PEP Topic 
Chemotherapy-Induced Diarrhea

Charcoal is ash and carbon residue from animal and plant substances. Charcoal has been used for treatment of upset stomach. Charcoal has been studied in patients with cancer for prevention of chemotherapy-induced diarrhea.

Effectiveness Not Established

Research Evidence Summaries

Maeda, Y., Ohune, T., Nakamura, M., Yamasaki, M., Kiribayashi, Y., & Murakami, T. (2004). Prevention of irinotecan-induced diarrhoea by oral carbonaceous adsorbent (Kremezin) in cancer patients. Oncology Reports, 12(3), 581–585.


Study Purpose:

To examine the effectiveness of two interventions to ameliorate diarrhea after treatment with irinotecan

  • 2 g AST-120 (Kremezin™) oral adsorbent made of activated carbon given at the start of irinotecan infusion, immediately after irinotecan, and 3 hours later
  • An oral alkalization made of 2 g NaHCO3 (sodium bicarbonate), 2 g magnesium oxide, and 300 mg ursodeoxycholic acid given orally before irinotecan infusion and then every day for three days after

Sample Characteristics:

This was a nonrandomized trial of 13 Japanese patients with various cancers receiving 60–100 mg/m2 irinotecan every one to two weeks, alone or in combination regimens. Patients received one of three interventions. Four patients received AST-120; one of these four had previously received irinotecan with no prophylaxis and thus served as a control. Four patients received the oral alkalization; one of these also had previously received irinotecan with no prophylaxis and thus served as a control. Including these two controls, a total of seven control patients received irinotecan with no prophylaxis.

Measurement Instruments/Methods:

The number of bowel movements was recorded; however, volume was not recorded.


Oral AST-120 was associated with significantly decreased numbers of daily bowel movements during irinotecan treatment compared to no prophylaxis (p < 0.05). Oral alkalization was effective in ameliorating diarrhea, but the difference was not significant.


  • The sample size was very small with only 13 patients.
  • One patient in the AST-120 group and one in the oral alkalization group acted as their own controls. Only three other patients were in each interventional treatment  group.
  • Although further study is necessary regarding the effectiveness of oral AST-120 on plasma concentrations of irinotecan-related compounds, the absorption of irinotecan or SN-38 from the intestinal lumen is small, if any, and the remaining irinotecan-related compounds in the intestinal lumen cause diffuse mucosal damage in irinotecan treatments.

Michael, M., Brittain, M., Nagai, J., Feld, R., Hedley, D., Oza, A., … Moore, M.J. (2004). Phase II study of activated charcoal to prevent irinotecan-induced diarrhea. Journal of Clinical Oncology, 22(21), 4410–4417.

doi: 10.1200/JCO.2004.11.125

Intervention Characteristics/Basic Study Process:

In cycle 1, 28 patients received irinotecan plus 1,000 mg oral-activated charcoal (AC) plus 25 ml water the evening before irinotecan and then three times per day for 48 hours after, on an empty stomach. In cycle 2, 24 patients received irinotecan without AC.

Sample Characteristics:

This study reported on 52 patients with advanced colorectal cancer receiving 125 mg/m2 irinotecan weekly for four weeks with two weeks of rest.

Study Design:

This was a prospective, nonrandomized trial; patients served as their own controls.

Measurement Instruments/Methods:

  • Patient diaries were used to record diarrhea frequency and grading using the National Cancer Institute (NCI) Common Toxicity Criteria (CTC) and daily loperamide use.
  • Research nurses closely monitored compliance with the loperamide regimen (4 mg at first onset of delayed diarrhea and then 2 mg every 2 hours, 4 mg every 4 hours at night, until patient was diarrhea free for 12 hours) by inspection of provided diaries.


  • Administration of AC with irinotecan in cycle 1 was associated with
    • Decreased grade 3 and 4 diarrhea
    • Decreased loperamide use
    • Increased irinotecan dose intensity.
  • In cycle 1, 7.1% of patients recorded grade 3-4 diarrhea. In cycle 2, 25% of patients recorded grade 3-4 diarrhea.
  • In cycle 1, 46.1% of patients recorded grade 0 diarrhea. In cycle 2, 20.8% of patients recorded grade 0 diarrhea.
  • In cycle 1, 98% of patients received their planned doses. In cycle 2, 70% of patients received their planned doses.
  • In cycle 1, 25% of patients received more than 10 loperamide cycles. In cycle 2, 54% of patients received more than 10 loperamide cycles.


Any statistical comparison in the efficacy parameters defined in the trial would be associated with large confidence intervals.


  • The sample size was small.
  • Patients acted as their own controls.
  • Irinotecan dose reductions and supportive care are complex.

Nursing Implications:

This was an exploratory trial with small patient numbers; results are hypothesis-generating and require additional confirmation in a larger study.