What is the recommended steroid treatment for an ulcerative colitis (UC) flare?

Steroid Treatment for Ulcerative Colitis Flare

For an ulcerative colitis flare, oral prednisolone 40 mg daily with tapering over 6-8 weeks is recommended as the standard steroid treatment, with the specific regimen determined by disease severity. 1

Treatment Algorithm Based on Disease Severity

Mild to Moderate UC Flare

1. First-line therapy:

   • Oral and/or rectal 5-ASA (mesalamine) 2-4g/day 1, 2
   • If patient is 5-ASA intolerant or fails to respond within 4-8 weeks, proceed to steroids

2. Steroid therapy (when 5-ASA fails):

   • Oral prednisolone 40 mg daily with tapering over 6-8 weeks 1
   • Alternative: Budesonide MMX 9 mg daily for those wishing to avoid systemic steroids 1, 3

Moderate to Severe UC Flare

1. First-line therapy:

   • Oral prednisolone 40 mg daily with tapering over 6-8 weeks 1
   • Single daily dosing is as effective as split-dosing and causes less adrenal suppression 1

2. Monitoring response:

   • Evaluate response within 2 weeks 1, 4
   • If no improvement after 2 weeks, consider treatment escalation 1

Severe UC Flare Requiring Hospitalization

1. First-line therapy:

   • Intravenous corticosteroids: methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily 1, 2
   • Alternative: IV cyclosporine monotherapy (2 mg/kg/day) for patients who should avoid steroids 1

2. Monitoring response:

   • Assess response by day 3 1, 2, 4
   • Non-response at day 3 significantly increases risk of complications and colectomy 4

3. For non-responders by day 3:

   • Consider rescue therapy: infliximab (5 mg/kg) or cyclosporine (2 mg/kg/day) 2, 5
   • Consider colectomy if no improvement after 4-7 days of salvage therapy 1

Steroid Tapering Protocol

After initial response to 40 mg prednisolone daily:

• Taper by 5 mg weekly 6
• Total duration: 6-8 weeks 1

Important Considerations

• Do not use steroids for maintenance therapy: Corticosteroids are ineffective for maintaining remission and associated with significant adverse effects 1

• Monitor for adverse effects: Approximately 50% of patients experience short-term corticosteroid-related adverse events including acne, edema, sleep disturbances, mood changes, glucose intolerance, and dyspepsia 1

• Steroid-dependent patients: For patients requiring two or more courses of corticosteroids in the past year or who become steroid-dependent, treatment escalation with thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib is recommended 1

• Budesonide MMX: Consider for mild to moderate UC as an alternative to systemic steroids, with fewer systemic side effects 1, 3

Common Pitfalls to Avoid

1. Prolonged steroid use: Steroids should not be used for maintenance therapy due to significant adverse effects 1, 2

2. Delayed assessment of response: Failure to evaluate response by day 3 (IV steroids) or within 2 weeks (oral steroids) may delay necessary treatment escalation 1, 4

3. Inadequate initial dosing: Using less than 40 mg prednisolone daily is less effective for moderate to severe disease 1

4. Inappropriate tapering: Too rapid tapering can lead to relapse, while too slow tapering increases steroid exposure and side effects 6

5. Missing steroid-sparing strategies: Failure to implement steroid-sparing strategies in steroid-dependent patients 1, 2