June 06, 2026
Researchers in Mayo Clinic's Inflammatory Bowel Disease Clinic have found that bile acid sequestrant (BAS) therapies can significantly prolong the time to pouchitis recurrence. As described in Digestive Diseases and Science, the researchers also found that BAS therapies are not inferior to antibiotics for initial treatment response.
Up to half of patients experience at least one episode of pouchitis within two years of having proctocolectomy with ileal pouch-anal anastomosis (IPAA) for ulcerative colitis. Antibiotics have been the mainstay of treatment.
Recent research has identified bile acids as playing a possible role in the pathogenesis of chronic pouchitis — possibly by disrupting microbial balance and causing increased mucosal permeability and inflammation within the pouch. BAS therapies have emerged as a potential alternative or adjunctive treatment. But there is a paucity of evidence regarding their effectiveness compared with standard antibiotic therapy.
Mayo Clinic researchers conducted a real-world retrospective cohort study using a large federal research network. The analysis included 1,136 patients with acute pouchitis after having IPAA for ulcerative colitis. The patients were divided into three treatment groups: BAS, antibiotics, and combined BAS and antibiotic therapy. The study's primary outcomes were failure of initial therapy and the development of recurrent pouchitis within 12 months of an initial episode.
Key findings:
- There was no significant difference in the odds of early relapse or nonresponse with BAS compared with antibiotic monotherapy or combination therapy.
- Patients treated with BAS had a statistically significant lower rate of pouchitis recurrence compared with patients treated with antibiotics.
- The median time to recurrent pouchitis was 225 days for patients treated with BAS therapies compared with 99 days for patients treated with antibiotics.
- Combination therapy showed no significant advantage to the effects of BAS alone in the time for recurrence.
"These results offer a promising avenue for improving long-term outcomes and quality of life for people with ulcerative colitis," says Jana G. Al Hashash, M.D., M.S., a gastroenterologist in the Inflammatory Bowel Disease Clinic at Mayo Clinic in Jacksonville, Florida. "The reduction in recurrent pouchitis and delayed time to recurrence with BAS in our study likely stem from BAS therapies' unique mechanism of action."
Unlike antibiotics, which target bacteria, BAS therapies bind and sequester excess bile acids within the intestinal lumen. That helps balance the microbial environment, contributing to sustained mucosal healing, enhanced barrier function and a decreased risk of recurrent inflammation.
Another potential advantage involves the duration of therapy. Antibiotics typically are given for a limited time. But BAS therapies can be administered as long-term maintenance. That can lead to continuous modulation of bile acid levels and ongoing protection, and to maintaining remission and reducing the frequency of pouchitis recurrence.
"Our hypothesis is that by addressing the underlying dysbiosis and increasing a balanced microbial environment, BAS therapies might create an intestinal environment that is less susceptible to future inflammatory triggers," Dr. Al Hashash says.
She notes that decisions about incorporating BAS or combination therapies into pouchitis care might depend on patients' specific characteristics and diagnostic methodologies. "Using BAS might be particularly advantageous for patients with antibiotic resistance or intolerance," Dr. Al Hashash says.
For more information
Inflammatory Bowel Disease Clinic. Mayo Clinic.
Alsakarneh S, et al. Comparative effectiveness of bile acid sequestrants and antibiotics in the management of acute pouchitis: A matched cohort study from the United States. Digestive Diseases and Sciences. 2025;70:2760.
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