Metoclopramide and Racecadotril Combination in Acute Gastroenteritis
Do not use metoclopramide in acute gastroenteritis, as it is specifically contraindicated for this indication and provides no benefit while carrying significant risks. Racecadotril may be considered as adjunctive therapy to oral rehydration, though evidence is mixed and it is not available in all regions.
Why Metoclopramide Should Not Be Used
The American Gastroenterological Association explicitly recommends against metoclopramide as monotherapy or adjunctive therapy in patients with gastroenteritis (Grade D recommendation: fair evidence that it is ineffective or harms outweigh benefits). 1
Metoclopramide is a prokinetic agent that increases gastrointestinal motility, which is counterproductive in acute diarrheal illness where the goal is to reduce stool output, not accelerate transit. 1
The CDC guidelines emphasize that antimotility and antisecretory agents should not be used in acute gastroenteritis as they do not demonstrate effectiveness in reducing diarrhea volume or duration. 1, 2
Reliance on pharmacologic agents like metoclopramide shifts therapeutic focus away from appropriate fluid, electrolyte, and nutritional therapy—the cornerstone of gastroenteritis management. 1, 2
Racecadotril as Adjunctive Therapy
Racecadotril is an enkephalinase inhibitor with antisecretory properties that does not affect intestinal motility, making it mechanistically different from contraindicated antimotility agents. 3, 4
In children, individual patient data meta-analysis (n=1384) showed racecadotril as adjunct to oral rehydration solution significantly reduced diarrhea duration (HR=2.04,95% CI 1.85-2.32, p<0.001) and stool output (ratio 0.59-0.63 vs placebo). 5
In adults, racecadotril demonstrated similar efficacy to loperamide but with less rebound constipation (12.9% vs 29.0%), making it potentially preferable when antisecretory therapy is considered. 3, 6
However, the 2017 travelers' diarrhea guidelines note that racecadotril has not been evaluated in the travelers' diarrhea setting specifically, and evidence remains limited. 1
One negative outpatient pediatric trial (n=189) found no significant difference in bowel movements at 48 hours between racecadotril plus oral rehydration versus oral rehydration alone (3.8 vs 4.1 movements, p=NS). 7
Correct Management Approach
Oral rehydration solution (ORS) is the first-line treatment for mild to moderate dehydration, successfully rehydrating >90% of patients without any antiemetic or antidiarrheal medication. 2, 8
Administer ORS using small, frequent volumes (5-10 mL every 1-2 minutes) to prevent triggering vomiting, gradually increasing as tolerated. 2, 8
For moderate dehydration (6-9% fluid deficit), give 100 mL/kg ORS over 2-4 hours, replacing ongoing losses with 10 mL/kg for each watery stool. 2
Resume age-appropriate diet immediately during or after rehydration begins—early refeeding reduces illness severity and duration. 2
If antiemetic therapy is needed to facilitate oral rehydration when vomiting is significant, ondansetron 0.15 mg/kg (maximum 16 mg) is the appropriate choice in children >4 years and adults, not metoclopramide. 8
Common Pitfalls to Avoid
Never use metoclopramide in complete bowel obstruction, but gastroenteritis is not obstruction—the issue is that metoclopramide simply has no role in gastroenteritis management at all. 1
Do not delay rehydration therapy while considering pharmacologic adjuncts—ORS should be initiated immediately. 2
Avoid using antimotility agents (loperamide) in children <18 years with acute diarrhea, as serious adverse events including ileus and deaths have been reported. 1, 2
Do not use inappropriate fluids like sports drinks or juices as primary rehydration solutions—low-osmolarity ORS is superior. 2
Clinical Bottom Line
The combination of metoclopramide and racecadotril is not appropriate for acute gastroenteritis. Metoclopramide is contraindicated in this setting with Grade D evidence against its use. 1 If you are considering adjunctive pharmacologic therapy beyond ORS, racecadotril may have some benefit based on pediatric meta-analysis data 5, but it is not available in many regions including the United States. Focus management on aggressive oral rehydration with ORS using proper small-volume technique, early refeeding, and ondansetron if vomiting prevents adequate oral intake. 2, 8