Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

tropical sprue symptoms

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folic acid plus antibiotic therapy

Response to folic acid should be prompt and dramatic. Folic acid should be given for at least 3 months and up to 1 year depending on the patient's clinical response. There is ample evidence to support using large doses of folic acid as first-line treatment for all patients with TS.[31][32][33] This should be given when TS is suspected, even in patients without documented folate deficiency.[24]

Observational data has linked TS with bacterial infection of the small bowel. Antibiotics have proven effective and are now widely used as a first-line therapy.[36][37][38]​ The quality of evidence is limited by the era in which studies were performed. However, they are prescribed because of widespread availability and proven efficacy.

A tetracycline is the most commonly used antibiotic.

There are no studied antibiotic alternatives. Rifaximin would seem a reasonable choice, but there is no evidence to support it. Another alternative would be to refer tetracycline-allergic patients to an allergist to verify true allergy and perform desensitization.

Failure to respond to folic acid should elicit doubt about the diagnosis. Further specialist advice on appropriate antibiotics should be sought in cases unresponsive to folic acid.

Primary options

folic acid (vitamin B9): 5 mg orally once daily for at least 3 months

and

tetracycline: 250 mg orally four times daily for 3 months; or 500 mg orally twice daily for 3 months

Secondary options

folic acid (vitamin B9): 5 mg orally once daily for at least 3 months

and

doxycycline: 100 mg orally once daily for 3 months

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Plus – 

vitamin B12

Treatment recommended for ALL patients in selected patient group

Some would reserve this treatment for those with documented vitamin B12 deficiency. The benefits of treating with vitamin B12 are not clear, as in most patients folic acid alone is sufficient to improve symptoms and correct many laboratory abnormalities.

Some favor an approach that only treats patients who have proven vitamin B12 deficiency, whereas others treat empirically with subcutaneous vitamin B12.

Primary options

cyanocobalamin (vitamin B12): 1000 micrograms subcutaneously once weekly for 3 months

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Choose a patient group to see our recommendations

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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