Efficacy and tolerability of racecadotril in acute diarrhea in children

Assessing safety and efficacy of a novel glucose-free amino acid oral rehydration solution for watery diarrhea management in children: a randomized, controlled, phase III trial

Background

Diarrhoeal disease poses a significant global health challenge, especially in children under three years old. Despite the effectiveness of oral rehydration therapy (ORT), its adoption remains low. Glucose-based ORS (GORS) is the standard, but novel formulations like glucose-free amino acid-based VS002A have emerged as potential alternatives. This study aimed to compare the safety and efficacy of VS002A against the standard WHO-ORS in treating non-cholera acute watery diarrhoea in children.

Methods

A triple-blind, randomized trial enrolled 310 male infants and children aged 6-36 months, who were assigned to receive WHO-ORS or VS002A over a 16-month period, from June 2021 to September 2022. Both groups received standard of care, including zinc supplementation. The Primary study outcome measured was the duration of diarrhoea. Secondary outcomes included stool output, treatment failure and adverse events. Exploratory endpoints included urinary output, body weight changes, blood biochemistry, stool microbiology and gut health biomarkers.

Findings

Both VS002A and WHO-ORS were well-tolerated with a low adverse event rate. While not different statistically (p = 0.10), duration of diarrhoea was shorter in children treated with VS002A vs. WHO-ORS (65.4 h vs. 72.6 h). Similarly, stool output was also lower vs. WHO-ORS in children treated with VS002A, though not statistically different (p = 0.40). Serum citrulline levels, an indicator of gut health, were higher in the VS002A group at 24 h suggesting a potential protective effect (p = 0.06).

Interpretation

The findings of this study support the non-inferiority of VS002A, a glucose-free amino acid-based ORS compared to the WHO-ORS standard of care. VS002A was shown to be safe and effective in treating non-cholera acute watery diarrhoea in young children. VS002A may offer advantages in pathogen-driven diarrhoea, supported by trends toward a lower duration of diarrhoea and stool output within the per protocol group. Furthermore, individuals with prolonged diarrhoea, severe malnutrition, environmental enteric dysfunction or have issues with obesity or insulin resistance, could benefit from a glucose-free ORS. This research contributes to addressing the persistent challenge of childhood diarrhoea by presenting an alternative glucose-free ORS formulation with potential advantages in select scenarios, offering a promising avenue for improving paediatric diarrhoea management worldwide.

Funding

The study was funded by Entrinsic Bioscience, LLC., Norwood, MA, USA.

National Consensus for the Management of Acute Gastroenteritis in Jordanian Children: Consensus Recommendations Endorsed by the Jordanian Paediatric Society

Diarrhoeal diseases are one of the leading worldwide preventable causes of death among children under 5 years of age. Almost half of children do not receive optimal acute gastroenteritis (AGE) treatment in Jordan. With neither regional nor local guidelines available for AGE, consensus recommendations on the management of paediatric AGE in Jordan were developed by a panel of senior paediatricians and paediatric gastroenterologists and are endorsed by the Jordanian Paediatric Society. Recommendations are based on international guidelines and available relevant literature in relation to the AGE landscape and the healthcare system in Jordan. The prevention of diarrhoeal diseases should focus on the improvement of nutrition, hygiene, and sanitation, the introduction of routine vaccination against rotavirus, and the adoption of a standardised approach for AGE management (oral rehydration solution (ORS) use±adjunct therapies, continued feeding, and avoiding routine antibiotic use). Ondansetron, diosmectite, racecadotril, probiotics, and zinc can be considered adjunct to ORS, if needed. Local data gaps should be addressed. The clinical algorithm for the management of paediatric AGE could promote adherence to practice recommendations and by extension improve health outcomes in children.

A double-blind clinical trial to compare the efficacy and safety of a multiple amino acid-based ORS with the standard WHO-ORS in the management of non-cholera acute watery diarrhea in infants and young children: "VS002A" trial protocol

BACKGROUND

Diarrhea is the second deadliest disease for under-five children globally and the situation is more serious in developing countries. Oral rehydration solution (ORS) is being used as a standard treatment for acute watery diarrhea for a long time. Our objective is to compare the efficacy of amino acid-based ORS "VS002A" compared to standard glucose-based WHO-ORS in infants and young children suffering from acute non-cholera watery diarrhea.

METHODS

It is a randomized, double-blind, two-cell clinical trial at Dhaka Hospital of icddr,b. A total of 312 male children aged 6-36 months old with acute non-bloody watery diarrhea are included in this study. Intervention arm participants get amino acid-based ORS (VS002A) and the control arm gets standard glucose-based WHO-ORS. The primary efficacy endpoint is the duration of diarrhea in the hospital.

DISCUSSION

Oral rehydration therapy (ORT) with the present ORS formulation has certain limitations - it does not reduce the volume, frequency, or duration of diarrhea. Additionally, the failure of present standard ORS to significantly reduce stool output likely contributes to the relatively limited use of ORS by mothers as they do not feel that ORS is helping their child recover from the episode of diarrhea. Certain neutral amino acids (e.g., glycine, L-alanine, L-glutamine) can enhance the absorption of sodium ions and water from the gut. By using this concept, a shelf-stable, sugar-free amino acid-based hydration medicinal food named 'VS002A' that effectively rehydrates, and improves the barrier function of the bowel following infections targeting the gastrointestinal tract has been developed. If the trial shows significant benefits of VS002A use, this may provide evidence to support consideration of the use of VS002A in the present WHO diarrhea management guidelines. Conversely, if there is no evidence of benefit, these results will reaffirm the current guidelines.

TRIAL REGISTRATION

ClinicalTrials.gov NCT04677296 . Registered on December 21, 2020.

Racecadotril for acute diarrhoea in children

BACKGROUND

Acute diarrhoea is a leading cause of death for children under five years of age. Most deaths are caused by excessive fluid and electrolyte losses. Racecadotril is an anti-secretory drug that has been used for acute diarrhoea in children as an adjunct to oral rehydration therapy.

OBJECTIVES

To assess the efficacy and safety of racecadotril for treating acute diarrhoea in children under five years of age.

