Faecal calprotectin in inflammatory bowel disease

Faecal calprotectin (FC) is a marker of inflammation in the gut and can help to differentiate between non-inflammatory conditions (eg, irritable bowel syndrome) and inflammatory diseases (eg, irritable bowel disease). FC can be used to assist with clinical decision making in IBD management.

Faecal calprotectin in inflammatory bowel disease

Date published : 13 August 2021

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  • FC is a surrogate marker of intestinal inflammation which can assist in the differentiation of noninflammatory conditions (eg, irritable bowel syndrome) from inflammatory diseases (eg, IBD) thereby guiding the selection of patients requiring further investigations.1
  • FC can be used to assist with clinical decision making in IBD management.2
  • FC levels < 100 micrograms/g correspond to mucosal healing/histological remission in ulcerative colitis (UC) and luminal Crohn Disease (CD).3
  • FC prior to therapeutic de-escalation is inversely related to risk of relapse; FC levels > 100 micrograms/g are associated with higher risk of relapse within 1 year.4
  • Elevated FC correlates with endoscopic inflammation in UC and CD, with FC levels > 250 micrograms/g differentiating active disease from remission (sensitivity 80%, specificity 82%).5
  • In CD affecting the small bowel without affecting the colon, accuracy of FC may be lower; patients with isolated small bowel CD may have normal FC despite active disease.6
  • FC levels may begin to rise 3 months before symptoms of relapse become apparent.7

Use of FC in clinical decision making for patients with diagnosed IBD

Symptomatic patient
Asymptomatic patient
Exclude gastrointestinal
infection
Faecal calprotectin test
Faecal calprotectin test as
part of regular monitoring
6 monthly
< 100 μg/g
100–250 μg/g
> 250 μg/g
< 100 μg/g
100–250 μg/g
> 250 μg/g
Consider non-inflammatory cause for symptoms.
Intermediate result – see below.
Indicative of active
disease.
Consider escalation
of IBD treatment.
Indicative of
mucosal healing/
remission.
Continue current
therapy.
Wean/cease
corticosteroids if patient is still taking
these.
Consider
de-escalation of therapy if indicated
based on the clinical scenario.
Intermediate result – see below.
Indicative of intestinal inflammation.
Exclude gastrointestinal infection.
Consider further evaluation of disease activity eg, imaging, endoscopy.
Consider escalation of IBD treatment.

Intermediate result

  • Needs to be interpreted in the clinical context.
  • Check adherence to therapy.
  • Consider the change from baseline and past levels and trends of FC in the individual patient.
  • Consider other factors which can increase FC results (eg, infection, diverticulitis, medications (non-steroidal anti-inflammatory drugs, proton pump inhibitors), excessive alcohol intake).
  • A FC cut off of 250 micrograms/g, in conjunction with other indicators of disease activity, has been used to guide dose escalation and de-escalation in a treat to target approach.8
  • Consider repeating FC test in 2–3 weeks to assess trend1(NB: Only one FC/year Medicare rebatable – see item descriptor).
  • Correlate FC with more specific investigations eg, imaging, endoscopy.
 

Team communication

General practitioners are often the first point of contact for patients with IBD. Clear communication between gastroenterologists and other team members regarding the use and interpretation of FC testing can facilitate timely and appropriate access to testing as part of the treatment plan.

From 1st November 2021, a Medicare rebate will be available for FC testing if specific criteria are met.

Patients aged ≤ 50 years with gastrointestinal symptoms suggestive of inflammatory or functional bowel disease of more than 6 weeks’ duration who are presenting to a Medical Practitioner; where infectious causes have been excluded and the likelihood of malignancy has been assessed as low, and where no clinical alarms are present. A maximum of 1 test may be performed in any 12-month period.

Patients aged ≤ 50 years with gastrointestinal symptoms suggestive of inflammatory or functional bowel disease and where no clinical alarms are present, presenting to a Specialist Gastroenterologist, in whom an initial faecal calprotectin test was inconclusive (50–100 micrograms/g), and where the Specialist feels an endoscopic examination is not initially warranted. A maximum of 1 test may be performed in any 12-month period.

Check the MBS Online for details.

 

References

  1. Gastroenterological Society of Australia. Clinical update for general practitioners and physicians: Inflammatory bowel disease. Melbourne: GESA, 2018 (accessed 9 February 2021).
  2. Lamb CA, et al. Gut 2019;68:s1-s106.
  3. Guardiola J, et al. Gastroenterología y Hepatología (English Edition) 2018;41:514–29.
  4. Buisson A, et al. Journal of Crohn’s and Colitis 2019;13:1012–24.
  5. Lin J-F, et al. Inflammatory Bowel Diseases 2014;20:1407–15.
  6. Gecse KB, et al. Scand J Gastroenterol 2015;50:841–7.
  7. Maaser C, et al. J Crohns Colitis 2019;13:144–64.
  8. Colombel J-F, et al. The Lancet 2017;390:2779–89.
 

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Faecal calprotectin in inflammatory bowel disease

Date published : 13 August 2021

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