Transcript ORS

Acute Diarrhea and Oral
Rehydration
Dr. Alaa Jumaa
Acute Gastroenteritis
 Acute Gastroenteritis (AGE) remains a major cause
of morbidity and mortality in the USA
• Over 1.5 million outpatient visits
• 200,000 hospitalizations
• 300 death a year
 Worldwide diarrheal disease is the leading cause of
morbidity and mortality
• 1.5-2.5 million deaths annually among children
younger than 5
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Acute Gastroenteritis
 Direct medical cost in the US reach $ 250
million/year and is estimated to reach 1 billion
worldwide
 Even though the number of death associated to
AGE worldwide is still high, a decrease has been
noticed since the start of Oral Rehydration Therapy
(ORT) campaigns
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Choices of ORS
 In 1975 the WHO and UNICEF decided to promote
a single ORS (WHO-ORS)
• It contained (mEq/L) Na 90, K 20, CL 80, base
30 and Glu 111(mmol/L) with an Osm of 311
• This composition allowed for a single solution to
be use for treatment of diarrhea caused by a
multitude of agents
• Has been proven to be effective and safe for
over 25 year
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Choices of ORS
 In 2002 the WHO announced a new ORS
formulation with a lower osmolarity
• 2002 WHO-ORS contains 75mEq/L of Na, 75
mmol/L of Glu and an Osm of 245
• Lower osmolarity as been associated to less
stool output, less vomiting and reduced need of
IV among infants and children with non-cholera
diarrhea
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Choices of ORS
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Solution
Carbs
(gm/L)
Sodium
(mmol/L
Potassium
(mmol/L)
Chloride
(mmol/L
Base
(mmol/L)
Osmolarity
(mOsm/L)
WHO-ORS
(2002)
13.5
75
30
65
30
245
WHO-ORS
(1975)
20
90
20
80
30
311
Pedialyte
25
45
20
35
30
250
Enfalyte
30
50
25
45
34
200
Rehydralyte
25
75
20
65
30
305
CeraLyte
40
50-90
20
N/A
30
220
Gatorade
14
110
30
Apple Juice
120
0.4
44
45
N/A
730
Coca-Cola
112
1.6
N/A
N/A
13.4
650
290-303
Oral Rehydration Therapy
 The full benefits of ORT have not been realized in
developing countries
 One of the reasons for the low use of ORT is the
ingrained use of IV therapy
 The vast majority of pediatricians (30-49%) report
always using IVF to treat moderate dehydration and
1/3 report using IVF to treat mild dehydration
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Oral Rehydration Therapy
 Randomized trials of ORT vs. IV hydration have
demonstrated
• Shorter ED stays
• Greater parental satisfactions
• As effective as IV in moderately dehydrated
children < 3 years
• Faster initiation of rehydration
• Lower hospitalization rate
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Oral Rehydration Therapy
 Barriers for ORT
• Lack of parental knowledge
• Lack of training of medical professionals
• Cost of commercially available ORS
• Preferences among physicians
• The practice of continued feeding during
diarrheal disease have been hard to establish
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Physiologic Basis of ORT
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Physiologic Basis of ORT
 This co-transport remains intact even in infections
of E. coli, salmonella, shigella and rotavirus
 The mechanism essential for the efficacy of oral
rehydration solution (ORS) is the couple transport
of sodium and glucose in the intestinal brush border
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Limits of ORT
 Mild to moderate dehydration from diarrhea
of any cause can be treated effectively with
ORS except in :
1.
2.
3.
4.
5.
6.
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patients with severe dehydration
those with uncontrollable vomiting
those unable to drink because of extreme fatigue
stupor, or coma
those with gastric or intestinal distention
1 % of diarrhea is due to carbohydrate
malabsorption
Oral Rehydration Therapy
 ORT includes two phases:
• Rehydration Phase
 50 mL/kg of ORS should be given within 4 hr to
patients with mild dehydration and
 100 mL/kg over 4 hr to those with moderate
dehydration
 An additional 10 mL/kg of ORS is given for each
stool.
 feeding should be allowed after rehydration
 Vomiting may occur during the first 2 hr of
administration of ORS, but it usually does not
prevent successful oral rehydration
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Oral Rehydration Therapy
• Maintenance Phase
 Patients with mild diarrhea usually can then be
treated at home with 100 mL of ORS/kg/24 hr
until the diarrhea stops.
 Patients with more severe diarrhea require
continued supervision, an intake of 10–15 mL
of ORS/kg/hr is appropriate.
 Breast-feeding or supplemental water intake
should be maintained.
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Flavouring/colouring of ORS
 The theoretical advantage of flavoured and
coloured ORS is greater acceptability, and
consequently increased use. Because this, in turn,
might lead to over-consumption, the WHO/CDD
Programme conducted a safety/efficacy study in
Egypt and an acceptability study in the Philippines
of flavoured and coloured ORS solutions.
 The results of these studies showed neither an
advantage nor disadvantage for the flavoured and
coloured ORS when compared to the standard
ORS with regard to safety, acceptability and correct
use.
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Flavouring/colouring of ORS
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In 1968, cyclamic acid was reported to cause cancer
high dose of saccharine are suspected to be carcinogenic;
dulcine is recognized as toxic and carcinogenic; and
aspartame is known to be unstable at temperatures above 40
degrees Celsius.
 For all these products, the above mentioned guidelines
specify the maximum dose to be consumed per kg of body
weight and per day (i.e., aspartame 40 mg/kg body
weight/day).
 it also seems that certain flavouring agents can cause
allergies and other side effects, particularly in infants and
small children.
 Finally, it must be noted that the flavouring of ORS may
increase cost of the product by up to 20-30%, especially when
the additional ingredients must be imported.
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New advancement
 The amino acid- and/or maltodextrin-containing ORS
 Studies to evaluate cooked rice as a replacement for glucose
in ORS solution began in 1980. Initially, solutions were
prepared by cooking rice powder (50-80g/l) for at least 10
minutes and then adding salts in concentrations identical to
those of the ORS recommended by WHO.
 rice-based ORS is superior to standard ORS for adults and
children with cholera, and may be used to treat such patients
wherever its preparation is convenient;
 rice-based ORS is not superior to standard ORS in the
treatment of children with acute non-cholera diarrhoea,
especially when food is given shortly, after rehydration, as is
recommended to prevent malnutrition.
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The ORS in liquid and tablet form
 In 1980 TETRA PAK International AB, in
collaboration with the Department of Paediatrics of
the University of Lund, Sweden, offered to evaluate
the production of liquid ORS in aseptic packages
and to develop a method to sterilize liquid ORS.
 The objective was to make liquid ORS available in
locations where water supply was problematic, for
example after a natural disaster.
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The ORS in liquid and tablet form
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 With the support of the CDD Programme, the
Programme for Appropriate Technology in Health
(PATH) developed ORS in tablet form. The
manufacturing guidelines became available in 1983.
Since then PATH has offered a licensing agreement to
transfer the technology to manufacturers in developing
countries. The formulation of the tablet complies with
that recommended by WHO/UNICEF, but contains
excipients that are needed to compress the product. It
has a size of 15/16” and will make 150 ml of solution.
 It disintegrates in less than 90 seconds. Later, CIBAGEIGY, Basle, Switzerland developed an effervescent
tablet for 120 ml of solution, that is now marketed
worldwide.
Thanks
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