SEARCH METHODS

We searched the Cochrane Infectious Diseases Group Specialized Register; the Cochrane Central Register of Controlled Trials (CENTRAL, published in the Cochrane Library Issue 3, March 2019); MEDLINE; Embase; LILACS; ClinicalTrials.gov; and the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP), up to 4 March 2019, for clinical trials regardless of publication language or status.

SELECTION CRITERIA

Randomized controlled trials (RCTs) that compared racecadotril to placebo or no intervention in addition to standard care (oral rehydration therapy) in children under five with acute diarrhoea. The primary outcomes were failure of oral rehydration, duration of diarrhoea, and number of stools. The secondary outcomes were stool output, length of the hospital stay, and adverse events.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial eligibility, extracted the data and assessed risk of bias. We presented dichotomous data with risk ratios (RR) and continuous data with mean difference (MD) or standardized mean difference (SMD). Where appropriate, we combined trials with meta-analysis and used a random-effects model if there was significant heterogeneity (I² ≥ 50%). We assessed the certainty of the evidence using the GRADE approach.

MAIN RESULTS

Seven RCTs with a total of 1140 participants met the inclusion criteria. The trials were carried out on children aged three months to five years, in outpatient and inpatient facilities from France, Spain, Peru, India, Kenya, and Ecuador. The efficacy and safety of racecadotril were compared to placebo or no treatment. Racecadotril may reduce the risk of rehydration failure (RR 0.41, 95% CI 0.13 to 1.23; 2 RCTs, 192 participants; low-certainty evidence). Data on duration of diarrhoea, number of stools in the first 48 hours are insufficient to reach a conclusion; stool output in the first 48 hours appears to be lower in the two trials measuring this, although the data is not combinable. Length of hospital stay was similar in two studies measuring this, and overall there was no evidence that racecadotril increased overall rate of adverse events (RR 0.90, 95% CI 0.66 to 1.22; 5 RCTs, 688 participants; low-certainty evidence). Most adverse events in the racecadotril group were mild or moderate.

AUTHORS' CONCLUSIONS

Racecadotril seems to be a safe drug but has little benefit in improving acute diarrhoea in children under five years of age. Current evidence does not support routine use of racecadotril in management of acute diarrhoea in children under five outside of the context of placebo controlled RCTs. 18 December 2019 Up to date All studies incorporated from most recent search All studies identified during the most recent search (4 Mar, 2019) have been incorporated in the review, and no ongoing studies identified.

Oral administration of tannins and flavonoids in children with acute diarrhea: a pilot, randomized, control-case study

BACKGROUND

AG is the most common cause of pediatric consultations among children between 2 and 5 years of age and it still leads to high mortality and morbidity. Its management is based on rehydration therapy, but this treatment is not effective in reducing duration of diarrhea. For this reason, other safer and less expensive interventions, which could be added to oral rehydration therapy, are of great interest.

METHODS

A pilot, randomized, case-controlled trial was conducted in 60 children affected by AG (< 7 days) with mild-moderate dehydration, according to WHO recommendations, from1 year to 17 years old. Patients were divided into 2 Groups: Group 1 consisting of 30 children treated with Actitan F and standard oral rehydration (SOR); Group 2 consisting of 30 children who received only SOR. Both groups received treatment for seven days, respectively. Patients of Group 1 stopped for their own choice, SOR after the first 24 h and continued only with Actitan F.

RESULTS

After 24 h of treatment, the median number of stools was 3.5 for Group 1, and 4 for Group 2. In Group 1 the difference between the number of stools at baseline (n = 5) and after 24 h of treatment (n = 3.5) was significant (p < 0.0001). At the end of treatment, the median duration of diarrhea in Group 1 was 5 days, compared with 4 days in the Group 2, this difference was not statically significant (p 0.48).

CONCLUSIONS

Oral administration of Actitan F associated with SOR seems safe and effective treatment in shortening the duration of AG in children. Further studies confirming these data are needed.

TRIAL REGISTRATION

NCT03356327 (retrospectively registered).

Racecadotril in the treatment of acute diarrhea in children: a systematic, comprehensive review and meta-analysis of randomized controlled trials

BACKGROUND

Racecadotril is a guideline-recommended option for the treatment of acute diarrhea in children but existing guidelines and previous reviews of the field are based on a small fraction of published evidence. Therefore, we have performed a systematic search for randomized controlled trials evaluating racecadotril as add-on or in comparison to other treatments.

METHODS

A search was performed in PubMed, Scopus and Google Scholar without limits about country of origin or reporting language. A meta-analysis was conducted for the five most frequently used efficacy parameters.

RESULTS

We have retrieved 58 trials, from nine countries including six in comparison to placebo, 15 in comparison to various active treatments and 41 as add-on to various standard treatments (some multi-armed studies allowing more than one comparison). Trials used 45 distinct efficacy parameters, most often time to cure, % of cured children after 3 days of treatment, global efficacy and number of stools on second day of treatment. Racecadotril was superior to comparator treatments in outpatients and hospitalized patients with a high degree of consistency as confirmed by meta-analysis for the five most frequently used outcome parameters. For instance, it reduced time to cure from 106.2 h to 78.2 h (mean reduction 28.0 h; P < 0.0001 in 24 studies reporting on this parameter). Tolerability of racecadotril was comparable to that of placebo (10.4% vs. 10.6% adverse events incidence) or that of active comparator treatments other than loperamide (2.4% in both groups).

CONCLUSIONS

Based on a comprehensive review of the existing evidence, we conclude that racecadotril is more efficacious than other treatments except for loperamide and has a tolerability similar to placebo and better than loperamide. These findings support the use of racecadotril in the treatment of acute diarrhea in children.

Cost utility, budget impact, and scenario analysis of racecadotril in addition to oral rehydration for acute diarrhea in children in Malaysia

Objective

To perform cost utility (CU) and budget impact (BI) analyses augmented by scenario analyses of critical model structure components to evaluate racecadotril as adjuvant to oral rehydration solution (ORS) for children under 5 years with acute diarrhea in Malaysia.

Methods

A CU model was adapted to evaluate racecadotril plus ORS vs ORS alone for acute diarrhea in children younger than 5 years from a Malaysian public payer’s perspective. A bespoke BI analysis was undertaken in addition to detailed scenario analyses with respect to critical model structure components.

