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

1st line – folic acid plus antibiotic therapy

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ONGOING
|
tropical sprue symptoms
1st line – 

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]

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 desensitisation.

There is no available literature on tropical sprue in pregnant women and children. Folic acid should be given to all patients, but in the rare instance of a pregnant patient, increasing the dose of folic acid to 10 mg daily throughout the entire pregnancy would be a sensible approach. Further consultant advice on appropriate antibiotics should be sought in cases unresponsive to folic acid.

Primary options

folic acid: 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: 5 mg orally once daily for at least 3 months

and

doxycycline: 100 mg orally once daily for 3 months

Plus – vitamin B12

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ONGOING
|
tropical sprue symptoms
|
with pre-treatment symptom duration >4 months or low vitamin B12 levels regardless of symptom duration
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 favour an approach that only treats patients who have proven vitamin B12 deficiency, whereas others treat empirically with subcutaneous vitamin B12.

Primary options

cyanocobalamin: 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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