Racecadotril for Acute Diarrhea
Racecadotril 100 mg three times daily is an effective antisecretory agent for acute watery diarrhea that should be used as an adjunct to oral rehydration therapy, not as a replacement. 1
Critical First Step: Assess Hydration Status
Before prescribing racecadotril, you must assess the degree of dehydration and rule out contraindications:
Hydration Assessment
- Mild dehydration (3-5% deficit): Slightly dry mucous membranes, normal mental status 2
- Moderate dehydration (6-9% deficit): Sunken eyes, prolonged skin tenting, decreased urine output 2
- Severe dehydration (≥10% deficit): Altered consciousness, cool extremities, prolonged capillary refill >2 seconds - this is a medical emergency requiring immediate IV rehydration 2
Absolute Contraindications to Racecadotril
- Do not use in bloody diarrhea (dysentery), high fever, or suspected Shiga toxin-producing E. coli infection 1
- Do not use in Grade 3-4 diarrhea or severe immunotherapy-induced colitis 1
- Do not use before establishing adequate hydration status 1
Treatment Algorithm
Step 1: Initiate Oral Rehydration Therapy (Primary Treatment)
- Mild dehydration: Give 50 mL/kg of ORS (50-90 mEq/L sodium) over 2-4 hours 2
- Moderate dehydration: Give 100 mL/kg of ORS over 2-4 hours 2
- No dehydration: Skip rehydration phase and proceed to maintenance therapy 2
Step 2: Add Racecadotril as Adjunct
- Dosage: 100 mg orally three times daily 1, 3
- Duration: Continue until diarrhea resolves, typically 1-3 days 3, 4
- Mechanism: Racecadotril is an enkephalinase inhibitor that reduces intestinal hypersecretion without affecting gut motility 3
Step 3: Replace Ongoing Losses
- Give 10 mL/kg of ORS for each watery stool passed 2
- Give 2 mL/kg of ORS for each episode of vomiting 2
Why Racecadotril Over Loperamide
While both agents are effective, racecadotril offers specific advantages:
- Comparable efficacy: Both resolve diarrhea in approximately 13-19 hours 3, 4, 5
- Less constipation: Racecadotril causes significantly less rebound constipation (13% vs 25-29% with loperamide) 3, 4, 5
- Better symptom relief: Racecadotril produces significantly greater reduction in abdominal pain and distension (P=0.024 and 0.03) 3
- Safer profile: Fewer adverse events overall (14% vs 24% with loperamide, P=0.001) 3
The European Society for Medical Oncology recommends racecadotril as first-line symptomatic treatment for Grade 1 immunotherapy-induced diarrhea, alongside loperamide 1
Common Pitfalls to Avoid
- Never use racecadotril as monotherapy: It is an adjunct to oral rehydration, not a replacement 1
- Do not use antimotility agents routinely: Neither racecadotril nor loperamide should be used in most acute diarrhea cases without first ensuring adequate hydration 2
- Avoid antibiotics in uncomplicated cases: Empiric antibiotics are NOT recommended for most acute watery diarrhea without recent international travel 1
- Monitor for treatment failure: If diarrhea persists >5 days, consider stool cultures and specific antimicrobial therapy 2