Results

According to the CU model, the intervention is less costly and more effective than comparator for the base case with a dominant incremental cost-effectiveness ratio of −RM 1,272,833/quality-adjusted life year (USD −312,726/quality-adjusted life year) in favor of the intervention. According to the BI analysis (assuming an increase of 5% market share per year for racecadotril+ORS for 5 years), the total cumulative incremental percentage reduction in health care expenditure for diarrhea in children is 0.136578%, resulting in a total potential cumulative cost savings of −RM 73,193,603 (USD −17,983,595) over a 5-year period. Results hold true across a range of plausible scenarios focused on critical model components.

Conclusion

Adjuvant racecadotril vs ORS alone is potentially cost-effective from a Malaysian public payer perspective subject to the assumptions and limitations of the model. BI analysis shows that this translates into potential cost savings for the Malaysian public health care system. Results hold true at evidence-based base case values and over a range of alternate scenarios.

The cost utility and budget impact of adjuvant racecadotril for acute diarrhea in children in Thailand

Objective

To evaluate the cost utility and the budget impact of adjuvant racecadotril for the treatment of acute diarrhea in children in Thailand.

Methods

A cost utility model has been adapted to the context of Thailand to evaluate racecadotril plus oral rehydration solution (R+ORS) versus oral rehydration solution (ORS) alone for acute diarrhea in children <5 years old. The decision tree Excel model evaluates the costs and effects (quality-adjusted life years) over a 6-day time horizon from a public health care payer’s perspective in Thailand. Deterministic sensitivity analysis and budget impact analysis have been undertaken.

Results

According to the cost utility model, the intervention (R+ORS) is less costly and more effective than the comparator (ORS) for the base case with a dominant incremental cost-effectiveness ratio of −2,481,390฿ for the intervention. According to the budget impact analysis (assuming an increase of 5% market share for R+ORS over 5 years), the year-on-year reduction for diarrhea as a percentage of the total health care expenditure is −0.0027%, resulting in potential net cost savings of −35,632,482฿ over 5 years.

Conclusion

Subject to the assumptions and limitations of the models, adjuvant racecadotril versus ORS alone is potentially cost-effective for children in Thailand and uptake could translate into savings for the Thailand public health care system.

Gelatin Tannate for Acute Childhood Gastroenteritis: A Randomized, Single-Blind Controlled Trial

BACKGROUND

Oral rehydration therapy is the recommended treatment for acute childhood gastroenteritis. The aim of this study was to assess the efficacy and safety of gelatin tannate plus oral rehydration compared with oral rehydration alone.

METHODS

We conducted a multicenter, parallel, randomized, controlled, single-blind, prospective, open-label trial. A central randomization center used computer generated tables to allocate treatments. The study was performed in two medical centers in Italy. Sixty patients 3-72 months of age with acute gastroenteritis were recruited (median age 18 months; age range 3-66 months): 29 received an oral rehydration solution (ORS) and 31 an ORS plus gelatin tannate (ORS + G). The primary outcome was the number of bowel movements 48 and 72 h after initiating treatment. Secondary outcomes were: duration of diarrhea, stool characteristics and adverse events.

RESULTS

No patient was lost at follow-up. No significant difference in the number of bowel movements after 48 h was reported (2.7 ± 1.3 ORS + G; 3.2 ± 0.8 ORS; p = 0.06), although the ORS + G group showed a significant improvement in stool consistency (3.7 ± 1.0 vs. 4.3 ± 0.8; p = 0.005). At 72 h, a significant reduction in bowel movements was reported in the ORS + G group compared with the ORS group (1.0 ± 1.4 vs. 2.0 ± 1.7; p = 0.01). Mean duration of diarrhea was significantly lower in the ORS + G group than in the ORS only group (76.8 ± 19.2 vs. 108 ± 24.0 h; p < 0.0001). No adverse events were reported.

CONCLUSIONS

Gelatin tannate added to oral rehydration in children with acute diarrhea was associated with a significant decrease in bowel movements at 72 h, with an early improvement in the stool consistency and shorter disease duration.

CLINICAL TRIAL REGISTRATION

NCT02644200-Gelatin Tannate as Treatment for Acute Childhood Gastroenteritis ( https://www.clinicaltrials.gov ).

Racecadotril in the Management of Rotavirus and Non-rotavirus Diarrhea in Under-five Children: Two Randomized, Double-blind, Placebo-controlled Trials

OBJECTIVE

To study the effect of racecadotril on reduction in the duration of acute rotavirus and non-rotavirus diarrhea.

DESIGN

Two randomized double-blind placebo-controlled trials.

SETTING

Community-based trial in an urban area in Vellore, hospital-based trial at a secondary hospital in Vellore.

PARTICIPANTS

199 and 130 3-59 month old children in the community- and hospital-based trials, respectively.

METHODS

Racecadotril (1.5 mg/kg/dose, thrice a day for three days) or placebo were given to manage acute diarrhea in both trials.

MAIN OUTCOME MEASURE

Median duration of diarrhea.

RESULTS

Among 124 children completing the hospital trial, the median duration of diarrhea was 25 h in both arms (P=0.5); median total stool weight was 74 g/kg and 53.5 g/kg in racecadotril group and placebo group, respectively (P=0.4); and average fluid intake per day was 3.6 mL/kg/h and 3mL/kg/h in racecadotril and placebo arms, respectively (P=0.3). Among rotavirus-positive children, median duration of diarrhea was 26.9 h and 30.2 h in racecadotril and placebo arms, respectively (P=0.7). In the community, 196 completed the trial, the median duration of diarrhea was 2 days for both arms (P=0.8) and rotavirus positive children had similar outcomes with median diarrheal duration of 3 d in both arms (P=0.4).

CONCLUSIONS

Treatment with racecadotril did not reduce diarrheal duration, stool volume or the requirement for fluid replacement in children with acute gastroenteritis, both with and without rotavirus infection.

Racecadotril for the treatment of severe acute watery diarrhoea in children admitted to a tertiary hospital in Kenya

BACKGROUND

Diarrhoea is the second most common cause of death in children under 5 years of age in Kenya. It is usually treated with oral rehydration, zinc and continued feeding. Racecadotril has been in use for over 2 decades; however, there is a paucity of data regarding its efficacy from Africa.

