Bile Acid Diarrhea Treatment Clinical Practice Guidelines (2020)

Canadian Association of Gastroenterology (CAG)

This is a quick summary of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

February 03, 2020

The Canadian Association of Gastroenterology (CAG) has issued guidelines on the diagnosis and treatment of bile acid diarrhea (BAD).[1]

Diagnosis of Bile Acid Diarrhea

In patients with chronic nonbloody diarrhea, the initial assessment for suspected bile acid diarrhea (BAD) should be based on risk factors (history of cholecystectomy, terminal ileal resection, radiotherapy) rather than symptoms.

In patients with chronic diarrhea, including diarrhea-predominant irritable bowel syndrome (IBS-D) and functional diarrhea, 75selenium homocholic acid taurine (SeHCAT) testing or 7α-hydroxy-4-cholesten-3-one (C4) assay is recommended to evaluate for BAD. SeHCAT testing is also recommended in patients with persistent diarrhea who have Crohn disease of the small intestine without objective evidence of inflammation. The guidelines do not take a position for or against the use of fibroblast growth factor 19 (FGF19) assay for BAD diagnosis.

In patients with suspected BAD, SeHCAT testing is preferred over initiation of empiric bile acid sequestrant therapy (BAST) to establish diagnosis.

Induction Therapy for Bile Acid Diarrhea

In patients with type 1 or type 3 BAD, any remediable causes (eg, Crohn disease, microscopic colitis, small intestinal bacterial overgrowth [SIBO]) should be treated along with BAD to induce a clinical response.

In patients with BAD, cholestyramine treatment is preferred over no treatment to induce a clinical response. Cholestyramine is preferred over other BASTs as initial therapy except in patients who cannot tolerate cholestyramine.

In patients who are receiving empiric BAST, the daily dose should be gradually titrated to minimize adverse effects.

BAST is discouraged in patients with Crohn disease with extensive ileal involvement or resection.

Patients with BAD who have recurrent or worsening symptoms despite stable BAST therapy should be re-evaluated diagnostically.

Concurrent medications should be reviewed in patients being considered for BAST therapy to minimize the possibility of drug interactions.

Maintenance Treatment for Bile Acid Diarrhea

In patients with BAD in whom BAST elicits a response, a trial of intermittent on-demand dosing is recommended.

Patients who are unable to tolerate BAST should receive alternative antidiarrheal agents instead of no treatment to alleviate long-term symptoms.

Empiric BAST being given as maintenance therapy should be administered at the lowest dose necessary to minimize symptoms. The guidelines do not take a position on whether to recommend for or against measuring fat-soluble vitamin levels at baseline and annually thereafter.

For more information, please go to Diarrhea.

For more Clinical Practice Guidelines, please go to Guidelines.


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