What is the role of steroids, such as prednisolone, in the treatment of gastritis and colitis?

Role of Steroids in the Treatment of Gastritis and Colitis

Corticosteroids are highly effective for inducing remission in moderate to severe gastritis and colitis but should not be used for long-term maintenance therapy due to significant adverse effects. 1, 2

Treatment Approach Based on Disease Severity

Mild to Moderate Disease

• First-line therapy: Oral 5-ASA (mesalamine) 2-4 g/day, often combined with topical 5-ASA for distal disease 1
• For inadequate response to 5-ASA:
  • Oral prednisolone 40 mg daily with gradual taper over 6-8 weeks 1, 3
  • Alternative: Budesonide MMX (topically-acting oral corticosteroid) for those wishing to avoid systemic effects 1

Moderate to Severe Disease

• Initial treatment: Oral prednisolone 40 mg daily, tapered over 6-8 weeks 1
• For hospitalized patients: IV methylprednisolone 60 mg/day or hydrocortisone 100 mg four times daily 2
• Assessment: Evaluate response by day 3 of IV therapy; lack of improvement indicates need for rescue therapy 2

Severe/Refractory Disease

• If no improvement after 2-3 days of IV steroids:
  • Add infliximab or vedolizumab (preferably within 2 weeks of symptom onset) 1
  • Consider surgical consultation if clinical deterioration continues 2

Steroid Dosing and Tapering

• Initial dose: Prednisolone 40 mg daily for moderate-severe disease 1
• Duration: Taper gradually over 6-8 weeks; rapid reduction associated with early relapse 1
• IV dosing: Methylprednisolone 60 mg/day or hydrocortisone 400 mg/day for severe disease 1, 2

Special Considerations for Immune Checkpoint Inhibitor-Induced Colitis/Gastritis

For immune-related adverse events from checkpoint inhibitors:

• Grade 2 (moderate): Hold immunotherapy, administer prednisone 1-2 mg/kg/day 1
• Grade 3-4 (severe): Permanently discontinue immunotherapy, administer IV methylprednisolone 1-2 mg/kg/day 1
• Steroid-refractory cases: Add infliximab or vedolizumab within 2 weeks of symptom onset 1, 4

Management of Steroid-Dependent or Refractory Disease

• For patients requiring ≥2 courses of steroids in past year or becoming steroid-dependent:
  • Add thiopurines (azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day) 1
  • Consider anti-TNF therapy (infliximab) or vedolizumab 1
  • For steroid-refractory immune checkpoint inhibitor colitis: consider fecal microbiota transplantation 1

Monitoring and Follow-up

• Daily assessment: Vital signs, abdominal examination, stool frequency, inflammatory markers 2
• Response criteria: Improvement in symptoms within 48-72 hours, decreasing stool frequency, normalizing vital signs 2
• Non-response indicators: Persistent fever, worsening abdominal pain, increasing stool frequency, rising inflammatory markers 2

Potential Adverse Effects of Steroid Therapy

• Short-term: Acne, edema, sleep disturbances, mood changes, glucose intolerance, dyspepsia 1
• Long-term: Osteoporosis, adrenal suppression, increased infection risk, hypertension 3
• Single daily dosing causes less adrenal suppression than split dosing 1

Common Pitfalls to Avoid

• Prolonged treatment with high-dose oral corticosteroids has diminishing chance of achieving remission 1
• Delaying treatment escalation in non-responders (assess response by day 3 for IV therapy) 2
• Using steroids for maintenance therapy (ineffective and increases adverse effects) 1, 2
• Failing to consider concomitant infections (always test for C. difficile) 2
• Delaying surgical consultation in severe cases 2

Steroids remain the mainstay of treatment for moderate to severe gastritis and colitis, but their use must be balanced against potential adverse effects. Early assessment of response and appropriate escalation to steroid-sparing strategies are essential for optimal outcomes.