OBJECTIVES

The objectives of this study were: to compare the number of stools in the first 48 hours in children with severe gastroenteritis requiring admission and treated with either racecadotril or placebo, to study the impact of racecadotril on duration of inpatient stay as well as duration of diarrhoea and to describe the side effect profile of racecadotril.

METHODS

This was a randomised, double-blinded, placebo-controlled trial. It enrolled children between the age of 3 and 60 months who were admitted with severe acute gastroenteritis. They received either racecadotril or placebo in addition to oral rehydration solution (ORS) and zinc and were followed up daily.

RESULTS

120 children were enrolled into the study. There were no differences in the demographics or outcomes between the 2 groups. Stools at 48 hours: median (IQR) of 5 (3-7) and 5 (2.5-7.5), respectively; p=0.63. The duration of inpatient stay: median (IQR): 4 days (1.5-6.5) and 4.5 (1.8-6.3); p=0.71. The duration of illness: 3 days (2-4) and 2 days (1-3); p=0.77. The relative risk of a severe adverse event was 3-fold higher in the drug group but was not statistically significant (95% CI 0.63 to 14.7); p=0.16.

CONCLUSIONS

Racecadotril has no impact on the number of stools at 48 hours, the duration of hospital stay or the duration of diarrhoea in children admitted with severe gastroenteritis and managed with ORS and zinc.

TRIAL REGISTRATION NUMBER

PACTR201403000694398; Pre-results.

Racecadotril for acute diarrhoea in children: systematic review and meta-analyses

OBJECTIVE

Racecadotril is an antisecretory agent that can prevent fluid/electrolyte depletion from the bowel as a result of acute diarrhoea without affecting intestinal motility. An up-to-date systematic review is indicated to summarise the evidence on racecadotril for the treatment of acute diarrhoea in children.

DESIGN

A Cochrane format systematic review of randomised controlled trials (RCTs). Data extraction and assessment of methodological quality were performed independently by two reviewers. Methodological quality was assessed using the Cochrane risk of bias tool.

PATIENTS

Children with acute diarrhoea, as defined by the primary studies.

INTERVENTIONS

RCTs comparing racecadotril with placebo or other interventions.

MAIN OUTCOME MEASURS

Duration of illness, stool output/volume and adverse events.

RESULTS

Seven RCTs were included, five comparing racecadotril with placebo or no intervention, one with pectin/kaolin and one with loperamide. Moderate to high risk of bias was present in all studies. There was no significant difference in efficacy or adverse events between racecadotril and loperamide. A meta-analysis of three studies with 642 participants showed significantly shorter duration of symptoms with racecadotril compared with placebo (mean difference -53.48 h, 95% CI -65.64 to -41.33). A meta-analysis of five studies with 949 participants showed no significant difference in adverse events between racecadotril and placebo (risk ratio 0.99, 95% CI 0.73 to 1.34).

CONCLUSIONS

There is some evidence that racecadotril is more effective than placebo or no intervention in reducing the duration of illness and stool output in children with acute diarrhoea. However, the overall quality of the evidence is limited due to sparse data, heterogeneity and risk of bias. Racecadotril appears to be safe and well tolerated.

Management strategies in the treatment of neonatal and pediatric gastroenteritis

Acute gastroenteritis, characterized by the onset of diarrhea with or without vomiting, continues to be a major cause of morbidity and mortality in children in mostly resource-constrained nations. Although generally a mild and self-limiting disease, gastroenteritis is one of the most common causes of hospitalization and is associated with a substantial disease burden. Worldwide, up to 40% of children aged less than 5 years with diarrhea are hospitalized with rotavirus. Also, some microorganisms have been found predominantly in resource-constrained nations, including Shigella spp, Vibrio cholerae, and the protozoan infections. Prevention remains essential, and the rotavirus vaccines have demonstrated good safety and efficacy profiles in large clinical trials. Because dehydration is the major complication associated with gastroenteritis, appropriate fluid management (oral or intravenous) is an effective and safe strategy for rehydration. Continuation of breastfeeding is strongly recommended. New treatments such as antiemetics (ondansetron), some antidiarrheal agents (racecadotril), and chemotherapeutic agents are often proposed, but not yet universally recommended. Probiotics, also known as "food supplement," seem to improve intestinal microbial balance, reducing the duration and the severity of acute infectious diarrhea. The European Society for Paediatric Gastroenterology, Hepatology and Nutrition and the European Society of Paediatric Infectious Diseases guidelines make a stronger recommendation for the use of probiotics for the management of acute gastroenteritis, particularly those with documented efficacy such as Lactobacillus rhamnosus GG, Lactobacillus reuteri, and Saccharomyces boulardii. To date, the management of acute gastroenteritis has been based on the option of "doing the least": oral rehydration-solution administration, early refeeding, no testing, no unnecessary drugs.

Role of antidiarrhoeal drugs as adjunctive therapies for acute diarrhoea in children

Acute diarrhoea is a leading cause of child mortality in developing countries. Principal pathogens include Escherichia coli, rotaviruses, and noroviruses. 90% of diarrhoeal deaths are attributable to inadequate sanitation. Acute diarrhoea is the second leading cause of overall childhood mortality and accounts for 18% of deaths among children under five. In 2004 an estimated 1.5 million children died from diarrhoea, with 80% of deaths occurring before the age of two. Treatment goals are to prevent dehydration and nutritional damage and to reduce duration and severity of diarrhoeal episodes. The recommended therapeutic regimen is to provide oral rehydration solutions (ORS) and to continue feeding. Although ORS effectively mitigates dehydration, it has no effect on the duration, severity, or frequency of diarrhoeal episodes. Adjuvant therapy with micronutrients, probiotics, or antidiarrhoeal agents may thus be useful. The WHO recommends the use of zinc tablets in association with ORS. The ESPGHAN/ESPID treatment guidelines consider the use of racecadotril, diosmectite, or probiotics as possible adjunctive therapy to ORS. Only racecadotril and diosmectite reduce stool output, but no treatment has yet been shown to reduce hospitalisation rate or mortality. Appropriate management with validated treatments may help reduce the health and economic burden of acute diarrhoea in children worldwide.

