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Tras B, Ok M, Parlak TM, Ider M, Yildiz R, Eser Faki H, Ozdemir Kutahya Z, Uney K. Can diarrhea affect the pharmacokinetics of racecadotril in neonatal calves? J Vet Pharmacol Ther 2022; 45:426-431. [PMID: 35706330 DOI: 10.1111/jvp.13078] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Revised: 04/11/2022] [Accepted: 05/31/2022] [Indexed: 11/30/2022]
Abstract
This study was aimed to determine the pharmacokinetics of antisecretory-acting racecadotril, used in the treatment of diarrhea in humans and dogs, following oral administration in both neonatal calves with healthy and neonatal calves with infectious diarrhea. The study was carried out on a total of 24 Holstein calves (2-20 days), of which 6 were healthy and 18 were infectious diarrhea. Calves with infectious diarrhea were divided into 3 groups according to the infectious agent (Escherichia coli, Cryptosporidium parvum, and rotavirus/coronavirus). Racecadotril was administered orally at 2.5 mg/kg dose to calves. The plasma concentrations of racecadotril and its main active metabolite (thiorphan) were determined using HPLC-UV. The pharmacokinetic parameters were analyzed using the non-compartmental method. In healthy calves, the t1/2ʎz , Cmax , Tmax, and AUC0-12 of racecadotril were determined 4.70 h, 377 ng/ml, 0.75 h, and 1674 h × ng/ml, respectively. In the plasma of calves with infectious diarrhea, racecadotril and thiorphan were only detected at the sampling time from 0.25 to 1.5 h. As in calves with infectious diarrhea, thiorphan in plasma was only detected in healthy calves from 0.25 to 1.5 h. Racecadotril showed a large distribution volume, rapid elimination, and low metabolism to thiorphan in healthy calves.
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Affiliation(s)
- Bunyamin Tras
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkiye
| | - Mahmut Ok
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkiye
| | - Tugba Melike Parlak
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkiye
| | - Merve Ider
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkiye
| | - Ramazan Yildiz
- Department of Internal Medicine, Faculty of Veterinary Medicine, University of Mehmet Akif Ersoy, Burdur, Turkiye
| | - Hatice Eser Faki
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkiye
| | - Zeynep Ozdemir Kutahya
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Cukurova, Adana, Turkiye
| | - Kamil Uney
- Department of Pharmacology and Toxicology, Faculty of Veterinary Medicine, University of Selcuk, Konya, Turkiye
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Keely SJ, Barrett KE. Intestinal secretory mechanisms and diarrhea. Am J Physiol Gastrointest Liver Physiol 2022; 322:G405-G420. [PMID: 35170355 PMCID: PMC8917926 DOI: 10.1152/ajpgi.00316.2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 02/07/2022] [Accepted: 02/09/2022] [Indexed: 01/31/2023]
Abstract
One of the primary functions of the intestinal epithelium is to transport fluid and electrolytes to and from the luminal contents. Under normal circumstances, absorptive and secretory processes are tightly regulated such that absorption predominates, thereby enabling conservation of the large volumes of water that pass through the intestine each day. However, in conditions of secretory diarrhea, this balance becomes dysregulated, so that fluid secretion, driven primarily by Cl- secretion, overwhelms absorptive capacity, leading to increased loss of water in the stool. Secretory diarrheas are common and include those induced by pathogenic bacteria and viruses, allergens, and disruptions to bile acid homeostasis, or as a side effect of many drugs. Here, we review the cellular and molecular mechanisms by which Cl- and fluid secretion in the intestine are regulated, how these mechanisms become dysregulated in conditions of secretory diarrhea, currently available and emerging therapeutic approaches, and how new strategies to exploit intestinal secretory mechanisms are successfully being used in the treatment of constipation.
