Chronic diarrhea that won’t go away-no blood, no fever, no obvious cause-can be one of the most frustrating health problems you’ll face. If you’ve been dealing with 5 to 10 watery bowel movements a day for months, and every test from blood work to colonoscopy came back normal, you might have microscopic colitis. It’s not as well-known as Crohn’s or ulcerative colitis, but it’s just as real. And for most people, the answer isn’t more tests-it’s budesonide.
What Exactly Is Microscopic Colitis?
Microscopic colitis is an inflammation of the colon that only shows up under a microscope. That’s why it’s called microscopic. Your colon looks perfectly normal during a colonoscopy. No ulcers, no redness, no swelling. But when a doctor takes a tiny tissue sample-a biopsy-and looks at it under high magnification, they see the problem: either too many immune cells packed between the lining cells (lymphocytic colitis) or a thickened collagen band under the surface (collagenous colitis). It’s not rare. Around 5 out of every 100,000 people get diagnosed each year, and that number is rising. Most patients are over 50, and women are twice as likely to be affected as men. Symptoms usually start slowly. You might think it’s just a bad stomach bug that never cleared up. But it sticks around-sometimes for years-before someone connects the dots. The diarrhea is always watery. No blood. No mucus. You might also have cramps, bloating, or sudden urges to go. About a third of people wake up at night because of it. Weight loss is more common in collagenous colitis. Fecal incontinence? Happens in up to a third of cases. It’s not just inconvenient-it steals your sleep, your confidence, your routine.Why Diagnosis Takes So Long
The average time from first symptom to diagnosis is 11 months. Why? Because doctors don’t automatically think of microscopic colitis. It’s not in the first round of tests. If you’re over 50 and have chronic diarrhea, a colonoscopy is usually ordered. But if the colon looks fine, many providers stop there. That’s the trap. The only way to confirm it is with biopsies. And not just one or two. You need at least four to six samples taken from different parts of the colon-especially the right side. A single biopsy can miss it. That’s why some patients get sent for multiple scopes before the right tissue is caught. If you’ve had unexplained diarrhea for more than 3 months and all other tests are normal, ask your doctor about microscopic colitis. Mention the word. Push for biopsies. Don’t let normal colonoscopy results rule it out.Budesonide: The First-Line Treatment That Actually Works
When you’re diagnosed, the question isn’t whether to treat it-it’s how. And the answer, backed by multiple high-quality studies, is budesonide. Budesonide is a corticosteroid, but it’s not like prednisone. It’s designed to work mostly in the gut. About 90% of it gets broken down by the liver before it enters your bloodstream. That means it shuts down inflammation in your colon without wrecking your bones, blood sugar, or mood like older steroids do. The standard dose is 9 mg a day for 6 to 8 weeks. In clinical trials, 75% to 85% of people went into full remission-meaning their diarrhea stopped, their cramps faded, and they could sleep through the night. That’s compared to just 25% to 30% on placebo. By week 4, most patients already feel better. One study showed 84% of collagenous colitis patients had complete remission after 8 weeks on budesonide. Only 38% did on dummy pills. That’s not just statistically significant-it’s life-changing.
How Budesonide Compares to Other Options
You might wonder: what about other drugs? - Prednisone works about as well-but side effects are brutal. Half of patients get insomnia, high blood sugar, weight gain, or bone thinning. Not worth it. - Mesalamine (common for ulcerative colitis) helps about half of people. But it’s not as reliable. And if it doesn’t work after 8 weeks, you’re back to square one. - Bismuth subsalicylate (Pepto-Bismol) has a 26% remission rate. Some people swear by it, but it’s a band-aid, not a cure. - Cholestyramine is used if bile acid malabsorption is suspected. It helps 60-70% of those cases. But you need to test for that first. - Anti-TNF drugs like infliximab? Too expensive ($2,500 per infusion), risky (serious infections), and only work in 1 in 5 people. Reserved for when everything else fails. Budesonide isn’t perfect, but it’s the best tool we have right now for getting quick, safe control of symptoms.The Catch: Relapse Is Common
Here’s the hard truth: once you stop budesonide, symptoms come back in 50% to 75% of people within months. That’s why many need maintenance therapy. Doctors often taper the dose slowly-drop from 9 mg to 6 mg, then 3 mg-over several weeks. Some stay on 6 mg daily for months or even years. That’s not ideal, but for many, it’s better than living with daily diarrhea. A 2020 study found 30% to 40% of patients need long-term maintenance. That means regular check-ins, blood tests, and bone density scans-especially if you’re over 50. Steroids, even low-dose ones, can still affect your bones and blood sugar over time. Some patients combine budesonide with cholestyramine or probiotics. One Reddit user wrote: “Budesonide plus bile acid binder fixed me after 3 years of misery.” Combination therapy isn’t official yet, but real people are finding relief that way.What Patients Really Say
Online forums are full of stories. On PatientsLikeMe, 68% of 247 users reported major improvement within two weeks. One wrote: “Went from 10 bathroom trips a day to 2 in 10 days. I cried the first morning I didn’t need to rush to the toilet.” But it’s not all wins. About a third had side effects: insomnia (15%), acne (12%), mood swings (8%). Others say the cost is a barrier. Generic budesonide runs $150-$250 for an 8-week course. Branded Entocort EC? $800-$1,200. Without insurance, that’s a lot. And then there’s the fear. “I’m on steroids,” patients say. “What’s going to happen to me?” The truth is, budesonide’s side effects are mild compared to other steroids. But the psychological weight of taking a steroid for months can be heavy.
What’s Next for Treatment?
Research is moving fast. The FDA gave fast-track status to vedolizumab-a biologic that targets gut-specific immune cells-for people who don’t respond to budesonide. Early trials show 65% remission at 14 weeks. That’s promising. Scientists are also looking at genetics. Preliminary data suggests people with certain immune genes (HLA-DQ2/DQ8) respond better to budesonide. In the future, a simple blood test might tell you if it’s the right drug for you. The European Microscopic Colitis Group is updating guidelines to include fecal calprotectin-a stool test-as a way to monitor inflammation without repeated biopsies. That could make follow-up easier. But for now, budesonide remains the gold standard. It’s in 90% of European guidelines and 85% of North American ones. It’s the drug gastroenterologists reach for first.What You Should Do If You Suspect Microscopic Colitis
If you’ve had chronic watery diarrhea for more than 3 months:- Ask your doctor for a colonoscopy with multiple biopsies (at least 4-6 samples).
- Make sure biopsies are taken from the right side of the colon.
- Don’t assume normal colonoscopy means no problem.
- If diagnosed, ask about budesonide 9 mg daily for 6-8 weeks.
- Discuss tapering and maintenance options before you start.
- Get baseline blood work: HbA1c, bone density scan (if over 50), blood pressure.