Metastatic NSCLC with Corey J. Langer, MD, David Spigel, MD, Denise O'Dea, NP, and Jack West, MD: Case 1 - Episode 17

Jack West, MD: Recommendations for Managing the Principle Adverse Event of Diarrhea

What are your recommendations for managing the principle adverse event of diarrhea in patients like Ingrid?

There are two main considerations that I would focus on. The first is dietary. Many of my patients have more of an issue when they eat more fiber-filled foods or fried foods. Those are the [foods] that many of my patients, over time, learn how to avoid. The other thing is to encourage patients to be liberal in their use of an antidiarrheal agent such as loperamide, and I usually have them take a 2-mg tablet every 2 hours until they are not having diarrhea for 12 hours at a time.

With these efforts, most of my patients can manage effectively without prohibitive toxicity in terms of diarrhea. In some cases, if that doesn’t remedy the issue enough, we will do a dose reduction. It’s certainly an option, but my first efforts are going to be based on diet and then giving antidiarrheal medication.


Ingrid C. is a 62-year-old corporate accountant from San Antonio, Texas. Her medical history is notable for depression, which is being treated with an SSRI, and she has no history of smoking.

At the start of busy tax season, she presents to her PCP with back and chest pain, a persistent cough, and intermittent dyspnea.

Her cardiac workup is negative, and her PCP orders a chest x-ray, which shows bilateral lung nodules and a large upper right lung mass with pleural effusion; she is referred for a follow-up CT scan.

The CT confirms the presence of multiple lung nodules and additional lesions in the thoracic vertebra; she is referred for further diagnostics.

Core biopsy of her lung mass shows adenocarcinoma stage IV; mutational testing showsEGFRdel 19.

Her performance status was 1.0 at diagnosis.

Ingrid has a family vacation in Tuscany planned for next year, and hopes to be able to keep her travel plans; her oncologist initiates her on afatinib 40 mg daily.

She returns to her oncologist in 2 weeks with persistent diarrhea (>5 stools/d) that has not responded to antidiarrheal medications, which were suggested by the nursing team, and her normal work day is being affected.

Her oncologist reduces her afatinib dose to 30 mg/day, and she continues therapy.

Nine weeks after initiating therapy, she reports to the nursing team symptoms of redness and swelling in her fingers and fingernails, and management strategies are recommended.

At her next follow-up 2 months later, her CT scan shows the right lung mass to be stable, with no new lesions. She has improved symptomatically.

Her diarrhea has improved sufficiently to allow her to resume her normal work load; her paronychia has been effectively managed with vinegar soaking and topical antibiotics.