FMT improves IBD remission, meta-analysis suggests
Researchers evaluated 7 trials involving 542 patients with UC or CD.
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01/23/2026
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by Doug Brunk
Fecal microbiota transplantation (FMT) may help more patients with inflammatory bowel disease (IBD) achieve remission and mucosal healing than standard care alone, according to a new meta-analysis of randomized trials presented during the 2026 Crohn’s & Colitis Congress®, a partnership of AGA and the Crohn's & Colitis Foundation, taking place in Las Vegas.
“While FMT has established utility in Clostridioides difficile infection, its role in IBD has remained ambiguous due to inconsistent outcomes across smaller trials,” presenting author Prince Shah-Riar, MD, an internal medicine resident at DHR Health in Edinburg, Texas, told GI & Hepatology News. “Our study helps bridge that evidence gap by identifying significant benefit in both clinical and endoscopic outcomes, suggesting FMT may be a valuable adjunct to standard therapies.”
The researchers conducted a systematic review and meta-analysis of randomized controlled trials published between 2020 and 2025. The analysis included seven high-quality trials involving 542 adults with UC or CD who received FMT or a control treatment, such as placebo or standard therapy. The main outcomes were clinical remission and mucosal healing.
Overall, patients who received FMT were significantly more likely to enter clinical remission than patients who did not. The pooled analysis showed a 74% higher likelihood of remission with FMT (RR 1.74; P<0.001). Benefits were also seen on endoscopy: 38.2% of patients treated with FMT achieved mucosal healing, compared with 24.6% of controls (HR 1.53; P=0.01).
Rates of serious adverse events were similar between FMT and control groups, suggesting that FMT did not increase the risk of major complications in these trials.
“What stood out was the magnitude of benefit for mucosal healing, which is a harder endpoint to achieve and often correlates with long-term remission,” Dr. Shah-Riar said. “We also noted that multi-donor FMT protocols yielded more consistent outcomes, and that patients with lower baseline microbial diversity appeared to respond more robustly. These findings were more nuanced than expected and highlight areas for future precision-medicine approaches.”
According to Dr. Shah-Riar, if the study’s overall findings are validated in larger trials, FMT could become a more widely accepted adjunctive treatment, particularly in UC, as a bridge therapy or in refractory cases. “It could also stimulate refinement in how we select donors, standardize FMT preparations, and stratify patients based on microbiome profiles or other biomarkers,” he said. “Ultimately, it may shift the paradigm from purely immunologic interventions to microbiota-modulating strategies.”
The researchers reported having no disclosures.
Summary content
7 Key Takeaways
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The guidelines emphasize four-hour gastric emptying studies over two-hour testing. How do you see this affecting diagnostic workflows in practice?
Dr. Staller: Moving to a four-hour solid-meal scintigraphy will actually simplify decision-making. The two-hour reads miss a meaningful proportion of delayed emptying; standardizing on four hours reduces false negatives and the “maybe gastroparesis” purgatory that leads to repeat testing. Practically, it means closer coordination with nuclear medicine (longer slots, consistent standardized meal), updating order sets to default to a four-hour protocol, and educating front-line teams so patients arrive appropriately prepped. The payoff is fewer equivocal studies and more confident treatment plans.
Metoclopramide and erythromycin are the only agents conditionally recommended for initial therapy. How does this align with what is being currently prescribed?
Dr. Staller: This largely mirrors real-world practice. Metoclopramide remains the only FDA-approved prokinetic for gastroparesis, and short “pulsed” erythromycin courses are familiar to many of us—recognizing tachyphylaxis limits durability. Our recommendation is “conditional” because the underlying evidence is modest and patient responses are heterogeneous, but it formalizes what many clinicians already do: start with metoclopramide (lowest effective dose, limited duration, counsel on neurologic adverse effects) and reserve erythromycin for targeted use (exacerbations, bridging).
Several agents, including domperidone and prucalopride, received recommendations against first-line use. How will that influence discussions with patients who ask about these therapies?
Dr. Staller: Two points I share with patients: evidence and access/safety. For domperidone, the data quality is mixed, and US access is through an FDA IND mechanism; you’re committing patients to EKG monitoring and a non-trivial administrative lift. For prucalopride, the gastroparesis-specific evidence isn’t strong enough yet to justify first-line use. So, our stance is not “never,” it’s just “not first.” If someone fails or cannot tolerate initial therapy, we can revisit these options through shared decision-making, setting expectations about benefit, monitoring, and off-label use. The guideline language helps clinicians have a transparent, evidence-based conversation at the first visit.
The guidelines suggest reserving procedures like G-POEM and gastric electrical stimulation for refractory cases. In your practice, how do you decide when a patient is “refractory” to medical therapy?
Dr. Staller: I define “refractory” with three anchors.
1. Adequate trials of foundational care: dietary optimization and glycemic control; an antiemetic; and at least one prokinetic at appropriate dose/duration (with intolerance documented if stopped early).
2. Persistent, function-limiting symptoms: ongoing nausea/vomiting, weight loss, dehydration, ER visits/hospitalizations, or malnutrition despite the above—ideally tracked with a validated instrument (e.g., GCSI) plus nutritional metrics.
3. Objective correlation: delayed emptying on a standardized 4-hour solid-meal study that aligns with the clinical picture (and medications that slow emptying addressed).
At that point, referral to a center with procedural expertise for G-POEM or consideration of gastric electrical stimulation becomes appropriate, with multidisciplinary evaluation (GI, nutrition, psychology, and, when needed, surgery).
What role do you see dietary modification and glycemic control playing alongside pharmacologic therapy in light of these recommendations?
Dr. Staller: They’re the bedrock. A small-particle, lower-fat, calorie-dense diet—often leaning on nutrient-rich liquids—can meaningfully reduce symptom burden. Partnering with dietitians early pays dividends. For diabetes, tighter glycemic control can improve gastric emptying and symptoms; I explicitly review medications that can slow emptying (e.g., opioids; consider timing/necessity of GLP-1 receptor agonists) and encourage continuous glucose monitor-informed adjustments. Pharmacotherapy sits on top of those pillars; without them, medications will likely underperform.
The guideline notes “considerable unmet need” in gastroparesis treatment. Where do you think future therapies or research are most urgently needed?
Dr. Staller: I see three major areas.
1. Truly durable prokinetics: agents that improve emptying and symptoms over months, with better safety than legacy options (e.g., next-gen motilin/ghrelin agonists, better-studied 5-HT4 strategies).
2. Endotyping and biomarkers: we need to stop treating all gastroparesis as one disease. Clinical, physiologic, and microbiome/omic signatures that predict who benefits from which therapy (drug vs G-POEM vs GES) would transform care.
3. Patient-centered trials: larger, longer RCTs that prioritize validated symptom and quality-of-life outcomes, include nutritional endpoints, and reflect real-world medication confounders.
Our guideline intentionally highlights these gaps to hopefully catalyze better trials and smarter referral pathways.
Dr. Staller is with the Division of Gastroenterology, Massachusetts General Hospital and Harvard Medical School, Boston.