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Affiliation(s)
- Stephen J Keely
- School of Pharmacy and Biomolecular Sciences, Royal College of Surgeons in Ireland, University of Medicine and Health Sciences, Dublin, Ireland
| | - Kim E Barrett
- Department of Medicine, School of Medicine, University of California San Diego, La Jolla, California
- Department of Physiology and Membrane Biology, School of Medicine, University of California, Davis, Davis, California
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Abstract
Acute diarrhoea is a leading cause of morbidity and mortality in the paediatric population. Racecadotril is an antisecretory drug recommended as an adjuvant antidiarrhoeal treatment.In the small bowel, the enzyme neutral endopeptidase (NEP) inhibits the action of enkephalins, which prevent water and electrolyte hypersecretion. By inhibiting NEP, racecadotril allows enkephalins to exhibit their antisecretory effects. Consequently, racecadotril reduces the secretion of water and electrolytes in the small intestine, without having an effect on intestinal motility. No serious adverse events related to racecadotril have been reported.Racecadotril has proven its efficacy as an adjuvant antidiarrhoeal drug with a good safety profile. Its addition to oral rehydration solution (ORS) appears clinically beneficial and potentially leads to health care savings.
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Abstract
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.
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Affiliation(s)
- Yi Liang
- West China Second University Hospital, Sichuan UniversityDepartment of PharmacyNo. 20, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
- Sichuan UniversityEvidence‐Based Pharmacy Center, West China Second University HospitalChengduChina
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)ChengduChina
- The University of Texas at AustinHealth Outcomes Division, College of PharmacyAustinTexasUSA
| | - Lingli Zhang
- West China Second University Hospital, Sichuan UniversityDepartment of PharmacyNo. 20, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
- Sichuan UniversityEvidence‐Based Pharmacy Center, West China Second University HospitalChengduChina
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)ChengduChina
| | - Linan Zeng
- West China Second University Hospital, Sichuan UniversityDepartment of PharmacyNo. 20, Section Three, Ren Min Nan Lu AvenueChengduSichuanChina610041
- Sichuan UniversityEvidence‐Based Pharmacy Center, West China Second University HospitalChengduChina
- Ministry of EducationKey Laboratory of Birth Defects and Related Diseases of Women and Children (Sichuan University)ChengduChina
| | - Morris Gordon
- University of Central LancashireSchool of MedicinePrestonLancashireUK
| | - Jin Wen
- West China Hospital, Sichuan UniversityDepartment of Hospital Management and Health PolicyNo. 37, Guo Xue XiangChengduSichuanChina610041
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Mizerska-Kowalska M, Kreczko-Kurzawa J, Zdzisińska B, Czerwonka A, Sławińska-Brych A, Maćkiewicz Z, Nidzworski D, Kandefer-Szerszeń M. Neutral endopeptidase (NEP) inhibitors - thiorphan, sialorphin, and its derivatives exert anti-proliferative activity towards colorectal cancer cells in vitro. Chem Biol Interact 2019; 307:105-115. [PMID: 31054283 DOI: 10.1016/j.cbi.2019.04.033] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2018] [Revised: 04/05/2019] [Accepted: 04/28/2019] [Indexed: 11/17/2022]
Abstract
Neutral endopeptidase (NEP) is an enzyme implicated in development of different tumors, e.g. colorectal cancer (CRC). In this study, the anti-cancer effects of NEP inhibitors, thiorphan (synthetic compound) and sialorphin (naturally occurring pentapeptide) on CRC cells were investigated. Moreover, we synthesized some derivatives of sialorphin (alanine scan analogues: AHNPR, QANPR, QHAPR, QHNAR; N-acetylated sialorphin; C-amidated sialorphin, and C-amidated alanine scan analogues) to examine the biological activity of these inhibitors on CRC cells. The cytotoxic activity of the NEP inhibitors against CRC cell lines (SW620 and LS180) and normal human fibroblasts (HSF) was evaluated. Additionally, the influence of NEP inhibitors on proliferation, cell cycle progression, induction of apoptosis, and the level of phosphorylation of MAP kinases and mTORC1 signaling pathway proteins in CRC cells were examined. The NEP inhibitors were non-cytotoxic to HSF cells; however, most of them slightly decreased the viability and inhibited proliferation of CRC cells. The N-acetylation or C-amidation of sialorphin or its alanine scan analogues resulted in decreased or abolished anti-proliferative activity of the NEP inhibitors towards the CRC cells. Additionally, thiorphan and sialorphin enhanced the anti-proliferative activity of other CRC-cell growth inhibitors (atrial natriuretic peptide-ANP and melphalan-MEL). The mechanisms involved in the anti-proliferative effects of the tested inhibitors were mediated via NEP and associated with induction of cell cycle arrest in the G0/G1 phase, increased activity of ERK1/2, and a reduced level of phosphorylation of mTOR (Ser2448), 4E-BP1, and p70S6K. However, the NEP inhibitors did not induce apoptosis in the CRC cells. These results have indicated that thiorphan and sialorphin or its derivatives AHNPR, QANPR, QHAPR, and QHNAR have the potential to be used as agents in treatment of patients with CRC.