A comprehensive review of the pharmacodynamics, pharmacokinetics, and clinical effects of the neutral endopeptidase inhibitor racecadotril

Racecadotril, via its active metabolite thiorphan, is an inhibitor of the enzyme neutral endopeptidase (NEP, EC 3.4.24.11), thereby increasing exposure to NEP substrates including enkephalins and atrial natriuretic peptide (ANP). Upon oral administration racecadotril is rapidly and effectively converted into the active metabolite thiorphan, which does not cross the blood–brain-barrier. Racecadotril has mainly been tested in animal models and patients of three therapeutic areas. As an analgesic the effects of racecadotril across animal models were inconsistent. In cardiovascular diseases such as hypertension or congestive heart failure results from animal studies were promising, probably related to increased exposure to ANP, but clinical results have not shown substantial therapeutic benefit over existing treatment options in cardiovascular disease. In contrast, racecadotril was consistently effective in animal models and patients with various forms of acute diarrhea by inhibiting pathologic (but not basal) secretion from the gut without changing gastro-intestinal transit time or motility. This included studies in both adults and children. In direct comparative studies with loperamide in adults and children, racecadotril was at least as effective but exhibited fewer adverse events in most studies, particularly less rebound constipation. Several guidelines recommend the use of racecadotril as addition to oral rehydration treatment in children with acute diarrhea.

Evaluating the cost utility of racecadotril for the treatment of acute watery diarrhea in children: the RAWD model

BACKGROUND

The safety and efficacy of racecadotril to treat acute watery diarrhea (AWD) in children is well established, however its cost effectiveness for infants and children in Europe has not yet been determined.

OBJECTIVE

To evaluate the cost utility of racecadotril adjuvant with oral rehydration solution (ORS) compared to ORS alone for the treatment of AWD in children younger than 5 years old. The analysis is performed from a United Kingdom National Health Service (NHS) perspective.

METHODS

A decision tree model has been developed in Microsoft(®) Excel. The model is populated with the best available evidence. Deterministic and probabilistic sensitivity analyses (PSA) have been performed. Health effects are measured as quality-adjusted life years (QALYs) and the model output is cost (2011 GBP) per QALY. The uncertainty in the primary outcome is explored by probabilistic analysis using 1000 iterations of a Monte Carlo simulation.

RESULTS

Deterministic analysis results in a total incremental cost of -£379 in favor of racecadotril and a total incremental QALY gain in favor of racecadotril of +0.0008. The observed cost savings with racecadotril arise from the reduction in primary care reconsultation and secondary referral. The difference in QALYs is largely attributable to the timely resolution of symptoms in the racecadotril arm. Racecadotril remains dominant when base case parameters are varied. Monte Carlo simulation and PSA confirm that racecadotril is the dominant treatment strategy and is almost certainly cost effective, under the central assumptions of the model, at a commonly used willingness to pay proxy threshold range of £20,000-£30,000 per QALY.

CONCLUSION

Racecadotril as adjuvant therapy is more effective and less costly compared to ORS alone, from a UK payer perspective, for the treatment of children with acute diarrhea.

The management of acute diarrhea in children in developed and developing areas: from evidence base to clinical practice

INTRODUCTION

Acute diarrhea remains a major problem in children and is associated with substantial morbidity, mortality and costs. While vaccination against rotavirus could reduce the burden of the disease, the persistent impact of intestinal infections requires effective treatment in adjunct to oral rehydration solutions, to reduce the severity and duration of diarrhea. Several therapeutic options have been proposed for acute diarrhea, but proof of efficacy is available for few of them, including zinc, diosmectite, selected probiotics and racecadotril. However, at present there is no universal drug, and therapeutic efficacy has only been shown for selected drugs in selected settings, such as: outpatients/inpatients, developed/developing countries and viral/bacterial etiology.

AREAS COVERED

This narrative review reports the opinions of experts from different countries of the world who have discussed strategies to improve the management of diarrhea.

EXPERT OPINION

More data are needed to optimize the management of diarrhea and highlight the research priorities at a global level; such priorities include improved recommendations on oral rehydration solution composition, and the reevaluation of therapeutic options in the light of new trials. Therapeutic strategies need to be assessed in different settings, and pharmacoeconomic analyses based on country-specific data are needed. Transfer to clinical practice should result from the implementation of guidelines tailored at a local level, with an eye on costs.

Racecadotril for childhood gastroenteritis: an individual patient data meta-analysis

BACKGROUND

Racecadotril is an antidiarrhoeal drug with intestinal antisecretory mechanism of action.

AIM

To assess racecadotril efficacy as an adjunct to oral rehydration solution, against oral rehydration solution alone or with placebo in childhood acute gastroenteritis.

METHODS

Individual patient data meta-analysis following multilevel mixed models testing the significance of the treatment effect adjusted for baseline covariates.

RESULTS

Nine randomised clinical trials (n=1384) were identified with raw data. Baseline dehydration level and Rotavirus were found as two essential predictors influencing the outcomes. The proportion of recovered patients was higher in racecadotril groups compared with placebo, Hazard Ratio HR=2.04, 95% CI (1.85; 2.32), p<0.001. For inpatient studies, the ratio of mean stool output racecadotril/placebo was 0.59 (0.51; 0.74), p<0.001. For outpatient studies, the ratio of the mean number of diarrhoeic stools racecadotril/placebo was 0.63 (0.51; 0.74), p<0.001.

CONCLUSION

Dehydration level and Rotavirus at baseline are essential adjustments to compare treatments. As an adjunct to oral rehydration solution, racecadotril has a clinically relevant effect in reducing diarrhoea (duration, stool output and stool number), irrespective of baseline conditions (dehydration, Rotavirus or age), treatment conditions (inpatient or outpatient studies) or cultural environment.

Pharmacological management of diarrhea

According to the World Health Organization, there are approximately 2 billion annual cases of diarrhea worldwide. Diarrhea is the leading cause of death in children younger than 5 years and kills 1.5 million children each year. It is especially prevalent in the developing world, where mortality is related to dehydration, electrolyte disturbance, and the resultant acidosis, and in 2001, it accounted for 1.78 million deaths (3.7% of total deaths) in low- and middle-income countries. However, diarrhea is also a common problem in the developed world, with 211 million to 375 million episodes of infectious diarrheal illnesses in the United States annually, resulting in 73 million physician consultations, 1.8 million hospitalizations, and 3100 deaths. Furthermore, 4% to 5% of the Western population suffers from chronic diarrhea. Given the high prevalence of diarrhea, research has been directed at learning more about the cellular mechanisms underlying diarrheal illnesses in order to develop new medications directed at novel cellular targets. These cellular mechanisms and targets are discussed in this article.

