What is the role of corticosteroids (steroids) in the treatment of diverticulitis?

From the Guidelines

Steroids are not recommended for the treatment of diverticulitis due to the increased risk of perforation and complications. The use of corticosteroids, such as prednisone, can impair the body's immune response and delay healing of the intestinal wall, as noted in the study by 1. Instead, the standard treatment for uncomplicated diverticulitis includes antibiotics, such as ciprofloxacin (500 mg twice daily) plus metronidazole (500 mg three times daily) for 7-10 days, or amoxicillin-clavulanate (875/125 mg twice daily) for the same duration, as suggested by 1. For severe cases requiring hospitalization, intravenous antibiotics like ceftriaxone plus metronidazole may be used.

Key Considerations

• The American College of Physicians (ACP) suggests that clinicians use abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis, as stated in the study by 1.
• Patients with uncomplicated diverticulitis can be managed in an outpatient setting, with a low threshold for hospitalization if complications arise, as recommended by 1.
• Antibiotic therapy should be tailored to the individual patient's needs, taking into account the severity of infection, presumed pathogens, and risk factors for antimicrobial resistance, as suggested by 1.

Treatment Approach

• Patients with mild diverticulitis should follow a clear liquid diet initially, gradually advancing to a low-fiber diet during the acute phase, then transitioning to a high-fiber diet (25-30g daily) once symptoms resolve to help prevent recurrence.
• Pain management with acetaminophen is preferred, while avoiding NSAIDs which may increase bleeding risk.
• The use of steroids, such as prednisone, is not recommended due to the increased risk of complications, as noted in the study by 1.

From the FDA Drug Label

Gastrointestinal Steroids should be used with caution in active or latent peptic ulcers, diverticulitis, fresh intestinal anastomoses, and nonspecific ulcerative colitis, since they may increase the risk of a perforation Steroids should be used with caution in patients with diverticulitis as they may increase the risk of a perforation.

• The use of steroids in diverticulitis requires careful consideration of the potential risks and benefits.
• Patients with diverticulitis should be closely monitored for signs of perforation when receiving steroid therapy 2, 2.

From the Research

Steroids for Diverticulitis

There is no direct evidence in the provided studies regarding the use of steroids for diverticulitis.

Treatment of Diverticulitis

• The treatment of diverticulitis typically involves antibiotic therapy aimed at anaerobes and gram-negative rods 3.
• For uncomplicated diverticulitis, outpatient treatment is recommended in afebrile, clinically stable patients 4.
• Antibiotics have no proven benefit in reducing the duration of the disease or preventing recurrence in patients with uncomplicated diverticulitis, and should only be used selectively 4, 5.
• For complicated diverticulitis, non-operative management, including bowel rest and intravenous antibiotics, is indicated for small abscesses 4.
• Surgical intervention is indicated for peritonitis or in failure of non-operative management 3, 4.

Use of Antibiotics

• The evidence on antibiotic treatment for uncomplicated acute diverticulitis suggests that the effect of antibiotics is uncertain for complications, emergency surgery, recurrence, elective colonic resections, and long-term complications 5.
• Rifaximin has demonstrated to be effective in obtaining symptoms relief at 1 year in patients with uncomplicated diverticular disease and to improve symptoms and maintain periods of remission following acute colonic diverticulitis 6.
• Antibiotics seem to remain the mainstay of treatment in symptomatic uncomplicated diverticular disease and acute diverticulitis 6.

Management and Prevention

• Diet and lifestyle factors could affect the risk of diverticulitis through their effects on the intestinal microbiome and inflammation 7.
• Less-aggressive and more-nuanced treatment strategies have been developed, including elective surgical resection not being recommended solely based on the number of recurrent events or young patient age 7.