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Affiliation(s)
- Magdalena Mizerska-Kowalska
- Maria Curie-Sklodowska University, Faculty of Biology and Biotechnology, Department of Virology and Immunology, Lublin, Poland.
| | - Joanna Kreczko-Kurzawa
- University of Gdansk, Laboratory of Biological Macromolecules' Chemistry, Department of Molecular Biotechnology, Faculty of Chemistry, Gdansk, Poland.
| | - Barbara Zdzisińska
- Maria Curie-Sklodowska University, Faculty of Biology and Biotechnology, Department of Virology and Immunology, Lublin, Poland.
| | - Arkadiusz Czerwonka
- Maria Curie-Sklodowska University, Faculty of Biology and Biotechnology, Department of Virology and Immunology, Lublin, Poland.
| | - Adrianna Sławińska-Brych
- Maria Curie-Sklodowska University, Faculty of Biology and Biotechnology, Department of Cell Biology, Lublin, Poland.
| | - Zbigniew Maćkiewicz
- University of Gdansk, Laboratory of Biological Macromolecules' Chemistry, Department of Molecular Biotechnology, Faculty of Chemistry, Gdansk, Poland.
| | - Dawid Nidzworski
- The Institute of Biotechnology and Molecular Medicine, Gdansk, Poland.
| | - Martyna Kandefer-Szerszeń
- Maria Curie-Sklodowska University, Faculty of Biology and Biotechnology, Department of Virology and Immunology, Lublin, Poland.
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Rugo HS, Di Palma JA, Tripathy D, Bryce R, Moran S, Olek E, Bosserman L. The characterization, management, and future considerations for ErbB-family TKI-associated diarrhea. Breast Cancer Res Treat 2019; 175:5-15. [PMID: 30671765 PMCID: PMC6491395 DOI: 10.1007/s10549-018-05102-x] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2018] [Accepted: 12/12/2018] [Indexed: 12/12/2022]
Abstract
Purpose Diarrhea is recognized as a common adverse event associated with tyrosine kinase inhibitors (TKIs), with those targeting the ErbB family of receptors being associated with the highest rate of diarrhea. Methods This paper reviews data on the incidence, timing, and duration of diarrhea associated with US Food and Drug Administration-approved ErbB family-targeted TKIs from the published literature, and sets forth recommendations for management. Results In the absence of anti-diarrheal prophylaxis the incidence of any-grade diarrhea varies and typically occurs early during the course of treatment. Although it is difficult to determine if the incidence and severity of diarrhea is related to inhibition of a particular kinase target because of the multi-targeted and overlapping activity of many agents, evidence suggests that second-generation TKIs with broader target profiles (i.e., afatinib, lapatinib, neratinib) result in a higher incidence of diarrhea compared with highly specific first- (erlotinib, gefitinib) or third- (osimertinib) generation agents. The mechanisms responsible for TKI-associated diarrhea are not fully understood and are likely multi-factorial, involving dysregulated ion transport, inflammation, and mucosal injury. Management strategies have been developed—and continue to be refined—to prevent and reduce the severity and duration of TKI-associated diarrhea. For agents associated with more significant symptoms, anti-diarrheal prophylaxis reduces the incidence and severity of diarrhea, and ongoing studies are evaluating specific strategies to further reduce incidence and duration of TKI-associated diarrhea. Conclusions Continued investigations into risk factors and pharmacogenomic markers for diarrhea may further improve management of this common toxicity.
