Controversies | Clinician's Corner

Clinical Concerns About Reduced-Osmolarity Oral Rehydration Solution

David R. Nalin, MD; Norbert Hirschhorn, MD; William Greenough III, MD; George J. Fuchs, MD; Richard A. Cash, MD
JAMA. 2004;291(21):2632-2635. doi:10.1001/jama.291.21.2632.
Text Size: A A A
Published online


Demonstration of the benefits of oral therapy for cholera in 19681 soon led to application of the method to all forms of infectious diarrheal diseases.2 The original oral rehydration solution (ORS) formulation developed by the World Health Organization (WHO) (Table 1) struck a compromise between the ideal solutions for these diverse disorders to meet the programmatic goal of a single formulation and packaging for global use in cholera and noncholera diarrheas, in both adults and children. Recently, WHO recommended a new oral solution (Table 1) for all acute diarrheas, including cholera. This new formula would replace the original ORS, which saved millions of lives, with a new formulation containing less sodium and glucose.3 This change was ostensibly to reduce gross stool volume and use of unscheduled intravenous therapy by lowering solution osmolarity. However, the reduced-osmolarity formulation is particularly unsuitable for universal use because it contains an amount of sodium insufficient to maintain sodium balance in cholera patients, in whom its use induces negative sodium balance and may lead to hyponatremia,4,5 polyuria,4 and a small but clinically significant risk of neurologic complications. The new reduced-osmolarity formulation stretches the original compromise to the breaking point. It may be time to promote use of different solutions for patients with cholera, beginning in controlled settings such as cholera treatment centers and hospitals.

Figures in this Article

Sign In to Access Full Content

Don't have Access?

Register and get free email Table of Contents alerts, saved searches, PowerPoint downloads, CME quizzes, and more

Subscribe for full-text access to content from 1998 forward and a host of useful features

Activate your current subscription (AMA members and current subscribers)

Purchase Online Access to this article for 24 hours

First Page Preview

View Large
First page PDF preview


Figure. Net Water and Ion Movement During Intestinal Osmoregulation in the Presence of Cholera Toxin
Graphic Jump Location
Intestinal absorption of sodium, chloride, and water is severely impeded in cholera. Osmoregulation of luminal fluids occurs chiefly by net sodium and chloride movement into hypotonic saline solutions (A) and by net water movement into hypertonic solutions (B). In A, water losses are slowed but sodium losses are heightened; in B, water losses are massively increased and diarrhea worsens. In C and D, addition of substrates, which enhance active sodium transport, increases net sodium, chloride, and water absorption and promotes rehydration. In C, however, net sodium deficits occur because sodium enters luminal fluids when its concentration is below plasma levels.18,28,29




You need to register in order to view this quiz.
Citing articles are presented as examples only. In non-demo SCM6 implementation, integration with CrossRef’s "Cited By" API will populate this tab (http://www.crossref.org/citedby.html).


Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 11

Sign In to Access Full Content

Related Content

Customize your page view by dragging & repositioning the boxes below.

See Also...
Articles Related By Topic
Related Topics
PubMed Articles