What is the treatment for a patient with elevated fecal calprotectin?

Treatment Approach for Elevated Fecal Calprotectin (195 μg/g)

For a patient with elevated fecal calprotectin of 195 μg/g, treatment should be guided by symptom severity, with endoscopic assessment recommended for mild symptoms and empiric treatment adjustment for moderate to severe symptoms.

Assessment Based on Symptom Severity

For Patients with Moderate to Severe Symptoms

• Fecal calprotectin >150 μg/g with moderate to severe symptoms suggests active intestinal inflammation that warrants treatment adjustment without requiring immediate endoscopic assessment 1
• The American Gastroenterological Association (AGA) suggests using fecal calprotectin >150 μg/g to rule in active inflammation and inform treatment adjustment in patients with moderate to severe symptoms 2
• Treatment should be initiated or adjusted based on the specific inflammatory bowel disease (IBD) type (Crohn's disease or ulcerative colitis) 1

For Patients with Mild Symptoms

• For patients with mild symptoms and fecal calprotectin >150 μg/g, endoscopic assessment is recommended before empiric treatment adjustment 2
• The AGA suggests that in patients with UC with mild symptoms and elevated biomarkers, endoscopic assessment should be performed rather than empiric treatment adjustment 2
• Implementation consideration: In patients who underwent recent treatment adjustment in response to moderate to severe symptoms and now have mild residual symptoms, elevated biomarkers may be used to inform treatment adjustments 2

Treatment Options for IBD with Elevated Calprotectin

For Ulcerative Colitis

• For moderate to severely active ulcerative colitis, biologic therapy such as infliximab may be indicated at a dose of 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks followed by maintenance every 8 weeks 3
• Patients who do not respond by Week 14 are unlikely to respond with continued dosing and consideration should be given to discontinue treatment 3

For Crohn's Disease

• Similar to UC, moderate to severely active Crohn's disease with elevated calprotectin may require biologic therapy 3
• The recommended dose for infliximab in Crohn's disease is 5 mg/kg given as an intravenous induction regimen at 0,2, and 6 weeks followed by maintenance every 8 weeks 3

Monitoring Response to Treatment

• Repeat fecal calprotectin measurement is recommended 2-4 months after initiating or adjusting therapy to monitor response 1
• Among patients with elevated fecal calprotectin levels and known IBD, 66% went on to have escalation of therapy within 12 months compared to only 18% if the fecal calprotectin levels were normal 4
• Consider endoscopic assessment 6-12 months after treatment initiation to confirm mucosal healing 1

Special Considerations

• Fecal calprotectin may be elevated due to non-intestinal sources of infection or inflammation; stool testing for Clostridioides difficile and other enteric pathogens is important to help rule out other causes 2
• For patients in symptomatic remission with elevated calprotectin (>150 μg/g), repeat measurement in 3-6 months may be a reasonable alternative to immediate endoscopic assessment 2
• If biomarkers remain elevated on repeat evaluation, then endoscopic assessment is warranted 2
• The sensitivity of fecal calprotectin at a cutoff of 150 μg/g for detecting moderate to severe endoscopic inflammation is approximately 81% with a specificity of 72% 2

Pitfalls and Caveats

• A normal fecal calprotectin alone does not completely exclude IBD; combining with other markers like albumin or platelet count may improve diagnostic accuracy 5
• Various factors may affect calprotectin results including age, medication use, and day-to-day variation 6, 7
• Different commercial calprotectin assays have marked differences in performance, and at present no standardized reference material exists 6
• Biomarkers of inflammation have no role in dysplasia detection and surveillance 2