Background: Gastrointestinal tract involvement is highly prevalent in systemic sclerosis, with few treatment options. We assessed the efficacy and safety of faecal microbiota transplantation using standardised anaerobic cultivated human intestinal microbiome (ACHIM) as a novel treatment option for patients with systemic sclerosis and symptomatic lower gastrointestinal tract involvement., Methods: In this phase 2, randomised, double-blind, placebo-controlled trial done at four university hospitals in Norway, we enrolled adults aged 18-85 years with systemic sclerosis and moderate-to-severe lower gastrointestinal tract symptoms (bloating or diarrhoea). Participants were randomly assigned 1:1 to intestinal infusions of placebo or ACHIM at weeks 0 and 2, stratified by worst symptom (bloating or diarrhoea). The primary endpoint was change in worst lower gastrointestinal tract symptom (bloating or diarrhoea) from week 0 to week 12, measured using the University of California Los Angeles Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 scoring system in the intention-to-treat population. Safety was assessed at weeks 0, 2, 4, 6, and 12 in all participants who received at least one infusion. A person with lived experience of systemic sclerosis was involved in the study planning and conduct. This trial was registered at ClinicalTrials.gov, NCT04300426., Findings: Between Sept 24, 2020, and Jan 14, 2022, 67 participants were enrolled and randomly allocated to placebo (n=34) or ACHIM (n=33). Mean age was 58·91 years (SD 11·59). 62 (93%) of 67 participants were women, five (7%) were men, and 50 (75%) were anti-centromere antibody positive. Change in worst lower gastrointestinal tract symptom from week 0 to week 12 did not differ between participants who received ACHIM (-0·13, 95% CI -0·37 to 0·11) and participants who received placebo (-0·33, -0·57 to -0·09; average marginal effect 0·20, 95% CI -0·12 to 0·52; p=0·22). Adverse events, mostly mild and short-lived gastrointestinal tract symptoms, were reported by 16 (48%) of 33 participants in the ACHIM group and 19 (56%) of 34 in the placebo group. During gastroscopy, one participant had a duodenal perforation., Interpretation: Faecal microbiota transplantation with ACHIM was well tolerated in participants with systemic sclerosis but did not result in an improvement in lower gastrointestinal tract symptoms., Funding: KLINBEFORSK., Translation: For the Norwegian translation of the abstract see Supplementary Materials section., Competing Interests: Declaration of interests ICO declares grants or contracts from Horizon 2020, Horizon Europe, and Helse Sør-Øst, with all payments made to his institution; consulting fees from Dilafor AB and Simplexia AB; and has participated on data safety monitoring boards for EVOLVD, FLECAPRO, TEN-CRAOS, My-JIA and ALPHA2PREVENT. OD has consulted for, received research funding from, or served as a speaker in the area of potential treatments for systemic sclerosis and its complications in the last 3 years for AbbVie, Acceleron, Amgen, AnaMar, Arxx Therapeutics, Baecon, Bayer, Blade, Boehringer Ingelheim, ChemomAb, Corbus, CSL Behring, Galapagos, GSK, Glenmark, Horizon (Curzion), Inventiva, iQvia, Italfarmaco, Kymera, Medac, Medscape, Merck Sharp & Dohme, Mitsubishi Tanabe, Novartis, Pfizer, Roche, Roivant, Sanofi, Serodapharm, Target Bioscience, Topadur, 4P-Pharma, Alcimed, Altavant Sciences, AstraZeneca, EMD Serono, Gossamer, Janssen, Lupin, Miltenyi Biotec, Nkarta, Orion, Prometheus Biosciences, Redxpharma, and UCB; holds a leadership or fiduciary role at the FOREUM Foundation, European Respiratory Society, European Alliance of Associations for Rheumatology, European Scleroderma Trials and Research Group, Swiss Clinical Quality Management in Rheumatic Diseases, Swiss Academy of Medical Sciences, and Hartmann Müller Foundation; is named on a patent issued for “mir-29 for the treatment of systemic sclerosis” (US8247389, EP2331143); and is co-founder of Citus AG. DK declares grants or contracts to his institution from NIH RO1, US Department of Defense, Boehringer Ingelheim, Merck; consulting fees from AbbVie, Amgen, Argenx, Boehringer Ingelheim, Bristol Myers Squibb, Cabaletta, CErta, Merck, and Zura Bio; and has participated on a Data Safety Monitoring Board or Advisory Board for AbbVie. TM declares that he is one of the co-founders of ACHIM Biotherapeutics AB and has shares in ACHIM Biotherapeutics AB. ØMi is the son of TM. HF has received a speaker's fee from Boehringer Ingelheim, with payment made to his institution. AMHV reports grants from Boehringer Ingelheim and Janssen; consulting fees from AbbVie, Arxx Therapeutics, Bristol Myers Squibb, Boehringer Ingelheim, Genentech, Janssen, Merck Sharp & Dohme, Pliant Therapeutics, Roche, and Werfen; payment or honoraria from Boehringer Ingelheim, Janssen, Medscape, Merck Sharp & Dohme, Novartis, and Roche; support for meetings or travel from Boehringer Ingelheim; and holds a leadership or fiduciary role at the European Respiratory Society and European Alliance of Associations for Rheumatology. All other authors declare no competing interests., (Copyright © 2025 Elsevier Ltd. All rights reserved, including those for text and data mining, AI training, and similar technologies.)