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Prophylaxis and Treatment of Chemotherapy-Induced Diarrhea

The following systemic anticancer therapies used in urology can cause persistent diarrhea as an adverse effect: immune checkpoint inhibitors (atezolizumab, nivolumab, and pembrolizumab), tyrosine kinase inhibitors (pazopanib, sorafenib, and sunitinib), mTOR inhibitors (everolimus and temsirolimus), bevacizumab, 5-fluorouracil, methotrexate, and anthracyclines, as well as abdominal and pelvic radiation therapy.

CTCAE Grading of Chemotherapy-Induced Diarrhea:

• Grade 0: The patient has no symptoms.
• Grade 1: The stool frequency increases by <4 stools per day over baseline.
• Grade 2: The stool frequency increases by 4–6 stools per day over baseline.
• Grade 3: The stool frequency increases by ≥7 stools per day over baseline, or the patient develops fecal incontinence, or requires hospitalization.
• Grade 4: The patient develops potentially life-threatening complications that require intensive care treatment.
• Grade 5: The patient dies due to diarrhea-related complications.

Prophylaxis and Treatment of Chemotherapy-Induced Diarrhea

Basic Measures:

• Recommend a low-lactose, low-fiber, high-carbohydrate diet that is easy to digest. Divide meals into several small portions throughout the day.
• Replace fluid and electrolyte losses orally (e.g., an oral rehydration solution).
• Prescribe loperamide based on symptoms: 4 mg initially, followed by 2 mg after each unformed stool (maximum 16 mg per day).

Management of Severe and Refractory Diarrhea:

• Fever, severe abdominal pain, blood in the stool, dehydration, or persistently severe diarrhea are indications for hospital admission.
• Obtain stool testing, including culture for Salmonella and Campylobacter and appropriate testing for diarrheagenic Escherichia coli when clinically indicated, and test for Clostridioides difficile (toxin assay and/or PCR).
• Abdominal CT scan, if complications are suspected.
• Parenteral fluid replacement.
• Consider octreotide 100μg subcutaneously 1–3 times per day.
• Pause or discontinue systemic therapy.
• Prescribe antibiotics only when a pathogen is identified or when there is strong clinical suspicion of a clinically significant bacterial infection. If Clostridioides difficile is detected, initiate targeted therapy.

References

Leitlinienprogramm Onkologie (Deutsche Krebsgesellschaft, Deutsche Krebshilfe, AWMF): Supportive Therapie bei onkologischen PatientInnen https://www.leitlinienprogramm-onkologie.de/leitlinien/supportive-therapie

  Deutsche Version: Prophylaxe und Therapie der Chemotherapie-induzierten Diarrhoe

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