What is the appropriate corticosteroid (steroid) dosing for ulcerative colitis (UC)?

From the Guidelines

For ulcerative colitis, the recommended corticosteroid dosing regimen is oral prednisone 40-60 mg daily for 1-2 weeks, followed by a taper of 5-10 mg per week until reaching 20 mg, and then a slower taper of 2.5-5 mg per week until discontinuation, as supported by the most recent and highest quality study 1. This dosing regimen is based on the British Society of Gastroenterology consensus guidelines, which recommend oral prednisolone for patients with mild to moderate ulcerative colitis who have failed to respond to 5-ASA therapy 1. The guidelines also suggest that topically-acting oral corticosteroids, such as budesonide MMX, can be used as alternative treatments for those wishing to avoid systemic corticosteroids. Some key points to consider when using corticosteroids for ulcerative colitis include:

• Starting with a high dose to quickly reduce symptoms, and then tapering to minimize the risk of adrenal insufficiency
• Using calcium and vitamin D supplements to prevent bone loss
• Monitoring for side effects like mood changes, increased blood sugar, and infections
• Planning to transition to maintenance therapy, such as mesalamine or immunomodulators, to minimize long-term use of corticosteroids It's also important to note that prolonging treatment with high-dose oral corticosteroids has a diminishing chance of achieving remission, and patients who do not respond after 2 weeks should be considered for treatment escalation to biologics or admission to hospital, depending on their overall health status 1.

From the FDA Drug Label

Ulcerative Colitis (2. 4): • Adults: 160 mg on Day 1 (given in one day or split over two consecutive days), 80 mg on Day 15 and 40 mg every other week starting on Day 29. Discontinue in patients without evidence of clinical remission by eight weeks (Day 57).

The appropriate corticosteroid dosing for ulcerative colitis (UC) is not mentioned in the provided drug label, as it refers to the dosing of adalimumab, which is a tumor necrosis factor (TNF) blocker, not a corticosteroid. However, the dosing of adalimumab for UC is provided.

• The dosing is as follows:
  • 160 mg on Day 1
  • 80 mg on Day 15
  • 40 mg every other week starting on Day 29
  • Discontinue in patients without evidence of clinical remission by eight weeks (Day 57) 2

From the Research

Corticosteroid Dosing for Ulcerative Colitis (UC)

• The appropriate corticosteroid dosing for ulcerative colitis (UC) can vary depending on the severity of the disease and the patient's response to treatment 3, 4, 5, 6, 7.
• For moderate to severe UC, methylprednisolone 40-60 mg intravenous every 24 hours or hydrocortisone 100 mg intravenous 3 times daily is considered appropriate for inpatient management 7.
• Oral corticosteroids, such as prednisolone, can be effective in inducing remission in UC, with doses ranging from 40-75 mg per day 5.
• In patients who fail to respond to oral corticosteroids, intravenous corticosteroids may be considered, with initial response rates ranging from 75-80% 4.
• The duration of corticosteroid treatment can vary, but typically ranges from several weeks to several months, with a median total duration of therapy of 4 months 5.

Discharge Planning and Postdischarge Care

• Discharge criteria for patients with UC hospitalized for moderate-severe flares include resolution of rectal bleeding and return to baseline stool frequency and form 7.
• Patients can be discharged on 40 mg of prednisone, with follow-up within 2 weeks and lower endoscopy within 4-6 months after discharge 7.
• For patients being discharged on steroids without in-hospital biologic or small molecule therapy initiation, it is appropriate to start antitumor necrosis factor (TNF) therapy after discharge for anti-TNF-naive patients 7.

Steroid Dependency and Management

• Approximately 20% of patients with UC have a chronic active disease, often requiring several courses of systemic steroids to achieve remission, but followed by relapse of symptoms during steroid tapering or soon after their discontinuation 6.
• The management of steroid-dependent UC is not well understood, and very few evidence-based data are available concerning the management of patients with steroid-dependent UC 6.
• Alternative therapeutic strategies, such as aminosalicylates, thiopurines, methotrexate, infliximab, and leukocyte apheresis, may be considered in the treatment of steroid-dependent UC 6.