How long should I discontinue budesonide (corticosteroid) before getting a cortisone injection?

Discontinuation Period Between Budesonide and Cortisone Injection

You should discontinue budesonide 9mg daily for at least 1-2 weeks before receiving a cortisone injection to minimize adrenal suppression risks and optimize treatment outcomes. 1, 2

Understanding Budesonide's Effects on the Adrenal System

Budesonide is a corticosteroid with high topical activity and lower systemic effects compared to conventional corticosteroids like prednisolone due to its extensive first-pass hepatic metabolism (approximately 90%) 3. However, it still has potential to cause adrenal suppression:

• Budesonide 9mg daily can cause dose-related reduction in basal and corticotropin-stimulated plasma cortisol concentrations 4
• When used for 8 weeks at therapeutic doses, mean morning plasma cortisol concentrations typically remain within normal range but individual responses vary 5

Rationale for Discontinuation Period

1. Adrenal Recovery:

   • When remission is achieved with budesonide, guidelines recommend tapering over 1-2 weeks 1, 2
   • This tapering period allows the hypothalamic-pituitary-adrenal (HPA) axis to begin recovery

2. Avoiding Cumulative Steroid Effects:

   • Receiving a cortisone injection while on budesonide therapy could lead to additive corticosteroid effects
   • This increases risk of systemic side effects including further adrenal suppression

Clinical Decision Algorithm

Step 1: Assess Current Disease Status

• If Crohn's disease is in remission: Proceed with discontinuation plan
• If disease is active: Consider postponing injection or consulting with gastroenterologist

Step 2: Discontinuation Timeline

• Begin tapering budesonide rather than stopping abruptly
• Reduce from 9mg to 6mg for 3-4 days
• Further reduce to 3mg for 3-4 days
• Complete discontinuation at least 7-10 days before planned injection

Step 3: Monitoring During Discontinuation

• Watch for signs of disease flare (increased abdominal pain, diarrhea)
• Monitor for symptoms of adrenal insufficiency (fatigue, weakness, dizziness)

Special Considerations

• Disease Type: The British Society of Gastroenterology recommends budesonide for mild to moderate ileocaecal Crohn's disease for 8-week treatment courses 1
• Timing of Injection: If possible, schedule the cortisone injection at least 2 weeks after complete budesonide discontinuation for optimal safety
• Restarting Therapy: If budesonide needs to be restarted after injection, wait at least 1 week after cortisone injection

Common Pitfalls to Avoid

1. Abrupt Discontinuation: Never stop budesonide suddenly as this may precipitate adrenal crisis or disease flare 1

2. Ignoring Disease Activity: Ensure Crohn's disease remains controlled during the discontinuation period

3. Overlooking Patient-Specific Factors: Duration of budesonide therapy affects degree of adrenal suppression - longer courses (>8 weeks) may require longer discontinuation periods

4. Failing to Communicate Between Providers: Ensure the provider administering the cortisone injection is aware of recent budesonide use

By following this approach, you can minimize risks while optimizing the benefits of both treatments.