Analysis of factors influencing the overall effect of racecadotril on childhood acute diarrhea. Results from a real-world and post-authorization surveillance study in Venezuela

Drug efficacy might differ from clinical trial results when performed in clinical daily conditions. Therefore, it is mandatory to conduct trials about effectiveness to improve external validity. This post-authorization, open-label, noncontrolled, prospective, multicenter, observational, and naturalistic trial was designed to search for factors influencing the racecadotril overall effect on childhood acute watery diarrhea in a real-world setting of Venezuela. There were 3,873 children with acute watery diarrhea treated with racecadotril, an enkephalin breakdown blocker plus oral rehydration therapy by 97 pediatricians. Evaluations were carried out daily until emission of two consecutive formed stools or absence of watery bowel movements for 24 hours. The primary end-point was time-to-relief, defined as the time from first racecadotril dose to the last watery bowel movement time. Age, gender, nursing type, nursing status during diarrhea, diarrhea severity, and co-medication were considered as factors in the statistical analysis. The primary end-point was evaluated by factors using UNIANOVA, and post-hoc tests were done. A multiple regression analysis was carried out to identify factors affecting drug performance, racecadotril effectiveness and tolerability overall assessment was searched by physicians and patients, and inter-observer agreement was evaluated by kappa statistics. The mean time-to-relief was 18.5 ± 12.5 hours [95% confidence interval 17.9–19.0] and the diarrhea severity was the only variable with significant and independent weight on racecadotril effectiveness explaining 23% of time-to-relief variance, but even in severe diarrhea cases this time was less than 24 hours. High agreement about satisfactory perception on effectiveness and tolerability was reached among physicians and patients. In conclusion, the racecadotril overall effect, evaluated in a real-world setting of Venezuela, was in agreement with results of some earlier controlled trials. It was only influenced by severity of diarrhea episode, as well as being considered an effective and well tolerated treatment by physicians and patients.

Diarrhées aiguës de l’enfant

La diarrhée aiguë est toujours potentiellement grave chez l’enfant, mais les variations des tableaux cliniques sont importantes. De nombreuses recommandations existent, mais on ne peut définir des indications thérapeutiques applicables à tous les cas. L’analyse clinique et l’évaluation de la déshydratation sont cruciales. Les solutions de réhydratation par voie orale sont d’utilisation systématique chez le jeune enfant. Le traitement antibiotique est réservé à certaines étiologies. Les médicaments antidiarrhéiques sont utiles, toujours en complément de la réhydratation par voie orale. La réalimentation précoce est systématique. Le processus diarrhéique peut durer quelques jours, comme par exemple lors d’une infection à rotavirus, cause la plus fréquente des diarrhées. Toute persistance exagérée doit faire rechercher un risque de passage à la chronicité, source de dénutrition qu’il faut savoir prévenir.

[An evidence based Iberic-Latin American guideline for acute gastroenteritis management in infants and prescholars]

Acute gastroenteritis (AG) morbidity and mortality rates in infants and prescholars continue to be high in developing countries. Authors want to develop an evidence-based document that supports decision making regarding AG therapy in infants and children younger than 5 y/o. A systematic review of the literature was performed (May, 2008). Evidence grading was established according to Oxford guidelines and Latin American experts submitted their opinions on the recommendations generated. Oral rehydration solutions are the threatment's keystone for children with AG, showing lesser complications due to therapy than IV fluids. AG is no contraindication of a normal diet. Racecadotril, zinc and smectite can contribute to AG treatment, as well as Lactobacillus GG and Saccharomycces boulardii. No other drugs are recommended. It is recommended to treat children presenting AG with oral rehydration solutions among racecadotril, zinc or smectite as well as some probiotics.

Clinical role of diosmectite in the management of diarrhea

BACKGROUND

Diosmectite (DS), an antidiarrheal absorbent natural clay, was proposed for treatment of acute gastroenteritis and more recently considered for diarrhea within the functional bowel disorder syndrome.

OBJECTIVE

To review pharmacology efficacy, mechanisms of action and safety of DS.

METHODS

We consulted PubMed/Medline using the keywords of smectite and diarrhea or gastroenteritis, and reviewed most recent recommendations by scientific societies.

CONCLUSIONS

Solid data show that DS is effective in infectious diarrhea, mainly as an ion antisecretory agent and in preventing intestinal damage. Despite clinical data being consistent and convincing, DS is not considered as first-line treatment because of the presence of alternative therapeutic options. However, it definitely may play a role in infectious colitis, where treatment options are less convincing. Some available evidences demonstrate a role of DS in functional diarrhea.

Acute infectious diarrhea in children

BACKGROUND

Acute infectious enteritis is one of the more common childhood diseases worldwide, especially in the first three years of life. Every year, in Germany, one in six children under age 5 is taken to a physician at least once because of infectious diarrheal disease. 10% of the children presenting with rotavirus infection are admitted to hospital. The existing national and international recommendations for the treatment of acute infectious diarrheal disease are inadequately followed, despite the high level of evidence on which they are based.

METHODS

Selective literature search based on national and international guidelines.

RESULTS AND CONCLUSIONS

The therapeutic goal is to replace the fluid and electrolyte losses resulting from diarrhea and vomiting. The administration of a hypotonic oral rehydration solution (ORS) is indicated to treat impending dehydration (infants aged up to 6 months with diarrhea and/or more than 8 watery stools in the last 24 hours and/or more than 4 episodes of vomiting in the last 24 hours), or when mild or moderate dehydration is already present. Oral rehydration with ORS given in frequent, small amounts over 3-4 hours is successful in more than 90% of cases. Regular feeding can be begun immediately afterward. Laboratory testing of blood or stool is usually unnecessary. Children who can be rehydrated orally or through a nasogastric tube should not be given intravenous fluids.

