From the Guidelines
The best treatment for diarrhea due to bile acid malabsorption is bile acid sequestrants, with cholestyramine (Questran) being the first-line option, as recommended by the most recent and highest quality study 1.
Treatment Approach
- Typical dosing of cholestyramine starts at 4 grams once or twice daily, which can be titrated up to 4 grams four times daily as needed for symptom control.
- Alternative bile acid sequestrants include colestipol (Colestid) and colesevelam (Welchol), which may be better tolerated by some patients, as noted in 1 and 1.
- These medications work by binding excess bile acids in the intestine, preventing them from stimulating fluid secretion in the colon that leads to diarrhea.
Key Considerations
- Treatment is typically long-term as bile acid malabsorption is often a chronic condition.
- Patients should take these medications before meals for maximum effectiveness.
- Common side effects include constipation, bloating, and nausea.
- It's essential to take other medications at least 4 hours apart from bile acid sequestrants, as they can interfere with absorption, as mentioned in 1 and 1.
- Dietary modifications like reducing fat intake may also help manage symptoms as a complementary approach, since dietary fat stimulates bile acid release.
Diagnostic Testing
- The 75Se-HCAT scan is a useful diagnostic tool for identifying bile acid malabsorption, with a sensitivity of 89% and specificity of 100%, as reported in 1.
- However, this test may not be widely available, and alternative diagnostic approaches, such as measuring serum metabolites or quantifying excreted bile acids, may be considered, as discussed in 1.
From the Research
Treatment Options for Diarrhea due to Bile Acid Malabsorption
- The most commonly used treatment for bile acid malabsorption is bile acid sequestrants, such as colestyramine, colestipol, and colesevelam 2, 3, 4, 5.
- Colestyramine treatment was successful in 70% of 801 patients (range: 63-100%) 2.
- Alternative therapies, including aluminium hydroxide and obeticholic acid, may also have a role in treating bile acid malabsorption 2, 4.
- Dietary intervention, such as a low-fat diet supplemented with medium-chain triglycerides, may be beneficial for patients with severe bile acid malabsorption 3.
Diagnostic Testing
- The SeHCAT test is the most commonly used diagnostic test for bile acid malabsorption, but it is not available in many countries 2, 4, 6.
- Measuring fecal bile acids or serum 7α-hydroxy-4-cholesten-3-one may be alternative means of diagnosis 3, 5, 6.
- Bile acid testing can help predict response to treatment with bile acid sequestrants, but no predictors of response were identified in one study 5.
Clinical Outcomes
- Nearly two-thirds of patients with microscopic colitis had a partial or complete response to treatment with bile acid sequestrants 5.
- The dose of bile acid sequestrants was not associated with response, and there were no differences in outcomes between those on bile acid sequestrants alone or combined with other medications 5.
- Recurrence of diarrhea after discontinuation of bile acid sequestrants was common, occurring in 41.6% of patients at a median of 21 weeks 5.