Sorbitol intolerance

When sorbitol is administered intravenously, it is converted to fructose rather than to glucose. It is poorly absorbed in the small intestine, and much is fermented by colonic bacteria to short-chain fatty acids, CO2, and Hj, leading to abdominal pain and diarrhea (sorbitol intolerance). 

Certain other patients are especially sensitive to the gastrointestinal effects of sorbitol for example, diabetics can be prone to sorbitol intolerance, because of altered gastrointestinal transit time and motility. Some of them also have a higher consumption of sorbitol-containing dietary foods. Patients on chronic hemodialysis can be predisposed to sorbitol intolerance as a result of carbohydrate malabsorption (25). 

Jain NK, Patel VP, Pitchumoni CS. Sorbitol intolerance in adults. Prevalence and pathogenesis on two continents. J Chn Gastroenterol 1987 9(3) 317-19. 

Contraindications Intestinal obstruction, GI tract not anatomically intact patients at risk of hemorrhage or GI perforation, if use would increase risk and severity of aspiration not effective for cyanide, mineral acids, caustic alkalis, organic solvents, iron, ethanol, methanol poisoning, lithium do not use charcoal with sorbitol in patients with fructose intolerance, hypersensitivity to charcoal or any component of the formulation... 

Life-threatening adverse reactions with IV sorbitol infusions have been reported in patients with fructose intolerance. 

Osmotic diarrhoea. Occurs if osmotically active solutes are retained in the intestinal lumen water will not be absorbed and diarrhoea will result. Ingestion of poorly absorbed substrates, such as mannitol, sorbitol, Epson salts (MgS04) and some antacids (MgOHj), can occur in a number of malabsorption syndromes. For example, a failure to digest lactose (lactose intolerance) means that lactose remains in the intestinal lumen and osmotically holds water. 

Many healthy individuals are intolerant of sorbitol, and develop abdominal cramping and diarrhea with less than the usual laxative dose (23). It has been suggested that more than 30% of healthy adults, irrespective of ethnic origin, cannot tolerate 10 g of sorbitol (24). 

The problems that can result from the administration in total parenteral fluid infusions of D-fructose or sorbitol have been reviewed (4). Either of these can cause life-threatening hypoglycemia, unless glucose is administered concurrently, in patients who have underlying hereditary fructose intolerance. Unless there is a clear clinical history of the condition, it may not be readily identified. In some countries, fructose and D-glucitol (sorbitol) have been eliminated from the pharmacopoeia for this reason. 

Hereditary fructose intolerance affects one in 21 000 persons, and there have been more than 12 severe complications caused by these solutions, several lethal. Since a prior history of fructose intolerance is often not obtained, it has been argued that the use of fructose- and sorbitol-containing infusion fluids must be regarded as offering doubtful advantage but carrying definite lethal risk, and that their use should be discontinued. A modified intravenous fructose tolerance test should at least be carried out before infusions of fructose or sorbitol are giveu (8). 

A 16-year-old girl died after an uncomplicated appen-dicectomy (10). She had undiagnosed hereditary fructose intolerance and had been given sorbitol and fructose postoperatively. 

Sachs M, Asskali F, Forster H, Encke A. Wiederholte perioperative Application von Fructose und sorbit bei einer Patientin mit hereditarer fructoserntoleranz (HFI). [Repeated perioperative administration of fructose and sorbitol in a female patient with hereditary fructose intolerance (HFI).] Z Ernahrungswiss 1993 32(l) 56-66. 

Some months later, a statement by the Australian Drug Evaluation Committee reflected similar thinking and made closely similar recommendations (52). It was pointed out, inter alia, that the rapid metabolism of fructose and sorbitol can cause rapid accumulation of uric and lactic acids as well as phosphate depletion, especially in states of anoxia, and that acidosis and decreased tissue energy metabolism can occur. Glucose has, among other things, the advantage that it poses no risk to patients with familial laevulose intolerance. 

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