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Affiliation(s)
- Hope S Rugo
- Department of Medicine (Hematology/Oncology), University of California San Francisco Helen Diller Family Comprehensive Cancer Center, 1600 Divisadero St., Box 1710, San Francisco, CA, 94143-1710, USA.
| | - Jack A Di Palma
- Division of Gastroenterology, University of South Alabama College of Medicine, 75 S. University Blvd., Mobile, AL, 36688, USA
| | - Debu Tripathy
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, 1515 Holcombe, Unit 1354, Houston, TX, 77030, USA
| | - Richard Bryce
- Puma Biotechnology, Inc., 10880 Wilshire Blvd. Suite 2150, Los Angeles, CA, 90024, USA
| | - Susan Moran
- Puma Biotechnology, Inc., 701 Gateway Blvd, Suite 500, South San Francisco, CA, 94080, USA.,QED Therapeutics, 421 Kipling St, Palo Alto, CA, 94301, USA
| | - Elizabeth Olek
- Puma Biotechnology, Inc., 701 Gateway Blvd, Suite 500, South San Francisco, CA, 94080, USA
| | - Linda Bosserman
- City of Hope Medical Group, Inc, 1500 E Duarte Rd, Duarte, CA, 91010, USA
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Genova RM, Meyer KJ, Anderson MG, Harper MM, Pieper AA. Neprilysin inhibition promotes corneal wound healing. Sci Rep 2018; 8:14385. [PMID: 30258206 PMCID: PMC6158251 DOI: 10.1038/s41598-018-32773-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 09/10/2018] [Indexed: 12/11/2022] Open
Abstract
Neprilysin (NEP), an ectoenzyme that modulates inflammation by degrading neuropeptides, was recently identified in the human corneal epithelium. The cornea expresses many NEP substrates, but the function of NEP in homeostatic maintenance and wound healing of the cornea is unknown. We therefore investigated the role of this enzyme under naive and injured conditions using NEP-deficient (NEP-/-) and wild type (WT) control mice. In vivo ocular surface imaging and histological analysis of corneal tissue showed no differences in limbal vasculature or corneal anatomy between naive NEP-/- and WT mice. Histological examination revealed increased corneal innervation in NEP-/- mice. In an alkali burn model of corneal injury, corneal wound healing was significantly accelerated in NEP-/- mice compared to WT controls 3 days after injury. Daily intraperitoneal administration of the NEP inhibitor thiorphan also accelerated corneal wound healing after alkali injury in WT mice. Collectively, our data identify a previously unknown role of NEP in the cornea, in which pharmacologic inhibition of its activity may provide a novel therapeutic option for patients with corneal injury.
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Affiliation(s)
- Rachel M Genova
- Department of Molecular Physiology and Biophysics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Kacie J Meyer
- Department of Molecular Physiology and Biophysics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Iowa City Department of Veterans Affairs Center for the Prevention and Treatment of Visual Loss, Iowa City, IA, USA
- Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Michael G Anderson
- Department of Molecular Physiology and Biophysics, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Iowa City Department of Veterans Affairs Center for the Prevention and Treatment of Visual Loss, Iowa City, IA, USA
- Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA, USA
- Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Matthew M Harper
- Iowa City Department of Veterans Affairs Center for the Prevention and Treatment of Visual Loss, Iowa City, IA, USA.
- Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
| | - Andrew A Pieper
- Department of Molecular Physiology and Biophysics, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Iowa City Department of Veterans Affairs Center for the Prevention and Treatment of Visual Loss, Iowa City, IA, USA.
- Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Stephen A. Wynn Institute for Vision Research, Department of Ophthalmology and Visual Sciences, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Department of Psychiatry, University of Iowa Carver College of Medicine, Iowa City, IA, USA.
- Harrington Discovery Institute, University Hospital Case Medical Center, Department of Psychiatry, Case Western Reserve University, Geriatric Research Education and Clinical Centers, Louis Stokes Cleveland VAMC, Cleveland, OH, USA.
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Eberlin M, Chen M, Mueck T, Däbritz J. Racecadotril in the treatment of acute diarrhea in children: a systematic, comprehensive review and meta-analysis of randomized controlled trials. BMC Pediatr 2018; 18:124. [PMID: 29614995 PMCID: PMC5883268 DOI: 10.1186/s12887-018-1095-x] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2017] [Accepted: 03/20/2018] [Indexed: 12/21/2022] Open
Abstract
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.
