A blind, randomized comparison of racecadotril and loperamide for stopping acute diarrhea in adults

AIM: Racecadotril is a specific enkephalinase inhibitor that exhibits intestinal antisecretory activity without affecting intestinal transit. Loperamide is an effective anti-diarrheal agent, but it usually induces constipation. This study is to compare the efficacy, safety, and tolerability of racecadotril versus loperamide in the outpatient treatment of acute diarrhea in adults. METHODS: A two-center, randomized, parallel-group, single-blind study was carried out to compare the efficacy, tolerability, and safety of racecadotril (100 mg thrics daily) and loperamide (2.0 mg 2 twics daily) in 62 adult patients suffering from acute diarrhea. The main efficacy criterion used was the duration of diarrhea after beginning the treatment (in hours). Other signs and symptoms were also evaluated. RESULTS: The clinical success rates for these anti-diarrheal treatments were 95.7% and 92.0% for racecadotril and loperamide respectively. Patients on racecadotril had a median duration of diarrhea of 19.5 h compared with a median of 13 h for patients on loperamide. Rapid improvement in anal burn and nausea was found for each drug. However, more patients on loperamide suffered from reactive constipation (29.0% vs 12.9%). Itching, another adverse event was notably higher in the racecadotril group (28.6% vs 0%). With regard to other adverse events, the two medications showed similar occurrence rates and similar concomitant medication usage rates. CONCLUSION: Racecadotril and loperamide are rapid, equally effective treatments for acute diarrhea in adults, but loperamide treatment is associated with a higher incidence of treatment-related constipation.     

Loperamide

In castor oil challenged rats, low doses of loperamide inhibit diarrhea and normalize intestinal propulsion. Unlike other opioids, loperamide is devoid of central opiate-like effects, including blockade of intestinal propulsion, up to the highest subtoxic oral dose. Nevertheless, the antidiarrheal action of loperamide can be considered to be -opiate receptor mediated, only a fewin vitro effects at rather high concentrations being not naloxone-reversible. There is little evidence that interactions with intestinal opiate receptors directly change epithelial cell function. When secretory stimuli increase mucosal tension, however, loperamide may reverse the elevated hydrostatic tissue pressure that opposes normal absorption. This antisecretory effect at the mucosal level is accompanied by motor effects when loperamide reaches the myenteric -opiate receptors. At therapeutic doses for the treatment of acute diarrhea, it is likely that the mucosal effect prevails.     

A Multinational Comparison of Racecadotril and Loperamide in the Treatment of Acute Watery Diarrhoea in Adults

Background: Racecadotril (acetorphan) is an orally active, potent inhibitor of enkephalinase, which exerts an antihypersecretory effect without increasing intestinal transit time. The aim of this study was to compare the efficacy, safety and tolerability of racecadotril with those of loperamide by assessing their effects on the resolution of the signs and symptoms of diarrhoea in patients in developing countries who had acute watery diarrhoea of less than 5 days' duration. Methods: 945 outpatients from 21 centres in 14 countries received racecadotril (100 mg) or loperamide (2 mg) three times daily in a single-blind study. Duration of diarrhoea was the primary measure of efficacy; secondary criteria were overall clinical response, occurrence and duration of abdominal pain and distension, and occurrence of other associated signs and symptoms. Occurrence of constipation and adverse events were the main safety assessments. Results: Diarrhoea resolved rapidly with both racecadotril and loperamide (55.0 h in both groups), 92% of patients on racecadotril and 93% on loperamide being treatment successes. Racecadotril produced a significantly greater reduction in abdominal pain and distension than loperamide ( P = 0.024 and 0.03, respectively). The duration of abdominal distension was significantly shorter with racecadotril (5.4 versus 24.4 h; P = 0.0001), and constipation was also significantly less frequent (16% versus 25%; P = 0.001). One-hundred-and-eighty patients (19%) experienced one or more adverse event during the study: 67 (14.2%) in the racecadotril group and 113 (23.9%) in the loperamide group ( P = 0.001). Conclusions: Racecadotril resolved the symptoms of acute diarrhoea rapidly and effectively, and produced more rapid resolution of abdominal symptoms and less constipation than loperamide.     

