The use of faecal microbiota transplantation (FMT) for ulcerative colitis remains promising but is certainly not yet ready for prime time, according to an expert consensus.
The first international consensus on FMT in the setting of IBD, published in Gut [link here], said there was even less evidence for FMT as a treatment for Crohn’s disease or pouchitis.
The expert panel, including Dr Sam Costello from the Queen Elizabeth Hospital in Adelaide and Dr Sudarshan Paramsothy from Concord Repatriation General Hospital in Sydney, found at least 80% agreement on 33 statements after up to three rounds of voting.
On the evidence from FMT trials in IBD, the consensus included agreement that FMT is effective for the treatment of recurrent C. difficile infection in patients with and without IBD.
On the routine use of FMT for inducing remission in ulcerative colitis, it found the evidence was “promising” but undermined by relatively small sample sizes in trials and variations in study design.
“For this reason, there are insufficient available data to support the routine clinical use of FMT to induce remission in patients with UC,” it said.
“However, the experts agreed that FMT might be used under specific circumstantial conditions, which should be considered on a case-by-case basis and discussed in detail with all parties concerned.”
The consensus was that patients with UC who achieve remission following FMT generally do not have sustained remission beyond 1 year and that repeated infusions were probably important.
They noted that serious adverse events from FMT were uncommon but included aspiration and suspected small bowel perforation when performed by upper GI administration.
Disease worsening requiring hospitalisation and, in limited cases, colectomy, has also been reported.
In recommendations for ongoing research, the experts agreed future studies should take strictly defined patient phenotypes into account when considering outcomes of FMT in IBD.
“These studies have the potential to identify specific phenotypes that are associated with a positive response, or lack of response, after FMT administration.”
They also highlighted the need to identify biomarkers that could predict response to FMT, the optimal formulation and administration of FMT, and whether FMT had a role as a stand-alone treatment for IBD or in combination with currently available treatment modalities.
The consensus also provided statements on donor selection and biobanking.
These included a statement that patients should not have direct access to stool banks for the treatment of IBD.
“Provision of FMT samples should always be under the guidance of a treating healthcare provider, in agreement with national and international guidelines and regulations,” it said.
The experts also agreed that stool donation should be voluntary while compensation for time and travel expenses was acceptable.
“Additionally, donors should be aware of the risks and benefits of donating, as the screening process might lead to discovery of diagnoses of previously unknown diseases (eg, HIV, colorectal cancer) or predisposition to other diseases (eg, those associated with microbiota alterations).”