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Affiliation(s)
- Marion Eberlin
- Department of Medical Affairs CHC GSA, Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany
| | - Min Chen
- Department of Anesthesiology, Wuhan Union Hospital, Wuhan, China
| | - Tobias Mueck
- Department of Medical Affairs CHC GSA, Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany
| | - Jan Däbritz
- Department of Pediatrics, University Hospital Rostock, Rostock, Germany
- Center for Immunobiology, Blizard Institute, Barts Cancer Institute, The Barts and the London School of Medicine & Dentistry, Queen Mary University, London, UK
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Fischbach W, Andresen V, Eberlin M, Mueck T, Layer P. A Comprehensive Comparison of the Efficacy and Tolerability of Racecadotril with Other Treatments of Acute Diarrhea in Adults. Front Med (Lausanne) 2016; 3:44. [PMID: 27790616 PMCID: PMC5064048 DOI: 10.3389/fmed.2016.00044] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Accepted: 09/20/2016] [Indexed: 12/27/2022] Open
Abstract
Racecadotril is a guideline-recommended treatment to alleviate symptoms of acute diarrhea. A systematic review of randomized studies was performed comparing efficacy and safety of treatment with racecadotril to that with placebo or active treatments in adults. In five double-blind studies, racecadotril and placebo had comparable tolerability, but racecadotril was more effective. This was consistent across multiple efficacy parameters including duration of diarrhea, number of diarrheic stools, abdominal pain, and meteorism; it was also consistent across countries in Africa, Asia, and Europe. In six randomized studies in outpatients comparing racecadotril to loperamide, resolution of symptoms occurred with similar speed and efficacy; however, racecadotril treatment was associated with less rebound constipation and less abdominal discomfort. The seventh comparative study performed in geriatric nursing home residents reported a superior efficacy of racecadotril. In direct comparison with Saccharomyces boulardii treatment, racecadotril exhibited similar tolerability but was more efficacious. One study compared racecadotril to octreotide in patients with acute diarrhea requiring hospitalization, rehydration, and antibiotic treatment; in this cohort, octreotide was more efficacious than racecadotril. In conclusion, in adults with acute diarrhea, racecadotril is more efficacious than placebo or S. boulardii, similarly efficacious as loperamide and, in patients with moderate to severe disease as add-on to antibiotics, less than octreotide. The tolerability of racecadotril is similar to that of placebo or S. boulardii and better than that of loperamide, particularly with regard to risk of rebound constipation. Taken together, these data demonstrate that racecadotril is a suitable treatment to alleviate symptoms of acute diarrhea in adults.
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Affiliation(s)
- Wolfgang Fischbach
- Medizinische Klinik II, Klinikum Aschaffenburg-Alzenau, Aschaffenburg, Germany
| | - Viola Andresen
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Germany
| | - Marion Eberlin
- Department of Medical Affairs CHC Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Tobias Mueck
- Department of Medical Affairs CHC Germany, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Peter Layer
- Medizinische Klinik, Israelitisches Krankenhaus, Hamburg, Germany
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Chiguru V, Lingesh A, R. S, N. S. Forced degradation study of racecadotril: Effect of co-solvent, characterization of degradation products by UHPLC-Q-TOF-MS/MS, NMR and cytotoxicity assay. J Pharm Biomed Anal 2016; 128:9-17. [DOI: 10.1016/j.jpba.2016.05.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2016] [Revised: 05/04/2016] [Accepted: 05/05/2016] [Indexed: 10/21/2022]
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12
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Faure C. Role of antidiarrhoeal drugs as adjunctive therapies for acute diarrhoea in children. Int J Pediatr 2013; 2013:612403. [PMID: 23533446 PMCID: PMC3603675 DOI: 10.1155/2013/612403] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2012] [Revised: 01/02/2013] [Accepted: 01/02/2013] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Christophe Faure
- Division of Gastroenterology, Department of Pediatrics, CHU Sainte-Justine, Montreal, QC, Canada H3T 1C5
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Eberlin M, Mück T, Michel MC. A comprehensive review of the pharmacodynamics, pharmacokinetics, and clinical effects of the neutral endopeptidase inhibitor racecadotril. Front Pharmacol 2012; 3:93. [PMID: 22661949 PMCID: PMC3362754 DOI: 10.3389/fphar.2012.00093] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2012] [Accepted: 04/27/2012] [Indexed: 11/15/2022] Open
Abstract
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.