A multinational comparison of racecadotril and loperamide in the treatment of acute watery diarrhoea in adults

BACKGROUND: Racecadotril (acetorphan) is an orally active, potent inhibitor of enkephalinase, which exerts an antihypersecretory effect without increasing intestinal transit time. The aim of this study was to compare the efficacy, safety and tolerability of racecadotril with those of loperamide by assessing their effects on the resolution of the signs and symptoms of diarrhoea in patients in developing countries who had acute watery diarrhoea of less than 5 days' duration. METHODS: 945 outpatients from 21 centres in 14 countries received racecadotril (100 mg) or loperamide (2 mg) three times daily in a single-blind study. Duration of diarrhoea was the primary measure of efficacy; secondary criteria were overall clinical response, occurrence and duration of abdominal pain and distension, and occurrence of other associated signs and symptoms. Occurrence of constipation and adverse events were the main safety assessments. RESULTS: Diarrhoea resolved rapidly with both racecadotril and loperamide (55.0 h in both groups), 92% of patients on racecadotril and 93% on loperamide being treatment successes. Racecadotril produced a significantly greater reduction in abdominal pain and distension than loperamide (P = 0.024 and 0.03, respectively). The duration of abdominal distension was significantly shorter with racecadotril (5.4 versus 24.4 h; P = 0.0001), and constipation was also significantly less frequent (16% versus 25%; P = 0.001). One-hundred-and-eighty patients (19%) experienced one or more adverse event during the study: 67 (14.2%) in the racecadotril group and 113 (23.9%) in the loperamide group (P = 0.001). CONCLUSIONS: Racecadotril resolved the symptoms of acute diarrhoea rapidly and effectively, and produced more rapid resolution of abdominal symptoms and less constipation than loperamide.     

Efficacy and tolerability of racecadotril in acute diarrhea in children

BACKGROUND & AIMS: Oral rehydration therapy is the only treatment recommended by the World Health Organization in acute diarrhea in children. Antisecretory drugs available could not be used because of their side effects, except for racecadotril, which is efficient in acute diarrhea in adults. METHODS: The efficacy and tolerability of racecadotril (1.5 mg/kg administered orally 3 times daily) as adjuvant therapy to oral rehydration were compared with those of placebo in 172 infants aged 3 months to 4 years (mean age, 12.8 months) who had acute diarrhea. The treatment groups were comparable in terms of age, duration of diarrhea, number of stools, and causative microorganism at inclusion. RESULTS: During the first 48 hours of treatment, patients receiving racecadotril had a significantly lower stool output (grams per hour) than those receiving placebo. The 95% confidence interval was 43%-88% for the full data set (n = 166; P = 0.009) and 33%-75% for the per-protocol population (n = 116; P = 0.001). There was no difference between treatments depending on rotavirus status. Significant differences between treatment groups were also found after 24 hours of treatment: full data set (n = 167; P = 0.026) and per-protocol population (n = 121; P = 0.015). Tolerability was good in both groups of patients. CONCLUSIONS: This study demonstrates the efficacy (up to 50% reduction in stool output) and tolerability of racecadotril as adjuvant therapy to oral rehydration solution in the treatment of severe diarrhea in infants and children.     

Efficacy and tolerability of racecadotril in the treatment of cholera in adults: a double blind,randomised, controlled clinical trial

BACKGROUND: The enkephalins, endogenous opiate substances, act as neurotransmitters along the entire digestive tract where they elicit intestinal antisecretory activity without affecting intestinal transit time or motility. Racecadotril, through inhibition of enkephalinase, reinforces the physiological activity of endogenous enkephalins and, therefore, shows intestinal antisecretory activity. AIM: We conducted the study to determine the role of racecadotril as an adjunct to the standard treatment of cholera in adults. METHODS: The study was a double blind, randomised, placebo controlled clinical trial involving 110 adult male cholera patients who received either racecadotril or placebo in addition to standard cholera treatment. The major outcome measures (stool output, oral rehydration solution (ORS) intake, requirements for unscheduled intravenous fluid infusion, and duration of diarrhoea) were compared between the groups. RESULTS: Of 110 patients enrolled, 54 received racecadotril and 56 received placebo. Admission clinical characteristics were comparable between the groups. There was no significant difference in (mean (SD)) total stool output (racecadotril v placebo 315 (228) v 280 (156) g/kg), total ORS intake (390 (264) v 369 (240) ml/kg), or duration of diarrhoea (35 (15) v 32 (13) hours) between the groups. Clinical success, defined as resolution of diarrhoea within 72 hours of initiation of study intervention, was similar in both groups (racecadotril v placebo 96% v 89%). The number of patients receiving unscheduled intravenous infusions was not significantly different between the groups (racecadotril v placebo 22% v 14%). No drug related adverse effect was noted. CONCLUSION: The study demonstrated that racecadotril therapy, although found to be safe, does not provide additional benefit in the treatment of severe cholera in adults.     

