, but in diarrhoeal states, the
therapeutic dosage normalizes transit.48±51
Evidence from controlled studies shows that lopera-
mide has no untoward effects in infectious non-
dysenteric (without high fever or blood in stool)
traveller's diarrhoea, even if caused by E. coli, Shigella,
Campylobacter or Salmonella, either alone or in combi-
nation with antibiotics.52±57 As monotherapy in mild
febrile dysentery, loperamide does not aggravate the
disease, although it is no more effective than
placebo.52, 58, 59 Used with antimicrobials, it reduces
the number of unformed stools and shortens the
duration of symptoms;52, 56, 59 when compared to the
antimicrobial alone, it does not prolong fever or delay
pathogen excretion.59 The outcome of the DuPont and
Hornick study on Lomotil is probably not applicable to
loperamide because intestinal transit is more prolonged
by both diphenoxylate and atropine than by lopera-
mide.13, 47, 60
Loperamide is not recommended for use in children
under the age of 2 years.61 It is among them that the
rare adverse central and peripheral (ileus) side-effects
have mainly occurred, probably due to immature
hepatic function and blood±brain barrier, or inadvertent
overdose.62 In adults, its safety pro®le has been
evidenced by more than two decades of experience
and recently, also by a controlled study in pregnancy.63
Newer agents, such as loperamide oxide, acetorphan
(racecadotril) and zaldaride are said to have no
signi®cant effect on gastrointestinal transit.29, 34 These
drugs are not available for self-medication.
Antimicrobial agents
In the majority of episodes of acute residential or
travellers diarrhoea, the cause usually remains
unknown, because of the self-limiting nature of the
disease, and the dif®culty and delay in identifying the
pathogen.14 Not only bacterial pathogens, but also
viruses and non-infectious agents may be the cause of
acute diarrhoea, especially in residents' diarrhoea; in
778 D. WINGATE et al.
this condition the routine use of antimicrobials is not
now recommended.14, 64 Travellers' diarrhoea is a
different matter.23, 65, 66 It is usually bacterial, and as
travellers are vulnerable to strains of pathogens against
which they have no acquired immunity, the resulting
illness may be more severe and prolonged. Because the
symptoms are non-speci®c, it is dif®cult to target the
treatment to a single pathogen and therefore if an
antimicrobial is used, a broad-spectrum drug is prefer-
able.
Most antimicrobials are usually only available on
prescription in developed countries. Nevertheless, it is
appropriate to consider their use in a review of options
for self-medication for travellers. Apart from the relative
severity of traveller's diarrhoea, the distress caused by
the disorder is compounded by the lack of facilities and
support from family or friends that are available at
home, while medical assistance may not be available. In
such circumstances, self-medication with antimicrobials
is a justi®able strategy. Travellers are often advised to
include antimicrobials in travel packs, and in many
areas of the world that attract tourists, they can be
easily purchased.
Agents with evidence of ef®cacy, but limited availab-
ility, include:
· bismuth subsalicylate, an antimicrobial with anti-
in¯ammatory, antisecretory and adsorbent proper-
ties, which is less effective than loperamide, even in
travellers' diarrhoea caused by E. coli; and;28, 29, 54
· antimicrobials, such as aztreonam, bicozamycin and
rifaximin, that are poorly absorbed, but effective in
travellers' diarrhoea.29, 67, 68
There are no recent data on the ef®cacy or bacterial
resistance for nitrofuran derivatives such as nifuroxa-
zide and furazolidone (antimicrobials with antiprotozoal
action), or for the combinations of neomycin with
bacitracin or erythromycin that are sold in some
Mediterranean countries. Macrolides (erythromycin),
azalides (azithromycin), penicillins (ampicillin) and
tetracyclines (doxycycline) are no longer recommended
because of widespread bacterial resistance.65, 66 Only
doxycycline remains an option because of its simulta-
neous value in malaria prophylaxis at low cost.69
Co-trimoxazole (trimethoprim/sulfmethoxazole) has
been proven effective, but increasing resistance is
compromising its use.70 Quinolones are currently the
empirical antimicrobials of choice for dysentery or
identi®ed infectious diarrhoea because bacterial resist-
ance appears to be limited.64±66, 71, 72 They can usually
be given as a short course (single dose to 2 days) in
travellers' diarrhoea that induces remission within
1±3 days.72±75 To hasten remission, they can be safely
combined with loperamide, both in non-dysenteric
diarrhoea and in mild febrile dysentery.52, 53, 55, 56, 59
So far, there is no proof that antimicrobials can
prevent the complications of acute diarrhoea, such as
dehydration, toxic dilatation, bacteremia or post-
diarrhoea irritable bowel syndrome. Apart from cost
and, in general the need for a prescription, their major
limitations include drug interactions, skin reactions or
photosensitivity (especially for cotrimoxazole or nitro-
furan derivatives), secondary diarrhoea/colitis, and
increasing bacterial resistance.29, 65 Dosages must be
modi®ed for use in children, pregnant and nursing
women, and the elderly. Quinolones, in general, are
well-tolerated with an incidence of minor gastrointes-
tinal, neurological and dermatological adverse events
lower than 10% and less than 1% for serious adverse
events.76 Because of increasing drug resistance, the
empirical use of antimicrobials for all acute diarrhoeal
episodes in developed countries, as proposed by Moss
and Read, is probably not in the best interest of public
health.76
Antimicrobials, however, are the drugs of choice for
empirical treatment of secretory/invasive travellers'
diarrhoea (quinolones ®rst-line, cotrimoxazole second-
line) and of secretory residential diarrhoea when the
pathogen is known.29, 64±66
Dietary restrictions
The only consensus on diet is the need to maintain ¯uid
intake.14, 29, 34, 64, 65 Oral rehydration solutions (devel-
oped for cholera) is widely recommended, but usu-
ally glucose-containing ¯uids and electrolyte-rich
soups are suf®cient for adults.1 There is controversy,
however, about fasting and the resumption of solid
food.14, 29, 34, 64, 65 Fasting is logical if diarrhoea is
associated with nausea and vomiting. Oral consumption
can provide a stimulus for defecation, and avoiding
large meals may diminish the gastrocolic response of an
already hyperactive gut. On the other hand, solutes
from food may be as effective as the solutes in oral
rehydration solutions in encouraging net ¯uid absorp-
tion.16, 77 In children, whether initially malnourished
or not, early resumption of feeding and solid food intake
has been reported to speed recovery.78, 79 There is no
Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 773±782

evidence in adults that fasting or dieting is bene®cial to
the treatment of acute diarrhoea, or that solid food
hastens or retards recovery.14
GUIDELINES FOR SELF-MEDICATION IN ADULTS
Target
The guidelines are for use by:
· pharmacists, or their equivalent, dispensing drugs;
· primary care physicians and nurses, and;
· agencies advising travellers.