Use of racecadotril as outpatient treatment for acute gastroenteritis: a prospective, randomized, parallel study

OBJECTIVE

To compare the efficacy of therapy with racecadotril plus oral rehydration versus oral rehydration alone in children with gastroenteritis in an outpatient setting care.

STUDY DESIGN

Prospective, randomized, open and parallel study performed in a Pediatric Emergency Service of a tertiary care hospital. The study included 189 patients, ages 3 to 36 months, with acute gastroenteritis: 94 were administered an oral rehydration solution (OR), 94 received oral rehydration solution plus racecadotril (OR + R). The principal variable studied was the number of bowel movements in 48 hours after initiating treatment.

RESULTS

The groups were comparable clinically and epidemiologically at enrollment. No significant differences were found in the number of bowel movements between the 2 groups 48 hours after initiating treatment (4.1 +/- 2.7 bowel movements in the OR group vs 3.8 +/- 2.4 bowel movements in the OR + R group). No differences were found in the average duration of gastroenteritis (4.7 +/- 2.2 days in the OR group, 4.0 +/- 2.1 days in the OR + R group; P = .15). The incidence of adverse events was similar in both groups (19 patients [20.2%] in the OR group, 18 patients [19.1%] in the OR + R group).

CONCLUSIONS

In our study group, the use of racecadotril did not improve the symptoms of diarrhea compared with standard rehydration therapy.

[Systematic review of the efficacy of racecadotril in the treatment of acute diarrhoea]

OBJECTIVE

To estimate, through a systematic review of the literature, the efficacy of racecadotril in the treatment of acute diarrhoea.

MATERIAL AND METHODS

Randomised trials carried out in children comparing racecadotril with placebo in terms of diarrhoea recovery, stools output and adverse effects were selected. Electronic databases (Medline, EMBASE, CENTRAL, CINAHL, mRCT, Pascal) and bibliographies of retrieved articles were searched, and the drug developer was contacted. Two authors independently assessed the quality of the retrieved articles and extracted the data.

RESULTS

Two small sample size randomised trials (135 and 172 children) of moderate quality were selected. They included children with less than five days diarrhoea and aged between 3 months and 4 years. There was no difference in the proportion of children who recovered by day 5 (RR=0.73, CI 95% 0.29 to 1.81), although the stools volume during the first 48 hours was less in the racecadotril group (SMD=-0.65, CI 95% -0.88 to -0.52). There is no difference in the risk of vomiting (RR=1.16, CI 95% 0.64 to 2.12).

CONCLUSION

The proportion of recoveries by the 5th day is the same, although the stool volumes during the first 48 hours are less in the racecadotril treated children. It would be interesting to study the efficacy in a primary care setting assessing the cure rate, the stool volumes and the admission rate to elucidate if there is room for this drug.

Diarreas agudas del niño

La diarrea aguda es siempre potencialmente grave en el niño, aunque las variaciones de los cuadros clínicos son importantes. Existen numerosas recomendaciones, pero no se pueden definir indicaciones terapéuticas aplicables a todos los casos. El examen clínico y la evaluación de la deshidratación resultan cruciales. Las soluciones de rehidratación por vía oral se utilizan sistemáticamente en el niño pequeño. El tratamiento antibiótico se reserva para ciertas etiologías. Los medicamentos antidiarreicos son útiles, siempre como complemento de la rehidratación por vía oral. La realimentación precoz es sistemática. El proceso diarreico puede durar varios días, como por ejemplo en el caso de una infección por rotavirus, la causa más frecuente de diarrea. Ante una diarrea persistente debe investigarse el riesgo de paso a la cronicidad, causa de desnutrición que es necesario saber prevenir.

Acute infectious diarrhoea in children: new insights in antisecretory treatment with racecadotril

In developing countries acute infectious diarrhoea remains one of the leading causes of death among young children, especially those under 1 year of age. In contrast, in industrialized nations the death rate is very low, although the disease is an important cause of morbidity and consumes substantial healthcare costs. A variety of viral, bacterial and parasitic organisms have been implicated in the pathogenesis of acute diarrhoea. The primary objectives of treatment of acute infectious diarrhoea are correction of dehydration with oral replacement therapy (ORT) and maintenance of good nutritional status via food intake. With regards drug therapy antimicrobial agents are not usually recommended since the disease is generally self‐limiting. Racecadotril is powerful and selective enkephalinase inhibitor and has emerged as a promising drug in the antisecretory therapy of acute infectious diarrhoea in children.

Conclusion: There is encouraging evidence that treatment with racecadotril can provide clinically relevant symptomatic relief by reducing the severity and duration of diarrhoeal episodes. The drug is well tolerated and has a favourable safety profile. However, further comparative studies and cost‐effectiveness analyses are needed to define the position of the drug in the management of diarrhoeal illness in children.

Prévention et traitement de la diarrhée aiguë du nourrisson

The prognosis of acute diarrhoea in infants is most often satisfactory in industrialized countries. However, it has been estimated that 10 to 15 children die every year in France from acute dehydration due to acute diarrhoea. In spite of an increasing use over the least few years, oral rehydration solutions (ORS) are used in only 70% of infants presenting with acute diarrhoea. The use of homemade ORS, plain water or fizzy drink should be strictly avoided. In case of acute diarrhoea there is no indication to stop breastfeeding or the use of infant formula for more than 4 hours. Lactose intolerance is observed in only 5-10% of infants. Lactose free formulae should only be used in infants with severe, persistent or recurrent diarrhoea. Under 3-4 months of age, infants with severe diarrhoea should receive for a period of 2-4 weeks lactose free protein hydrolysate formulae. Racecadotril is the only drug with anti-diarrheal properties, with a reduction of the stool output of 50%. Oral antibiotics should only be used in case of Shigella infection or in case of bacterial infection with severe sepsis or underlying debilitating disease. Oral Rotavirus vaccine, that is not reimbursed yet in France, has been shown to dramatically reduce the number of severe cases of diarrhoea with dehydration, and has been associated with a striking reduction of both morbidity and mortality, as well as of the number of hospitalisations during periods of epidemics.

Systematic review: racecadotril in the treatment of acute diarrhoea in children

BACKGROUND

Racecadotril (acetorphan) is an antisecretory drug that exerts its antidiarrhoeal effects by inhibiting intestinal enkephalinase.

