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Hi Shan,
You do have to be careful with metronidazole in general as a long-term medication. It can target overgrowth of not so beneficial bacteria, but it will also affect good bacteria as well. There are protocols where it is used alongside a steroid but the immune-modulating properties it is purported to have that would support its longterm use have never been really proven. And so in the last few years, it is falling out of favor more and more as a long-term medication. There are more concerns about actually depleting the GI biome and cultivating antibiotic resistance. There is more emphasis placed on prebiotics (fiber) and probiotics to cultivate more the beneficial bacterial populations.
From a practical standpoint, it doesn’t taste great and for some cats, even 1/4 of a 250mg tablet may be too much, requiring compounding. The Araydia brand of liquid metro labeled for dogs can be used in cats but palatability is a huge issue and it’s expensive for what it is compared to the tablets.
If an IBD case is still not doing well with a primary steroid +/- diet, further testing with ultrasound may be needed at a minimum to see if there are concerns for potential small cell lymphoma, which can appear similarly. There are also just very severe IBD cases. Only tissue biopsies can tell for sure, which is not commonly pursued. But in those refractory cases, I would say that chlorambucil is more often added vs. metronidazole.