Obeticholic acid for severe bile acid diarrhea with intestinal failure: A case report and review of the literature

Bile acid diarrhea results from excessive amounts of bile acids entering the colon due to hepatic overexcretion of bile acids or bile acid malabsorption in the terminal ileum. The main therapies include bile acid sequestrants, such as colestyramine and colesevelam, which may be given in combination with the opioid receptor agonist loperamide. Some patients are refractory to conventional treatments. We report the use of the farnesoid X receptor agonist obeticholic acid in a patient with refractory bile acid diarrhea and subsequent intestinal failure. A 32-year-old woman with quiescent colonic Crohn's disease and a normal terminal ileum had been diagnosed with severe bile acid malabsorption and complained of watery diarrhea and fatigue. The diarrhea resulted in hypokalemia and sodium depletion that made her dependent on twice weekly intravenous fluid and electrolyte infusions. Conventional therapies with colestyramine, colesevelam, and loperamide had no effect. Second-line antisecretory therapies with pantoprazole, liraglutide, and octreotide also failed. Third-line treatment with obeticholic acid reduced the number of stools from an average of 13 to an average of 7 per 24h and improved the patient's quality of life. The fluid and electrolyte balances normalized. The effect was sustained during follow-up for 6 mo with treatment at a daily dosage of 25 mg. The diarrhea worsened shortly after cessation of obeticholic acid. This case report supports the initial report that obeticholic acid may reduce bile acid production and improve symptoms in patients with bile acid diarrhea.     

Treatment of travelers' diarrhea: ciprofloxacin plus loperamide compared with ciprofloxacin alone. A placebo-controlled, randomized trial

OBJECTIVE: To compare the safety and efficacy of loperamide used in combination with ciprofloxacin or ciprofloxacin alone for the treatment of travelers' diarrhea. DESIGN: Double-blind, placebo-controlled, randomized clinical trial. SETTING: United States Army hospital in Egypt. PARTICIPANTS: United States military personnel with travelers' diarrhea (n = 104) during a military exercise in November 1989. Persons who were noncompliant, had bloody diarrhea, or had received antidiarrheal medications before entry into the study were excluded. INTERVENTIONS: All participants with travelers' diarrhea were treated with ciprofloxacin, 500 mg twice daily for 3 days. Fifty of these patients were randomly assigned to receive loperamide, a 4-mg first dose and 2 mg for every loose stool (as much as 16 mg/d), and 54 were randomly assigned to receive placebo. MEASUREMENTS: Enterotoxigenic Escherichia coli was isolated from 57% of patients; Shigella and Salmonella, seen in 4% and 2% of patients, respectively, were not common. MAIN RESULTS: After 24 hours, the symptoms of 82% of patients in the ciprofloxacin and loperamide group compared with 67% in the ciprofloxacin and placebo group had improved or fully recovered (odds ratio, 2.3; 95% CI, 0.8 to 6.3; P = 0.08). After 48 hours, the symptoms of 90% of both groups had improved or fully recovered. The mean number of stools for those receiving loperamide was not much lower than those who did not receive loperamide after 24 hours (1.9 +/- 0.2 [SE] compared with 2.6 +/- 0.2) or 48 hours (3.1 +/- 0.3 compared with 4.0 +/- 0.3) of treatment (P = 0.19). CONCLUSIONS: In a region where enterotoxigenic E. coli was the predominant cause of travelers' diarrhea, loperamide combined with ciprofloxacin was not better than treatment with ciprofloxacin alone. Loperamide appeared to have some benefit in the first 24 hours of treatment in patients infected with enterotoxigenic E. coli. Both regimens were safe.     

Treatment of traveler's diarrhea with ciprofloxacin and loperamide.

