Microscopic Colitis: Understanding Chronic Diarrhea and Why Budesonide Is the Go-To Treatment

Chronic diarrhea that won’t go away-no blood, no fever, no obvious cause-can be one of the most frustrating health problems out there. You’ve tried diet changes, probiotics, antidiarrheals, and still, you’re running to the bathroom 6, 8, even 10 times a day. If this sounds familiar, you might be dealing with microscopic colitis. It’s not as well-known as Crohn’s or ulcerative colitis, but it’s just as real, and for many people, it’s the hidden reason behind their daily struggles.

What Exactly Is Microscopic Colitis?

Microscopic colitis is an inflammation of the colon that doesn’t show up on a regular colonoscopy. Your colon looks perfectly normal to the doctor’s eyes. That’s why it’s called microscopic-you need a microscope to see the damage. Two types exist: collagenous colitis and lymphocytic colitis. Both cause the same symptoms, but under the scope, they look different. In collagenous colitis, there’s a thick band of collagen (a structural protein) under the colon lining. In lymphocytic colitis, there’s a flood of white blood cells stuck between the cells lining the colon.

This condition mostly hits people over 50, and women are far more likely to get it than men. It’s not rare. Studies show about 5 in every 100,000 people are diagnosed each year, and that number has been rising since the 1990s. Why? Better testing. More colonoscopies. More awareness. Doctors are finally looking for it.

What Does It Actually Feel Like?

The hallmark is watery diarrhea-no blood, no mucus, no cramps (though some people do have them). You might have 5 to 10 loose bowel movements a day, often at night. Fecal incontinence? Common. Weight loss? Happens in up to 40% of cases, especially with collagenous colitis. Many people say they feel like their body is leaking water. It’s not just inconvenient-it’s exhausting. People describe it as losing control of their life.

Unlike Crohn’s or ulcerative colitis, microscopic colitis doesn’t cause ulcers, bleeding, or structural damage. But that doesn’t mean it’s mild. Symptoms can drag on for months or even years before someone gets the right diagnosis. The average time from first symptom to confirmed diagnosis? Nearly a year. That’s a long time to suffer without answers.

Why Budesonide? The Gold Standard Treatment

When you’re diagnosed, the first thing your doctor will likely recommend is budesonide. It’s not a cure, but it’s the most effective treatment we have for bringing symptoms under control. Budesonide is a corticosteroid, but it’s not like prednisone. It’s designed to work mostly in your gut. About 90% of it gets broken down by your liver before it ever hits your bloodstream. That’s why side effects are much lower.

The standard dose is 9 milligrams a day for 6 to 8 weeks. In clinical trials, 75% to 85% of people saw their diarrhea stop completely by week 6. Compare that to placebo-only 25% to 30% got better. That’s a massive difference. In one major study, 84% of people with collagenous colitis went into full remission on budesonide versus just 38% on a sugar pill.

What makes budesonide stand out? It works fast. Many patients report feeling better within 10 days. One Reddit user wrote, “Went from 10 bathroom trips a day to 2 in 10 days. Finally felt like myself again.” That kind of turnaround is why doctors trust it.

How It Compares to Other Options

There are other drugs out there, but none match budesonide’s results. Bismuth subsalicylate (Pepto-Bismol) helps some people, but only about 26% see real improvement. Mesalamine, often used for ulcerative colitis, works in 40% to 50% of cases-better than nothing, but not great. Cholestyramine can help if bile acid malabsorption is part of the problem, which it often is. Some people do better on a combo: budesonide plus cholestyramine.

Prednisone? It works just as well as budesonide-but with way more side effects. Weight gain, high blood sugar, mood swings, bone thinning. That’s why doctors avoid it unless they have to. Anti-TNF drugs like infliximab? They’re expensive ($2,500 per infusion), risky (infection danger), and only help 20% to 30% of people. They’re saved for when budesonide fails.

The Catch: Relapse Is Common

Here’s the tough part: budesonide doesn’t fix the root cause. It just quiets the inflammation. Once you stop taking it, symptoms come back for 50% to 75% of people. That’s why many need maintenance therapy. After the initial 8 weeks, doctors often drop the dose to 6 mg daily for a few more months, or even longer. About 30% to 40% of patients stay on a low dose for over a year.

Some people can taper off successfully. Others find they’re stuck on it. One patient on PatientsLikeMe said, “Worked great for 6 weeks. Then symptoms returned. Now I’ve been on maintenance for two years.” That’s not failure-it’s the reality of the disease.

Side Effects and Safety

Budesonide is safe for most people, but it’s not harmless. The most common complaints: trouble sleeping (15%), acne (12%), and mood changes (8%). These are mild for most, but they matter. Elderly patients, especially those over 65, need monitoring. Long-term use could affect bone density or adrenal function. That’s why doctors check blood pressure, HbA1c, and do bone scans before starting-and sometimes again after 6 months.

It’s not safe for people with severe liver disease. Since the liver breaks down most of the drug, if your liver isn’t working right, too much of it can build up in your blood. That’s why your doctor will ask about your liver history.

Cost and Access

Generic budesonide costs $150 to $250 for an 8-week course in the U.S. The brand name, Entocort EC, can hit $800 to $1,200. Insurance usually covers it, but without it, the price is a barrier. Many patients on forums say cost is their biggest struggle. In countries with public healthcare, access is easier. In the U.S., copays and prior authorizations can delay treatment.

What Comes Next? The Future of Treatment

Research is moving fast. A new drug called vedolizumab, originally for Crohn’s, just got Fast Track status from the FDA for microscopic colitis. Early results show 65% of patients went into remission after 14 weeks. That’s promising for people who don’t respond to budesonide.

Scientists are also looking at genetics. Early data suggests people with certain genes (HLA-DQ2 or HLA-DQ8) respond better to budesonide. That could mean future testing to predict who will benefit most.

For now, budesonide remains the standard. It’s the first drug you try, the one that gets you back to normal, and often the one you stay on longer than you expected.

What Should You Do If You Suspect You Have It?

If you’ve had chronic watery diarrhea for more than a few weeks-with no clear trigger-you need a colonoscopy with biopsies. Don’t assume it’s IBS. Ask for deep biopsies from multiple parts of the colon. One biopsy isn’t enough. The inflammation can be patchy.

If you’re diagnosed, don’t panic. Budesonide has a strong track record. Talk to your doctor about the plan: how long you’ll take it, how you’ll taper, what side effects to watch for, and what comes next if it doesn’t work.

Final Thoughts

Microscopic colitis isn’t flashy, but it’s real. It steals your days, your sleep, your confidence. But it’s treatable. Budesonide isn’t perfect-it doesn’t cure, and relapses happen-but it’s the best tool we have. For most people, it’s the difference between living in fear of the bathroom and living again.