These actionable recommendations for the medical management of microscopic colitis were developed under the framework of the GRADE methodology and were consistent with the Institute of Medicine's Standards for Developing Trustworthy Clinical Practice Guidelines. This guideline is intended to reduce practice variation and promote high-value care. The weight of evidence supports the first-line use of budesonide for induction and, when appropriate, maintenance therapy. Because the technical review and guideline focused on treatments assessed in clinical trials, it did not address the full armamentarium of therapies currently used in practice. We would endorse clinical trials that more rigorously assess the effectiveness of lower-cost alternatives such as antidiarrheal agents (eg, loperamide) and cholestyramine monotherapy with accompanying cost-effective analyses. The role of combination therapies has yet to fully explored. Due to the absence of clinical trial data, this guideline did not address medical treatment of corticosteroid-refractory microscopic colitis. Very limited evidence from case series, however, suggests that immunosuppressants such as azathioprine and anti-tumor necrosis factor agents may benefit these patients. We encourage prospective clinical trials to further investigate these early findings.
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