To determine the efficacy of loperamide given with long- and short-course quinolone therapy for treating traveler's diarrhea, 142 US military personnel were randomized to receive a single 750-mg dose of ciprofloxacin with placebo, 750 mg of ciprofloxacin with loperamide, or a 3-day course of 500 mg of ciprofloxacin twice daily with loperamide. Culture of pretreatment stool specimens revealed campylobacters (41%), salmonellae (18%), enterotoxigenic Escherichia coli (ETEC, 6%), and shigellae (4%). Of the participants, 87% completely recovered within 72 h of entry. Total duration of illness did not differ significantly among the three treatment groups, but patients in the 3-day ciprofloxacin plus loperamide group reported a lower cumulative number of liquid bowel movements at 48 and 72 h after enrollment compared with patients in the single-dose ciprofloxacin plus placebo group (1.8 vs. 3.6, P = .01; 2.0 vs. 3.9, P = .01). While not delivering a remarkable therapeutic advantage, loperamide appears to be safe for treatment of non-ETEC causes of traveler's diarrhea. Two of 54 patients with Campylobacter enteritis had a clinical relapse after treatment that was associated with development of ciprofloxacin resistance.     

Update on traveler’s diarrhea

Diarrhea is one of the most common health problems among travelers. Although enterotoxigenic Escherichia coli is implicated most commonly, enteroaggregative E. coli has recently been described as a major pathogen. Shigella, Campylobacter, and Salmonella organisms are less common causes of acute diarrhea, and intestinal protozoa are typical causes of protracted diarrhea. Although education is the mainstay of prevention measures, behavior modification has been shown to be difficult. Chemoprevention is rarely required with the availability of effective treatment, but there has been some interest in the use of vaccines. Maintenance of hydration is most important in children. In addition to bismuth preparations and loperamide, newer agents being developed for symptomatic relief include zaldaride maleate and racecadotril. Fluoroquinolones effectively treat severe traveler’s diarrhea, and even a single dose may be sufficient. However, with the emergence of resistance, particularly in Campylobacter infection, other agents are required; interest has focused on azithromycin and rifaximin.     

A double blind,randomized, placebo-controlled study of SP-303 (Provir) in the symptomatic treatment of acute diarrhea among travelers to Jamaica and Mexico

OBJECTIVE: The study was designed to evaluate the effectiveness of SP-303 (Provir), a plant-derived product with novel antisecretory properties, in the treatment of travelers' diarrhea. METHODS: A total of 184 persons from the United States who acquired diarrhea in Jamaica or Mexico were enrolled in a double-blind, placebo-controlled study examining the effectiveness of three doses of SP-303 in reducing illness. Subjects were treated with 125 mg, 250 mg, or 500 mg SP-303 or a matching placebo four times a day for 2 days. Subjects kept daily diaries of symptoms and were seen each day for 3 days. Of the subjects, 169 (92%) were included in the efficacy analysis. RESULTS: The most common etiological agent identified was enterotoxigenic Escherichia coli, found in 19% of subjects. The mean time interval from taking the first dose of medication until passage of the last unformed stool during 48 h therapy (TLUS48) was 38.7 h for the placebo group. TLUS48 was shortened by SP-303: 30.6 h for the 125-mg dose group (p = 0.005); 30.3 h for the 250-mg group; and 32.6 h for the 500-mg group (p = 0.01). Treatment failures were seen in 29.3% in the placebo group compared with 7.3% (p = 0.01), 4.3 (p = 0.002), and 9.8 (p = 0.026) in the three treatment groups. SP-303 was well tolerated at all doses. CONCLUSIONS: SP-303 was effective in shortening the duration of travelers' diarrhea by 21%. This antisecretory approach works directly against the pathophysiology of travelers' diarrhea and is not likely to potentiate invasive forms of diarrhea or to produce posttreatment constipation.     

Ileostomy diarrhea

Opinion statement Ileostomy diarrhea is not an uncommon problem and can lead to considerable loss of quality of life. Unfortunately, well-designed therapeutic trials are lacking, and thus, treatment of patients with ileostomy diarrhea remains largely empiric. The majority of individuals will have "idiopathic" ileostomy diarrhea, or increased output due to proctocolectomy with limited ileal resection alone. Once other, less common causes are excluded, empiric treatment should be initiated with the safest, least costly option. In general, this consists of a dietary evaluation and symptomatic treatment with loperamide and advancing as needed to other, more expensive options, frequently with an increase in side effect profile. Other more recently evaluated treatment options include budesonide and oleic acid; however, efficacy has only been demonstrated in preliminary studies; further evaluation is needed. Limited data exist regarding success of surgical therapy such as reversed peristaltic ileal segments. It remains to be seen if surgery, other than ileostomy revision, has a role in the treatment of ileostomy diarrhea.     

