Issues for Surgery
Risk of prolonged ileus if continued following colorectal surgery.
Risk of QT-interval prolongation, particularly at high doses, if continued (see Interaction(s) with Common Anaesthetic Agents and Interaction(s) with other Common Medicines used in the Perioperative Period).
Advice in the Perioperative period
Consider an ECG for any patients taking greater than the recommended daily dose of 16mg, particularly those with underlying cardiac disease – see Further Information.
For patients presenting with acute diarrhoea (Bristol Stool Chart types 5 – 7) that is not clearly attributable to an underlying condition (e.g. inflammatory colitis, overflow) or therapy (e.g. enteral feeding), consider assessing them for Clostridium difficile infection (CDI)1.
Review if patient develops reduced gastrointestinal motility (e.g. ileus) post-operatively.
For patients undergoing Colorectal Surgery with Stoma Formation
For patients undergoing Stoma Reversal Surgery
In the event of an overdose with loperamide, naloxone should be administered as an antidote. The duration of loperamide is longer than that of naloxone (1 – 3 hours), so repeated treatment may be necessary; patients should be monitored closely for at least 48 hours to detect CNS depression2.
Interaction(s) with Common Anaesthetic Agents
Anaesthetic agents that may be used in the perioperative period that are known to, or predicted to, prolong the QT-interval include4: -
Monitor ECG with concurrent use if risk factors for QT-prolongation are also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia).
Interaction(s) with other Common Medicines used in the Perioperative Period
QT-Interval Prolongation (see also under Interaction(s) with other Common Medicines used in the Perioperative Period)
Medicines that may be used in the perioperative period that are known to prolong the QT-interval include3, 4: -
*Monitor ECG with concurrent use if the risk factors for QT-prolongation are also present (increasing age, female sex, cardiac disease, and some metabolic disturbances e.g. hypokalaemia).
Serious cardiovascular events (such as QT prolongation, torsades de pointes, and cardiac arrest), including fatalities, have been reported in associated with large overdoses of loperamide.
British Intestinal Failure Alliance (BIFA) Guidance on use of High Dose Loperamide in Patients with Intestinal Failure6
A European review of reports worldwide identified 19 cases suggestive of cardiac disorders associated with loperamide abuse and misuse. In all cases, there was evidence of intentional high doses being taken for unapproved indications. From these reports, daily doses in use ranged from 40 – 800mg.
Patients with short bowel / intestinal failure who have high gastrointestinal losses of salt and water may have life threatening metabolic / electrolyte disturbances that result in dehydration with renal failure that can become irreversible. Loperamide reduces intestinal motility and can decrease water and sodium output from an ileostomy by about 20-30%. On the basis that there are no reports of loperamide toxicity in patients with gastrointestinal diseases and as loperamide absorption is likely to be reduced in short bowel patients, BIFA recommend continued use of loperamide therapy (greater than 16mg daily) in these patients.