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Affiliation(s)
- Marion Eberlin
- Department of Medical Affairs Germany, Boehringer Ingelheim Pharma GmbH & Co KG Ingelheim, Germany
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Misawa K, Suzuki Y, Takahashi S, Yoshimori A, Takasawa R, Shibuya Y, Tanuma SI. Structure-based design of dipeptide derivatives for the human neutral endopeptidase. Bioorg Med Chem 2011; 19:5935-47. [DOI: 10.1016/j.bmc.2011.08.064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 08/26/2011] [Accepted: 08/27/2011] [Indexed: 12/01/2022]
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Lehert P, Chéron G, Calatayud GA, Cézard JP, Castrellón PG, Garcia JMM, Santos M, Savitha MR. Racecadotril for childhood gastroenteritis: an individual patient data meta-analysis. Dig Liver Dis 2011; 43:707-13. [PMID: 21514257 DOI: 10.1016/j.dld.2011.03.001] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2010] [Revised: 01/31/2011] [Accepted: 03/04/2011] [Indexed: 12/11/2022]
Abstract
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.
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Affiliation(s)
- Philippe Lehert
- Statistics Department, Faculty of Economics, FUCAM, Louvain Academy, Belgium.
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Prabu S, Singh T, Kumar C, Joseph A, Srinivasan K. High-performance thin-layer chromatographic method for analysis of racecadotril in the bulk drug. JPC-J PLANAR CHROMAT 2009. [DOI: 10.1556/jpc.22.2009.4.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Holzer P. Opioid receptors in the gastrointestinal tract. ACTA ACUST UNITED AC 2009; 155:11-7. [PMID: 19345246 DOI: 10.1016/j.regpep.2009.03.012] [Citation(s) in RCA: 266] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2009] [Accepted: 03/25/2009] [Indexed: 12/14/2022]
Abstract
Opium is arguably one of the oldest herbal medicines, being used as analgesic, sedative and antidiarrheal drug for thousands of years. These effects mirror the actions of the endogenous opioid system and are mediated by the principal mu-, kappa- and delta-opioid receptors. In the gut, met-enkephalin, leu-enkephalin, beta-endorphin and dynorphin occur in both neurons and endocrine cells. When released, opioid peptides activate opioid receptors on the enteric circuitry controlling motility and secretion. As a result, inhibition of gastric emptying, increase in sphincter tone, induction of stationary motor patterns and blockade of peristalsis ensue. Together with inhibition of ion and fluid secretion, these effects cause constipation, one of the most frequent and troublesome adverse reactions of opioid analgesic therapy. Although laxatives are most frequently used to ameliorate opioid-induced bowel dysfunction, their efficacy is unsatisfactory. Specific antagonism of peripheral opioid receptors is a more rational approach. This goal is addressed by the use of opioid receptor antagonists with limited absorption such as oral prolonged-release naloxone and opioid receptor antagonists that do not penetrate the blood-brain barrier such as methylnaltrexone and alvimopan. Preliminary evidence indicates that peripherally restricted opioid receptor antagonists may act as prokinetic drugs in their own right.
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Affiliation(s)
- Peter Holzer
- Research Unit of Translational Neurogastroenterology, Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Universitätsplatz 4, A-8010 Graz, Austria.
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Basniwal PK, Srivastava PK, Jain SK, Jain D. RP-LC Analysis and Hydrolytic Degradation Profile of Racecadotril. Chromatographia 2008. [DOI: 10.1365/s10337-008-0734-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Degos V, Loron G, Mantz J, Gressens P. Neuroprotective Strategies for the Neonatal Brain. Anesth Analg 2008; 106:1670-80. [DOI: 10.1213/ane.0b013e3181733f6f] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
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Tormo R, Polanco I, Salazar-Lindo E, Goulet O. Acute infectious diarrhoea in children: new insights in antisecretory treatment with racecadotril. Acta Paediatr 2008; 97:1008-15. [PMID: 18462465 PMCID: PMC7159603 DOI: 10.1111/j.1651-2227.2008.00830.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
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.