消旋卡多曲和酪酸梭菌二联活菌散在急性轮状病毒腹泻中的疗效和安全性

目的探究消旋卡多曲和酪酸梭菌二联活菌散在急性轮状病毒腹泻中的疗效和安全性。 方法选取新疆维吾尔自治区人民医院2017年6月至2018年6月诊断及就诊的急性轮状病毒腹泻患儿100例,使用随机数表法分为对照组(50例)和观察组(50例),对照组予以抗病毒、补液及纠正酸碱平衡等常规治疗,观察组在此基础上予以消旋卡多曲和酪酸梭菌二联活菌散治疗。比较两组治疗疗效、治疗后症状改变情况、治疗前后肿瘤坏死因子α(tumor necrosis factorα,TNF-α)、白细胞介素6(interleukin 6,IL-6)及内毒素水平及治疗期间不良反应发生情况。 结果观察组治疗总有效率显著高于对照组(98%比78%;χ²＝5.892,P＝0.014)。观察组腹泻时间、住院时间、发热时间、呕吐时间显著小于对照组(t＝13.875、12.438、7.348、9.382;P＝0.000、0.007、0.012、0.008),同时需静脉补液治疗及治疗7 d后仍腹泻的人数显著少于对照组(t＝5.005、5.982;P＝0.025、0.014)。治疗后观察组外周血中TNF-α、IL-6及内毒素显著小于对照组(t＝5.619、7.838、4.169;P＝0.000、0.000、0.001)。观察组治疗不良反应发生发生率显著小于对照组(18.00%比4.00%;χ²＝5.005,P＝0.025)。 结论消旋卡多曲联合酪酸梭菌二联活菌散治疗急性轮状病毒腹泻的疗效显著,能有效改善症状及炎症水平,且具有较好安全性。     

Antisecretory drugs for diarrheal disease

Acute diarrhea is a major cause of morbidity and mortality worldwide. Infants and pre-school children are the most vulnerable in whom there are 2-3 million deaths each year as a result of the associated dehydration and acidosis. Although oral rehydration therapy has reduced mortality during the past 30 years ago, the search for agents that will directly inhibit intestinal secretory mechanisms and thereby reduce faecal losses in patients with high-volume watery diarrhea has continued for more than 20 years. A variety of potential targets for antisecretory agents have been explored which include loci within the enterocyte (the chloride channel, calcium-calmodulin) and other sites such as enteric nerves and endogenous mediators (such as 5-HT, prostaglandins). Although the potential of calcium-calmodulin inhibition has as yet not been realised, preliminary studies suggest that there are chloride channel blockers under development that will find a place in the management of secretory diarrheas. Recent work has highlighted the importance of neurohumoral mechanisms in the pathogenesis of acute diarrhea. Potentiation of the effects of endogenous enkephalin activity by enkephalinase inhibition has already produced a safe, effective anti-secretory drug, racecadotril. Speculative early work indicates that there may be a role for antagonists of 5-HT, substance P, and VIP receptors. There now seems to be a real possibility that antisecretory therapy will become more widely available in the future.     

A practical approach to treating patients with chronic diarrhea

Although diarrhea is a common complaint, its evaluation and treatment can be challenging. Appropriately defining and classifying diarrhea provide the framework for approaching diagnostic and therapeutic options. Diarrhea can be defined based on frequency, consistency, and/or weight, and classified as acute or chronic with specific clinical characteristics and stool appearance. Colonoscopy is the most common diagnostic tool used in the evaluation of patients with chronic diarrhea. Other evaluation strategies include timed stool collections, evaluation of inflammatory markers, and hydrogen breath tests. A focused workup of chronic diarrhea may yield a specific diagnosis, including diarrhea-predominant IBS (dIBS), functional diarrhea, diabetic diarrhea, bile acid-induced diarrhea, and microscopic colitis. Ideally, therapeutic decisions are specifically tailored to target the underlying pathophysiology, including, for example, gluten restriction for celiac disease, rotating antibiotics for small bowel bacterial overgrowth, budesonide therapy for collagenous colitis, and loperamide for treatment of functional diarrhea. It is also important to assess the role of diet and medications in chronic diarrhea. However, if no specific causes are identified following workup, empiric therapy with simple opiate antidiarrheals such as loperamide may be effective. If this proves unsuccessful, the use of more potent agents, including codeine and opium, may be considered.     

Management of protease inhibitor-associated diarrhea.