The guidelines should be used when giving advice on
the management of acute adult diarrhoea, whether this
is within the residential habitat, when travelling, or for
the purchase of medication in advance for travel kits.
Criteria for self-medication
The consensus is that the empirical treatment of acute
diarrhoea by self-medication without delay is safe and
effective, under the following circumstances.
· Sudden onset of increased bowel action with loose
or watery stools considered severe enough to need
treatment. The adverse impact of the condition on the
quality of life is more than suf®cient justi®cation for
the alleviation of symptoms.
· Previously good health. Those with concomitant
signi®cant systemic illnesses, or with recurrent diar-
rhoea due to chronic bowel disease, and the frail or
elderly (> 75 years) should be directed to a physician
for treatment under medical supervision.
· Aged over 12 years (6 years is accepted in some
countries such as the USA).
· Absence of warning signs or symptoms: (i) dysentery,
de®ned as high fever (beyond 38.5 °C) and/or frank
blood in stools. Dysentery is optimally treated under
medical control; (ii) severe vomiting which could lead
to rapid dehydration; (iii) obvious dehydration.
In the case of advice prior to travel, these alarm
symptoms should be identi®ed to the individual at risk,
to clarify the appropriate treatment choices.
Options for self-medication
The panel makes the following recommendations for the
use of the currently available options for the manage-
Ó 2001 Blackwell Science Ltd, Aliment Pharmacol Ther 15, 773±782
TREATMENT OF DIARRHOEA 779
ment, by self-medication, of non-complicated acute
diarrhoea (as de®ned above).
· Fluid intake: maintain adequate ¯uid intake, as
indicated by thirst. The use of drinks containing
glucose (such as lemonades, sweet sodas or fruit
juices) or soups that are rich in electrolytes is
recommended.
· Oral rehydration solutions: although essential in
infantile diarrhoea, oral rehydration solutions are
not needed in otherwise healthy adult sufferers. There
is no evidence that proprietary formulations of oral
rehydration solutions relieve or shorten the duration
of the diarrhoea illness.
· Food intake: consumption of solid food should be
guided by appetite. There is no evidence in adults
that solid food hastens or retards recovery. Small
light meals can be recommended. Fatty, heavy, spicy
or stimulant foods (caffeine, also included in cola
drinks) are best avoided. Avoidance of lactose-
containing foods (such as milk) may be helpful in
the case of more prolonged episodes of acute
diarrhoea.
· Probiotics: these are not widely available at present,
and the available evidence does not support their use
in early treatment.
· Anti-diarrhoeal drugs: the drug of choice is lopera-
mide 2 mg (¯exible dose according to loose bowel
movements). Other anti-diarrhoeal agents are not
recommended because of uncertain ef®cacy, delay
in onset of action, or potential adverse side-
effects. There is no evidence that diminishing stool
output in adults prolongs the disorder; indeed, the
balance of evidence suggests that anti-diarrhoeal
medication may diminish diarrhoea and shortens its
duration.
· Antimicrobials: these are reserved for prescription-
only in residents' diarrhoea or for inclusion, with
loperamide, in travel kits. Empirical self-medication
with antimicrobials, can be justi®ed during a journey
abroad, based on medical advice, either prior to
departure or locally if needed when travelling.
Especially useful for moderate to severe travellers'
diarrhoea, or diarrhoea with fever and/or with bloody
stools. Quinolones are the antimicrobials currently
recommended by travel medicine specialists, with, as
second choice, cotrimoxazole. Advice before depar-
ture is strongly encouraged for those travelling to
remote areas.
780 D. WINGATE et al.
Medical intervention
Patients should seek medical advice if:
· no improvement is seen in 48 h;
· symptoms exacerbate or overall condition gets worse;
and
· warning signs or symptoms develop (severe vomiting
or dehydration, persistent fever, abdominal distension
or frank blood in the stools).
ACKNOWLEDGEMENTS
The authors are indebted to Dr S. Huijghebaert for her
expert bibliographic and technical assistance with the
preparation of this report.
The logistics of mounting the workshop in London,
including the travel expenses of the participants, were
sponsored by companies within the Johnson and
Johnson group. The sponsors did not participate in the
group discussion or in the formulation of the guidelines,
nor were they consulted over the content of this paper.
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