Table 1.

Summary of consensus recommendations for the management of BAD

Diagnosis of BAD
Statement 1. In patients with chronic nonbloody diarrhea, we recommend using risk factors (history of terminal ileal resection, cholecystectomy, or radiotherapy) as the initial assessment to identify patients with possible BAD.
GRADE. Strong recommendation, very low-certainty evidence. Vote on PICO question: strongly yes, 60%; yes, 40%.
Statement 2. In patients with chronic nonbloody diarrhea, we suggest against using symptom presentation as the initial assessment to identify patients with possible BAD.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: no, 100%.
Statement 3. In patients with chronic diarrhea including IBS-D and functional diarrhea, we suggest SeHCAT testing to identify patients with BAD.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: strongly yes, 20%; yes, 80%.
Statement 4. In patients with small intestinal Crohn’s disease without objective evidence of inflammation who have persistent diarrhea, we suggest SeHCAT testing.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: strongly yes, 20%; yes, 80%.
Statement 5. In patients with chronic diarrhea including IBS-D and functional diarrhea, we suggest using a C4 assay to identify possible BAD.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: strongly yes, 20%; yes, 60%; neutral, 20%.
Statement 6. In patients with suspected BAD, we suggest against initiating empiric BAST over performing SeHCAT to establish a diagnosis of BAD.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: yes, 20%; no, 40%; strongly no, 40%.
Induction therapy for BAD (BAST)
Statement 7. In patients with type 1 or type 3 BAD, we suggest the use of treatments for remediable causes (e.g., Crohn’s disease, microscopic colitis, SIBO) in addition to treatment for BAD for induction of clinical response.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: strongly yes, 80%; yes, 20%.
Statement 8. In patients with BAD, we suggest using cholestyramine over no treatment for induction of clinical response.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: strongly yes, 60%; yes, 40%.
Statement 9. In patients with BAD, we suggest using cholestyramine over other BASTs as initial therapy for induction of clinical response.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: yes, 80%; neutral, 20%.
Statement 10. In patients with BAD who are unable to tolerate cholestyramine, we suggest using an alternate BAST for induction of clinical response.
GRADE. Conditional recommendation, low-certainty evidence. Vote on PICO question: strongly yes, 40%; yes, 60%.
Statement 11. In patients with BAD receiving empiric BAST, gradual daily dose titration should be used to minimize side effects. Designated a good practice statement
Statement 12. In patients with Crohn’s disease with extensive ileal involvement or resection, we suggest against using BAST.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question (should we use BAST?): yes, 20%; no, 80%.
Maintenance therapy for BAD (BAST)
Statement 13. In patients with BAD who respond to BAST, we suggest that intermittent, on-demand dosing be tried.
GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: yes, 80%; neutral, 20%.
Statement 14. In patients with BAD who are unable to tolerate BAST, we suggest using alternative antidiarrheal agents versus no treatment for long-term symptomatic therapy.GRADE. Conditional recommendation, very-low-certainty evidence. Vote on PICO question: yes, 100%.
Statement 15. In patients with BAD receiving empiric BAST, maintenance therapy should be used at the lowest dose needed to minimize symptoms. Designated a good practice statement
Maintenance therapy for BAD (BAST)
Statement 16. In patients with BAD and recurrent or worsening symptoms despite stable BAST, diagnostic re-evaluation should be conducted. Designated a good practice statement
Statement 17. In patients being considered for BAST, a review of concurrent medications should be conducted to minimize the potential for drug interactions. Designated a good practice statement
Statements with no recommendations
No recommendation A. In patients with chronic diarrhea including IBS-D and functional diarrhea, the consensus group could not make a recommendation for or against the use of FGF19 assay to identify possible BAD.
GRADE. NO recommendation, very-low-certainty evidence. Vote on PICO question: strongly yes, 20%; neutral, 80%.
No recommendation B. In patients receiving long-term maintenance therapy with BAST, the consensus group could not make a recommendation for or against measuring fat-soluble vitamin levels at baseline and annually thereafter.
GRADE. NO recommendation; very-low-certainty evidence. Vote on PICO question: yes, 20%; neutral, 80%.

The strength of each recommendation was assigned by the consensus group, per the GRADE system, as strong (“we recommend...”) or conditional (“we suggest...”). A recommendation could be classified as strong despite low-certainty evidence to support it, or conditional despite the existence of high-certainty evidence due to the 4 components considered in each recommendation (risk:benefit balance, patients’ values and preferences, cost and resource allocation and certainty of evidence).

BAD, bile acid diarrhea; BAST, bile acid sequestrant therapy; C4, 7α-hydroxy-4-cholesten-3-one; FGF19, fibroblast growth factor 19; GRADE, Grading of Recommendation Assessment, Development and Evaluation; IBS-D, diarrhea-predominant irritable bowel syndrome; PICO, patient population, intervention, comparator, and outcome; SeHCAT, ⁷⁵selenium homocholic acid taurine; SIBO, small intestinal bacterial overgrowth.