Racecadotril Has No Role in the Management of Ileitis
Racecadotril should not be used for ileitis, as it is indicated only for symptomatic treatment of acute infectious diarrhea, not for inflammatory bowel disease affecting the ileum. The established treatment for ileal inflammation follows a completely different therapeutic approach targeting the underlying inflammatory process rather than secretory mechanisms.
Why Racecadotril is Not Appropriate for Ileitis
Mechanism Mismatch
- Racecadotril is an enkephalinase inhibitor that works purely as an antisecretory agent, preventing degradation of endogenous opioids to reduce intestinal water and electrolyte hypersecretion 1, 2.
- This mechanism addresses secretory diarrhea from acute infections, not the inflammatory pathophysiology of ileitis 3.
- Ileitis (whether from Crohn's disease or other inflammatory causes) requires anti-inflammatory therapy to address the underlying mucosal inflammation, not symptomatic antisecretory treatment 4.
Evidence Base is for Acute Infectious Diarrhea Only
- All clinical trials of racecadotril studied acute watery diarrhea of infectious origin in adults and children 5, 6.
- Studies compared racecadotril to placebo or loperamide for symptom relief in self-limited infectious diarrhea lasting days, not chronic inflammatory conditions 3, 2.
- No evidence exists for racecadotril in inflammatory bowel disease or ileitis specifically.
Correct Treatment Approach for Ileitis
Mild Ileocolonic Disease
- High-dose mesalazine 4 g daily is appropriate first-line therapy for mild ileal or ileocolonic Crohn's disease 4.
- This directly targets intestinal inflammation rather than merely controlling diarrhea symptoms.
Moderate to Severe Ileitis
- Oral prednisolone 40 mg daily is appropriate for moderate to severe disease or when mesalazine fails 4.
- Taper gradually over 8 weeks to prevent early relapse 4.
- Budesonide 9 mg daily is appropriate specifically for isolated ileo-caecal disease with moderate activity, though marginally less effective than prednisolone 4.
Severe Disease
- Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are required for severe ileitis 4.
- Concomitant intravenous metronidazole is advisable when distinguishing active inflammation from septic complications is difficult 4.
Steroid-Sparing Maintenance
- Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day should be used as adjunctive therapy and steroid-sparing agents for chronic disease 4.
Critical Pitfall to Avoid
Do not confuse symptomatic diarrhea treatment with disease-modifying therapy for inflammatory conditions. Using racecadotril for ileitis would be analogous to treating pneumonia with cough suppressants alone—it addresses a symptom while ignoring the underlying disease process that determines morbidity and mortality 7. The inflammation in ileitis requires immunosuppressive or anti-inflammatory therapy to prevent complications including strictures, fistulas, and need for surgery 4.