What to do for a 33-year-old female with bile acid malabsorption, experiencing diarrhea and bloating after developing constipation while on colesevelam (bile acid sequestrant)?

From the Guidelines

For a 33-year-old female with bile acid malabsorption, experiencing diarrhea and bloating after developing constipation while on colesevelam, I strongly recommend switching to cholestyramine as initial therapy, as suggested by the Canadian Association of Gastroenterology clinical practice guideline on the management of bile acid diarrhea 1. This approach is based on the guideline's suggestion to use cholestyramine as the initial therapy for bile acid diarrhea, with alternate bile acid sequestrant therapy (BAST) when tolerability is an issue.

• The patient's symptoms of diarrhea and bloating after developing constipation while on colesevelam indicate that the current treatment is not effective and may be causing adverse effects.
• Cholestyramine is a suitable alternative, as it may have a different side effect profile compared to colesevelam, and its use is supported by the guideline as the initial therapy for bile acid diarrhea 1.
• The guideline also suggests testing for bile acid diarrhea using 75 selenium homocholic acid taurine or 7a-hydroxy-4-cholesten-3-one, but in this case, the patient's symptoms and history of bile acid malabsorption suggest that switching to cholestyramine may be a more practical and effective approach.
• Additionally, dietary modifications, such as reducing fat intake and following a low-FODMAP diet, may also be beneficial in managing the patient's symptoms, as they can help reduce the bile acid load and minimize fermentable carbohydrates that contribute to bloating.
• It is essential to monitor the patient's response to the new treatment and adjust the dose or add other therapies as needed to achieve optimal control of symptoms and improve quality of life.

From the FDA Drug Label

5.2 Gastrointestinal Obstruction Postmarketing cases of bowel obstruction have occurred with colesevelam hydrochloride [see Adverse Reactions (6. 2)]. Because of its constipating effects, colesevelam hydrochloride is not recommended in patients with gastroparesis, other gastrointestinal motility disorders, and in those who have had major gastrointestinal tract surgery and who may be at risk for bowel obstruction. Colesevelam hydrochloride is contraindicated in patients with a history of bowel obstruction [see Contraindications (4)] Instruct patients to promptly discontinue colesevelam hydrochloride and seek medical attention if severe abdominal pain or severe constipation occurs.

The patient is experiencing diarrhea and bloating after developing constipation while on colesevelam.

• The drug label warns about gastrointestinal obstruction and constipating effects of colesevelam hydrochloride.
• It is recommended to discontinue colesevelam hydrochloride if severe abdominal pain or severe constipation occurs.
• However, the label does not provide specific guidance for managing diarrhea and bloating in this context.
• Considering the patient's symptoms and the potential risks associated with colesevelam hydrochloride, it is prudent to consult a healthcare professional for further guidance on managing the patient's condition 2.

From the Research

Bile Acid Malabsorption Treatment

The patient in question is experiencing diarrhea and bloating after developing constipation while on colesevelam, a bile acid sequestrant.

• The study 3 suggests that colesevelam is effective in treating bile acid diarrhea, with 64% of participants achieving remission.
• However, common adverse events associated with colesevelam include abdominal pain, bloating, and nausea, which the patient is currently experiencing.
• An alternative treatment option could be obeticholic acid, as shown in the case report 4, which reduced the number of stools and improved the patient's quality of life.

Management of Bile Acid Diarrhea

• A survey of UK expert opinion and practice 5 recommends the use of bile acid sequestrants, such as colestyramine or colesevelam, as the primary treatment for bile acid diarrhea.
• The systematic review 6 suggests that colestyramine is effective in 70% of patients, but may be poorly tolerated and reduce the bioavailability of co-administered agents.
• Increasing the dose, changing to an alternative sequestrant, use of loperamide, and a low-fat diet may be suggested for patients with an incomplete response to treatment.

Diagnostic Testing

• The SeHCAT test is the preferred diagnostic test for bile acid malabsorption, as recommended by the survey of UK expert opinion and practice 5.
• The study 3 used plasma 7α-hydroxy-4-cholesten-3-one (C4) as an alternative to the SeHCAT test, which may be useful in diagnosing bile acid diarrhea.