What is the best steroid for an acute flare of Crohn's disease?

Best Steroid for Acute Flare of Crohn's Disease

For an acute flare of Crohn's disease, oral prednisone 40-60 mg/day is the most effective steroid for inducing remission in moderate to severe disease, while budesonide 9 mg/day is the preferred first-line steroid for mild to moderate disease limited to the ileum and/or right colon. 1

Steroid Selection Algorithm Based on Disease Severity and Location

Mild to Moderate Disease

• Ileal and/or Right Colonic Disease:

  • First-line: Budesonide 9 mg/day orally 1
  • Evaluate response between 4-8 weeks
  • Advantages: Less systemic side effects due to high first-pass metabolism in the liver 1
  • Clinical remission rate: ~53% (vs. 66% with prednisolone) 2

• Colonic Disease Only:

  • Consider sulfasalazine 4-6 g/day for mild disease limited to the colon 1
  • Note: Not a steroid but mentioned as an alternative for this specific presentation

Moderate Disease (Failed Budesonide)

• Switch to prednisone 40-60 mg/day orally 1
• Evaluate response between 2-4 weeks

Moderate to Severe Disease

• First-line: Prednisone 40-60 mg/day orally 1
• Strong recommendation despite low-quality evidence
• Evaluate response between 2-4 weeks
• Clinical remission rates: 60-83% (vs. 30-38% with placebo) 1

Severe Disease Requiring Hospitalization

• Intravenous methylprednisolone 40-60 mg/day 1
• Evaluate response within 1 week
• Consider adding intravenous metronidazole to rule out septic complications 1

Important Considerations and Pitfalls

Duration and Tapering

• Avoid prolonged steroid use - no role in maintenance therapy 1
• Taper steroids gradually based on clinical response, generally over 8 weeks 1
• Too rapid reduction is associated with early relapse 1

Steroid Dependency and Resistance

• Nearly 50% of patients either fail to respond or become steroid-dependent within 1 year 3, 4
• For steroid-dependent patients, consider adding:
  • Thiopurines (azathioprine/6-mercaptopurine) 1, 5
  • Methotrexate 1, 5
  • Anti-TNF therapy (infliximab, adalimumab) 1, 6

Side Effects to Monitor

• Bone loss (can occur even with short-term, low-dose therapy)
• Metabolic complications (glucose intolerance, diabetes)
• Increased intraocular pressure and glaucoma
• Increased risk of serious infections 3
• Morning plasma cortisol suppression (more significant with prednisolone than budesonide) 2

Special Situations

Fistulizing Disease

• Steroids are not the primary treatment for fistulizing disease
• Consider antibiotics (metronidazole, ciprofloxacin), immunomodulators, or anti-TNF therapy 1

Steroid-Refractory Disease

• For patients not responding to steroids, consider:
  • Anti-TNF therapy (infliximab, adalimumab) 1, 6
  • Parenteral methotrexate 1
  • Surgical evaluation for localized disease 1

Remember that while steroids are highly effective for inducing remission in active Crohn's disease, they do not heal mucosal lesions and are not effective for maintaining remission 3. The goal should be to achieve remission with steroids and then transition to steroid-sparing maintenance therapy.