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Affiliation(s)
- Ramón Tormo
- Service of Paediatric Gastroenterology and Nutrition, Hospital Quirón, Barcelona, Spain.
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Freedman SB. Acute infectious pediatric gastroenteritis: beyond oral rehydration therapy. Expert Opin Pharmacother 2007; 8:1651-65. [PMID: 17685883 DOI: 10.1517/14656566.8.11.1651] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
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.
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Affiliation(s)
- Stephen B Freedman
- University of Toronto, Division of Pediatric Emergency Medicine, Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
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Abstract
Neuroprotective strategies can prevent lesions from getting worse but agents that have neurotrophic properties can also affect repair in a developing brain. Although prevention and treatment in the early stages of brain lesions are desirable, delayed cell death or improved post-lesion plasticity are the only realistic targets in many cases. Several trophic factors can limit delayed cell death in animal models of perinatal brain damage. In addition, melatonin and brain-derived neurotrophic factor have been shown to promote post-lesion plasticity following neonatal excitotoxic white-matter damage in newborn mice. Despite these promising results, additional preclinical data are required for most of the trophic factors that have been tested, although some candidate drugs, e.g. melatonin or erythropoietin, might reach clinical trials in the near future.
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Affiliation(s)
- Stéphane V Sizonenko
- Service du Développement et de la Croissance, Département de Pédiatrie, Faculté de Médecine, Geneva, Switzerland
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Abstract
Opioid analgesics are the mainstay in the treatment of moderate-to-severe pain, yet their use is frequently associated with adverse effects, the most common and debilitating being constipation. Opioid-induced motor stasis results from blockade of gastrointestinal peristalsis and fluid secretion, and reflects the action of the endogenous opioid system in the gut. Methylnaltrexone and alvimopan are new investigational drugs that selectively target peripheral mu-opioid receptors because they are poorly absorbed in the intestine and do not enter the brain. Clinical studies have proved the concept that these drugs prevent opioid-induced bowel dysfunction without interfering with analgesia. As reviewed in this article, opioid receptor antagonists with a peripherally restricted site of action also hold therapeutic promise in postoperative ileus and chronic constipation due to the fact that they have been found to stimulate intestinal transit.
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Affiliation(s)
- Peter Holzer
- Research Unit of Translational Neurogastroenterology, Institute of Experimental and Clinical Pharmacology, Medical University of Graz, Universitätsplatz 4, A-8010 Graz, Austria.
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Abstract
Rotavirus is the single most important cause of severe, dehydrating gastroenteritis in infants and young children worldwide. Rotavirus gastroenteritis is associated with high morbidity in developed countries and significant mortality in developing countries. Virtually all children are infected with rotavirus by 3 years of age. Fecal-oral transmission is the most likely route of virus spread. Group A serotype strains G1 through G4 account for more than 90% of rotavirus gastroenteritis in humans, with G1 being the predominant serotype. The virus preferentially infects the mature small-intestinal enterocytes. Rotavirus gastroenteritis is characterized by fever, vomiting, and diarrhea, with vomiting particularly prominent. Dehydration is a frequent complication because of the severity of the diarrhea and the associated vomiting. Rehydration and maintenance of proper fluid and electrolyte balance remain the mainstay of treatment. Hygienic measures have little effect on the reduction of rotavirus infection rates. The disease can be effectively controlled by universal rotavirus vaccination.
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Affiliation(s)
- Alexander K C Leung
- Department of Pediatrics, University of Calgary, Alberta Children's Hospital, Calgary, Alberta, Canada
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Abstract
This paper is the twenty-third installment of the annual review of research concerning the opiate system. It summarizes papers published during 2000 that studied the behavioral effects of the opiate peptides and antagonists, excluding the purely analgesic effects, although stress-induced analgesia is included. The specific topics covered this year include stress; tolerance and dependence; learning, memory, and reward; eating and drinking; alcohol and other drugs of abuse; sexual activity, pregnancy, and development; mental illness and mood; seizures and other neurological disorders; electrical-related activity; general activity and locomotion; gastrointestinal, renal, and hepatic function; cardiovascular responses; respiration and thermoregulation; and immunological responses.
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Affiliation(s)
- A L Vaccarino
- Department of Psychology, University of New Orleans, New Orleans, LA 70148, USA.
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