Secondary Prophylaxis of Docetaxel Induced Diarrhea with Loperamide: Case Report
A 72-yr old male patient was diagnosed with stage IV non-small-cell lung cancer (NSCLC) in March 2012. He was treated with weekly docetaxel-cisplatin (DP) chemotherapy: docetaxel 35 mg/m2 and cisplatin 30 mg/m2 on day 1 and 8 every 3 weeks. During the 1st cycle, grade 3 nausea and vomiting developed from day 3 of chemotherapy. Thus fasting, parenteral nutritional support, and hydration with intravenous administration of metoclopramide and lorazepam were given. During the 2nd cycle, neither nausea nor vomiting but grade 3 diarrhea (8-10 stools per day) developed from day 4 and he was admitted to hospital on day 6. Diarrhea was profuse and watery without blood or pus. Grade 3 dehydration was combined while there was no abdominal pain, tenderness or fever. Stool studies including culture revealed neither pathogen nor white/red blood cells. Laboratory examinations including white blood cell count, erythrocyte sedimentation rate, and C-reactive protein were within normal limits. Fasting, parenteral nutritional support and hydration with oral loperamide, starting with 4mg followed by 2 mg every 2 hr, were done. Despite of the management, diarrhea continued until day 9 of chemotherapy. On day 10 of his 2nd cycle, diarrhea was resolved and he started diet on day 12, but diarrhea redeveloped. The same management with loperamide was done and the diarrhea was resolved on day 15. Chemotherapy at day 8 of the 2nd cycle was delayed to day 16 and given with 20% reduced dose. After 3 days, grade 3 diarrhea developed again and he visited emergency room. The same management with loperamide was done for 3 days and diarrhea was resolved.\nWe concluded that docetaxel induced his diarrhea because of several reasons: no signs of infection, no use of antibiotics, repeated diarrhea after chemotherapy and little probability of diarrhea with other medications including dexamethasone, palonosetron and cisplatin. Chest computed tomography after 2 cycles of DP showed near complete response according to RECIST v 1.1 (). Thus we decided to continue DP chemotherapy despite of the severe repeated docetaxel induced diarrhea.\nOn day 1 of the 3rd DP chemotherapy with 20% reduced dose, prophylactic loperamide (2 mg every 8 hr) and fasting was started before administration of chemotherapy. Diarrhea did not develop with 4 days of fasting and 7 days of loperamide. Day 8 DP of 3rd cycle was delayed due to grade 2 asthenia and started on day 15. On day 15, prophylactic loperamide was started before chemotherapy and fasting was started after administration of chemotherapy. The duration of fasting and administration of loperamide were shortened to 2 and 5 days, respectively. The 3rd cycle was completed without diarrhea. Subsequent cycles of DP chemotherapy with 20% reduced dose could be given without diarrhea by virtue of loperamide. Now he finished 6 cycles of DP and which resulted near CR.