Microscopic colitis (MC) has long been one of the most common yet under-recognised causes of chronic diarrhoea. Although many patients achieve symptom control with budesonide, a substantial subgroup develops refractory, dependent or intolerant disease, creating significant therapeutic challenges for both patients and clinicians. Despite these unmet needs, evidence to guide treatment beyond budesonide has remained remarkably limited.
A new multinational ECCO CONFER study now represents an important milestone for the field (Verstockt et al. CGH 2026). Bringing together data across many countries, the study reports outcomes from 229 advanced therapy treatment cycles in 142 patients with MC, making it the largest real-world analysis of its kind to date.
Moving beyond anecdotal experience
Historically, the use of biologics and small molecules in MC has been guided predominantly by case reports, small series and expert opinion. The lack of robust supporting evidence has made clinicians hesitant to adopt advanced therapies.
The current ECCO CONFER collaboration provides a much-needed overview of real-world practice across Europe and beyond. Anti-TNF agents and vedolizumab emerged as the most commonly used advanced therapies, reflecting current treatment patterns in patients who no longer respond adequately to budesonide or cannot tolerate it. Importantly, meaningful clinical benefit was observed across several therapeutic classes, supporting the growing role of advanced therapies in carefully selected patients with severe disease.
New insights into treatment effectiveness
One of the key strengths of this study is its ability to evaluate not only short-term outcomes, but also treatment durability over time. Across all treatment cycles, nearly two-thirds of patients achieved clinical response (50% reduction of stool frequency) and almost half achieved clinical remission (< 3 stools or < 1 watery stool/day/week) after induction therapy. While these findings are encouraging, the study also highlights the challenges of long-term disease control, with treatment discontinuation remaining common across many therapeutic classes because of primary non-response, loss of response or intolerance.
The analysis identified differences between treatment classes, including favourable outcomes observed with JAK inhibitors. However, these observations arose from a relatively limited number of treatment cycles and should therefore be interpreted as hypothesis generating rather than as definitive evidence. Nevertheless, the results provide an important rationale for future prospective studies evaluating newer therapeutic approaches in MC.
Perhaps the most important conclusion is that advanced therapies can offer meaningful clinical benefit in patients with otherwise difficult-to-manage disease, while simultaneously underscoring the need for more rigorous prospective evaluation.
A changing view of microscopic colitis
The study also reinforces the evolving perception of MC within the IBD Community. Although MC has traditionally been described as a disease of older adults, patients requiring advanced therapy in this cohort were often diagnosed and treated at a comparatively younger age than many clinicians might expect. Combined with the significant impact of chronic diarrhoea, urgency and faecal incontinence on quality of life, this finding highlights the substantial burden that MC can impose across different stages of life. Increasingly, advances in molecular biology, immunology and translational research are revealing important overlaps between MC and IBD, especially Ulcerative Colitis. These insights are fostering renewed interest in disease mechanisms, treatment targets and personalised therapeutic strategies.
An exciting moment for the ECCO Community
The publication arrives at a particularly important time. Earlier this year, ECCO formally established the Microscopic Colitis Working Group, reflecting a growing recognition that MC deserves greater visibility within research, education and clinical practice. One of the group's first major projects is the development of a dedicated ECCO Topical Review on MC. Expected to be presented at ECCO'27 in Copenhagen, this will be the first ECCO Topical Review devoted entirely to MC. The review will provide a comprehensive overview of epidemiology, pathophysiology, diagnostics and treatment, while highlighting the increasing convergence between MC and other IBD.
Looking ahead
Our message is clear: MC is entering a new era. For years, management of refractory disease was based largely on limited evidence and individual clinical experience. Today, international collaborations are beginning to generate the data needed to support evidence-based therapeutic decisions. While many questions remain unanswered and prospective trials are urgently needed, the field now has a far stronger foundation on which to build.
As the first ECCO Topical Review on MC approaches and collaborative research efforts continue to expand, there is growing momentum toward improving outcomes for patients living with this often underestimated condition. The future focus will not simply be on new treatments but on developing a deeper understanding of the disease itself, regulatory frameworks and translating that knowledge into better, more personalised patient care.