Diarrhea is a common and often inadequately treated complication in patients with human immunodeficiency virus infection. Diarrhea has a significant impact on quality of life (QOL) and can contribute to malnutrition, weight loss, immunosuppression, and mortality. In addition, diarrhea may have a significant impact on compliance with antiretroviral therapy; however, this impact has not been adequately assessed. Medications, including protease inhibitors (PIs), are recognized as a common cause of diarrhea. Treatment of PI-associated diarrhea is largely nonspecific; most of the available literature is published only in abstract form and is based primarily on retrospective and survey data. Agents for which some efficacy has been shown for treatment of PI-associated diarrhea include oat bran, psyllium, loperamide, calcium carbonate, SP-303, and pancrelipase. Practitioners and patients need to work together to determine which treatment modality is appropriate based on efficacy, cost, and lifestyle. Management of diarrhea is crucial to improving QOL, controlling weight loss, and enhancing overall efficacy of antiretroviral therapy.     

Randomized trial of loperamide versus dose escalation of octreotide acetate for chemotherapy-induced diarrhea in bone marrow transplant and leukemia patients

This study compares maximal daily doses of loperamide to escalating doses of continuous intravenous (Cl) octreotide acetate in bone marrow transplant (BMT) and leukemia patients. A total of 36 patients were enrolled in the study. Of these, all were evaluable for intention to treat, and 31 were evaluable for initial response. Based on intent to treat at the initial 48 hr, patients receiving loperamide had a higher complete response rate (86% vs. 45%, P = 0.033) than did those who received octreotide. By treatment analysis (patients who actually received the drug), patients receiving loperamide had a higher complete response rate (92% vs. 56%, P = 0.0448) than did those who received octreotide at the 150 μg dosage level. Additional octreotide patients eventually achieved a CR at a higher dosage level (78%). Loperamide at maximal doses of 4 mg po q6h is more effective than octreotide 150 μg Cl in treating diarrhea following chemotherapy in BMT and leukemia patients. Higher doses of octreotide may be required in a significant number of patients not responding to lower doses. Following chemotherapy, BMT and leukemia patients who developed ≧600 ml of stool volume in a 24-hr period were randomized to receive loperamide 4 mg po q6h or octreotide 150 μg mixed in hyperalimentation solution or normal saline and administered Cl. Patients were assessed at 48 hr intervals for decrease in stool volume from baseline. Complete response (CR) was defined as ≧50% from baseline stool volume (BSV). Patients receiving octreotide who did not achieve a CR at 48 hr were dose escalated by doubling the dose to a maximum of 2,400 μg with evaluations at 48 hr intervals. Patients receiving loperamide who did not achieve a CR at 48 hr had treatment discontinued.     

Effect of somatostatin analog (SMS 201-995) onin vivo intestinal fluid transport in rats

Somatostatin analog, SMS 201-995, effectively inhibits the release of hormones from gastrointestinal endocrine tumors and reduces hormonally mediated diarrheas. Its clinical efficacy in nonhormonally mediated diarrhea is limited, despite a potent antisecretory and proabsorptive effect in vitro. The effect of serosal addition of SMS 201-995 on in vitro short-circuit current responses in rat intestine is dependent upon chloride and more marked in colon and ileum than jejunum. In contrast, in vivo loop studies demonstrated that systemic administration of SMS 201-995 for five consecutive days produced a paradoxical decrease in basal colonic fluid absorption with no effect in jejunum or ileum. Furthermore, systemically administered SMS 201-995 did not alter cholera toxin-stimulated intestinal secretion. We conclude that despite a previously identified intestinal antisecretory and proabsorptive effect of SMS 201-995 in vitro, this effect is not seen in vivo and may explain the limited use of SMS 201-995 as an antidiarrhoeal agent in nonhormonally mediated diarrhoea.     

Les colites microscopiques

Microscopic colitis is frequently found as a cause of chronic watery diarrhea in women after menopause. The disease can be associated with a medication side effect in half of the patients (non-steroidal anti-inflammatory drugs or proton pump inhibitors for instance). Colonic biopsies are mandatory for the diagnosis of microscopic colitis and should be performed in several locations of the colon. Management of microscopic colitis is first based on avoiding iatrogenic factors and smoking together with symptomatic treatment of diarrhea (loperamide, cholestyramine). In case of failure or severe symptoms, budesonide is the key treatment. The aim of the treatment is to achieve clinical remission, defined as less than 3 liquid stools per day, to improve quality of life. After a first course of budesonide, recurrence of diarrhea is frequent and a maintenance therapy can be prescribed for several months. In case of intolerance or refractoriness, second-line therapy (immunosuppressants, biological therapy, surgery) should be discussed in multidisciplinary team meeting.