AIM

To summarize studies testing the efficacy and safety of racecadotril for treating children with acute gastroenteritis.

METHODS

Reports were gathered by searching electronic databases MEDLINE, EMBASE, the Cochrane Library (all up to April 2007), relevant journals, and bibliographies of reviewed articles. Only randomized-controlled trials were included.

RESULTS

Three randomized-controlled trials (471 participants) met the inclusion criteria. Two trials reported stool output, and data suggested less stool output in the racecadotril group than in the control group. The duration of diarrhoea was significantly reduced in the three trials reporting this outcome. Achievement of a cure by day 5 was similar in both groups. Adverse effects were similar in both groups.

CONCLUSIONS

The small number of included trials provided some evidence in favour of the use of racecadotril over placebo or no intervention, to reduce the stool output and duration of diarrhoea in children with acute gastroenteritis. However, more data in out-patients are needed. The safety as well as the cost-effectiveness of the therapy should be explored, before routine therapy with racecadotril is recommended.

Acute infectious pediatric gastroenteritis: beyond oral rehydration therapy

Worldwide diarrheal diseases are a leading cause of childhood morbidity and mortality. Improvements in gastroenteritis management have reduced the annual number of pediatric deaths attributable to gastroenteritis from 5 million in 1982 to 2 million over 20 years. Recent advances are likely to contribute further to a reduction in morbidity and mortality secondary to acute infectious gastroenteritis. A new generation of vaccines against rotavirus is entering into routine use. Research into antisecretory agents has demonstrated that this class of medications may play a significant role in the future management of acute infectious gastroenteritis. A significant body of literature has recently emerged supporting the use of the antiemetic agent ondansetron. In developing countries, the routine use of zinc is now recommended by many experts, while, in developed countries, the use of probiotic agents has been associated with significant benefits in acute infectious gastroenteritis. Finally, more aggressive intravenous rehydration strategies are being employed; however, at present, limited data from randomized clinical trials are available to support its routine use.

Protection of endogenous enkephalin catabolism as natural approach to novel analgesic and antidepressant drugs

The most efficient drugs to alleviate severe pain are opioid compounds. However, their chronic use could be associated with serious drawbacks, such as tolerance, respiratory depression and constipation. Therefore, there is a need for compounds able to efficiently alleviate inflammatory and neurogenic pain following chronic treatment. The discovery that the endogenous opioid peptides, enkephalins, are inactivated by two metallopeptidases, neutral endopeptidase and aminopeptidase N, which can be blocked by synthetic dual inhibitors, represents a promising way to develop 'physiological' analgesics devoid of morphine side effects. These dual inhibitors also have antidepressant-like properties through enkephalin-related activation of delta-opioid receptors. This is expected to reduce the emotional component of pain in humans. This article reviews the promising data obtained for future development of a new class of analgesic that could be of major interest in a number of severe and chronic pain syndromes.

Role of nitric oxide during rotavirus infection

The pathophysiological mechanisms behind rotavirus-induced diarrhoea still remain incomplete. Current views suggest that the non-structural protein 4 (NSP4) of rotavirus and the enteric nervous system (ENS) participate in water secretion and diarrhoea. In the present work the role of nitric oxide (NO) in rotavirus infection and disease has been studied in vitro, mice and humans. Incubation of human intestinal epithelial cells (HT-29) with purified NSP4 but not with infectious virus produced NO2/NO3 accumulation in the incubation media. The NSP4-induced release of NO metabolites occurred within the first minutes after the addition of the toxin. Mice infected with murine rotavirus (strain EDIM) accumulated NO2/NO3 in the urine at the onset for diarrhoea. Following rotavirus infection, inducible nitric oxide synthetase (iNOS) mRNA was upregulated in ileum, but not in duodenum or jejunum of newborn pups within 5 days post-infection. A prospective clinical study including 46 children with acute rotavirus infection and age-matched controls concluded that rotavirus infection stimulates NO production during the course of the disease (P < 0.001). These observations identify NO as an important mediator of host responses during rotavirus infection.

Current status of anti-diarrheal and anti-secretory drugs in the management of acute childhood diarrhea

Each year 1.8 million children die due to diarrheal diseases. Indiscriminate use of antibiotics has resulted in increasing resistance to commonly used antibiotics. Moreover the recent outbreaks of shigella and cholera have revealed multi-drug resistance strains. There is a need for review of recommended antibiotics for shigellosis. From recent data it emerges that fluoroquinolones should be the first line of therapy and cephalosporins to be used as the second line. Among the anti-cholera antibiotics, tetracyclines which were the drug of choice for adults, has the advantage of high sensitivity and low cost. Single dose doxycycline would have minimal side effects, hence can be the drug of choice even in children. We should not allow the business pressures to force usage of probiotics and racecadotril as their role in the management of acute diarrhea is yet to be established. Nitazoxanide has high efficacy against Cryptosporodial diarrhea only. Strict adherence to the recommendations for the management of acute childhood diarrhea is needed or else we dilute the effect of standard management.

Novel agents for the control of secretory diarrhoea

Acute infectious diarrhoea continues to cause high morbidity and mortality worldwide. Although oral rehydration therapy has reduced the mortality associated with acute diarrhoea, stool volume often increases during the rehydration process. Therefore, for > 20 years there has been a search for agents that will directly inhibit intestinal secretory mechanisms and thereby reduce stool volume. The most obvious target for antisecretory therapy has been the chloride channel and second messengers within the enterocyte. So far, this search has been largely unrewarding, although recent evidence suggests that a new class of chloride channel blocker is effective in vitro but further evaluation in humans is required. In addition, research during the past decade has highlighted the importance of neurohumoral mechanisms in the pathogenesis of diarrhoea, notably the role of 5-hydroxtryptamine, substance P, vasoactive intestinal polypeptide and neural reflexes within the enteric nervous system. This new dimension of intestinal pathophysiology has already exposed possible novel targets for antisecretory therapy; namely, 5-hydroxytryptamine receptor antagonists, substance P antagonists and sigma-receptor agonists. There is also the possibility for potentiating the proabsorptive effects of endogenous enkephalins by using enkephalinase inhibitors. There now seems to be a real possibility that antisecretory therapy will become more widely available in the future.