From the Guidelines
The treatment approach for patients with elevated stool calprotectin levels indicative of intestinal inflammation should prioritize identifying and addressing the underlying cause, with a focus on monitoring and adjusting treatment based on biomarker levels, as suggested by the AGA clinical practice guideline 1.
Key Considerations
- For patients with ulcerative colitis (UC) in symptomatic remission, the American Gastroenterological Association (AGA) suggests a monitoring strategy that combines biomarkers, such as fecal calprotectin, and symptoms, rather than symptoms alone 1.
- Fecal calprotectin <150 mg/g may be used to rule out active inflammation and avoid routine endoscopic assessment of disease activity in patients with UC in symptomatic remission 1.
- In patients with UC in symptomatic remission but elevated stool or serum markers of inflammation, the AGA suggests endoscopic assessment of disease activity rather than empiric treatment adjustment 1.
Diagnostic Evaluation
- Diagnostic evaluation should include colonoscopy with biopsies to determine if inflammatory bowel disease (IBD), such as Crohn's disease or ulcerative colitis, is present.
- Fecal calprotectin is a useful surrogate marker of inflammatory activity in IBD, correlating well with endoscopic inflammation in UC and Crohn’s disease 1.
Treatment Approach
- For confirmed IBD, first-line treatments typically include 5-aminosalicylates (5-ASA) like mesalamine at doses of 2.4-4.8g daily for mild to moderate disease.
- Corticosteroids such as prednisone (40mg daily with taper over 8-12 weeks) may be used for acute flares.
- For maintenance therapy or steroid-dependent disease, immunomodulators like azathioprine (2-3mg/kg/day) or methotrexate (15-25mg weekly) are often employed.
- Biologic agents including anti-TNF medications (infliximab, adalimumab), anti-integrins (vedolizumab), or IL-12/23 inhibitors (ustekinumab) are reserved for moderate to severe disease or when other treatments fail.
Monitoring and Adjusting Treatment
- Regular monitoring of calprotectin levels helps assess treatment response, with levels below 50-100 μg/g generally indicating remission.
- The AGA suggests using fecal calprotectin >150 mg/g, elevated fecal lactoferrin, or elevated CRP to rule in active inflammation and inform treatment adjustment in patients with symptomatically active UC 1.
- In patients with UC who underwent recent adjustment of treatment in response to moderate to severe symptomatic flare, and now have mild residual symptoms, elevated stool or serum markers of inflammation may be used to inform treatment adjustments 1.
From the Research
Treatment Approach for Elevated Stool Calprotectin Levels
Elevated stool calprotectin levels are indicative of intestinal inflammation, which can be associated with various conditions, including inflammatory bowel disease (IBD) and colon cancer 2, 3. The treatment approach for patients with elevated stool calprotectin levels depends on the underlying cause of the inflammation.
Diagnostic Evaluation
A diagnostic evaluation is necessary to determine the cause of elevated stool calprotectin levels. This may include:
- Colonoscopy to rule out IBD or other organic pathologies 2
- Stool studies to rule out infectious causes
- Imaging studies, such as CT scans, to evaluate the extent of inflammation
- Endoscopy to assess the severity of inflammation and rule out other conditions, such as colon cancer 3
Management of Intestinal Inflammation
The management of intestinal inflammation depends on the underlying cause. For patients with IBD, treatment may include:
- Aminosalicylates, such as mesalamine, to reduce inflammation
- Corticosteroids, such as prednisone, to induce remission
- Immunomodulators, such as azathioprine, to maintain remission
- Biologics, such as infliximab, to induce and maintain remission 4
Monitoring and Follow-up
Regular monitoring and follow-up are necessary to assess the response to treatment and adjust the treatment plan as needed. This may include:
- Repeat stool calprotectin tests to assess the level of inflammation
- Endoscopy to assess the severity of inflammation and rule out other conditions
- Clinical evaluation to assess symptoms and adjust the treatment plan accordingly 5, 6
Key Considerations
When interpreting stool calprotectin results, it is essential to consider the following:
- Elevated stool calprotectin levels are not specific for IBD and can be associated with other conditions, such as colon cancer 3
- The sensitivity and specificity of stool calprotectin tests can vary depending on the population being tested and the cut-off values used 6
- Stool calprotectin tests should be used in conjunction with other diagnostic tests and clinical evaluation to determine the underlying cause of intestinal inflammation 2, 4