What should be done with a patient's prednisone (corticosteroid) regimen if they develop acute diverticulitis while already taking it for a few days?

Management of Prednisone in Acute Diverticulitis

Patients on prednisone who develop acute diverticulitis should continue their corticosteroid regimen while receiving appropriate antibiotic therapy, as abrupt discontinuation can lead to adrenal insufficiency and worsen outcomes. Corticosteroid use is a significant risk factor for complications in diverticulitis, requiring more aggressive management.

Risk Assessment for Patients on Corticosteroids

• Patients on chronic corticosteroid therapy are considered immunocompromised and at high risk for:
  • Treatment failure of standard non-operative management 1
  • Higher complication rates including perforation 1, 2
  • Higher mortality (up to 31.6% postoperative) 1
  • Higher recurrence rates (27.8%) after initially successful non-operative management 1

Management Algorithm

1. Continue Prednisone

• Do not discontinue prednisone abruptly - this can precipitate adrenal insufficiency
• Continue the patient's current prednisone dosage while treating diverticulitis
• Consider consulting endocrinology for potential stress-dose adjustments if patient shows signs of severe infection or sepsis

2. Initiate Antibiotic Therapy

• All patients on corticosteroids with diverticulitis require antibiotic therapy regardless of severity 3, 1
• For stable patients who can tolerate oral intake:
  • Amoxicillin-clavulanate or cefalexin with metronidazole 1, 4
• For unstable patients or those unable to tolerate oral intake:
  • IV antibiotics: ceftriaxone plus metronidazole or piperacillin-tazobactam 1, 4
• Duration: typically 7-10 days 1

3. Dietary Management

• Begin with clear liquid diet during acute phase 3
• Advance diet as symptoms improve 3
• If unable to advance diet after 3-5 days, immediate follow-up is required 3

4. Imaging and Monitoring

• CT scan with IV contrast is essential to assess severity and complications 1, 4
• More aggressive monitoring is required for patients on corticosteroids:
  • Daily assessment of vital signs, abdominal exam, and laboratory markers
  • Low threshold for repeat imaging if clinical deterioration occurs

5. Surgical Consultation

• Early surgical consultation is recommended for all patients on corticosteroids with diverticulitis 1
• Lower threshold for surgical intervention compared to immunocompetent patients

Special Considerations

• Complicated diverticulitis: Patients on corticosteroids have higher risk of developing complicated disease with abscess, perforation, or fistula formation 2
• Abscess management: Percutaneous drainage for abscesses ≥4cm plus IV antibiotics 1
• Follow-up: Colonoscopy recommended 4-6 weeks after resolution to rule out malignancy 1

Common Pitfalls to Avoid

1. Abrupt discontinuation of prednisone - can precipitate adrenal crisis
2. Underestimating severity - corticosteroids can mask inflammatory signs and symptoms
3. Delayed surgical consultation - higher threshold for surgery can lead to worse outcomes
4. Inadequate antibiotic coverage - all patients on corticosteroids require antibiotics regardless of diverticulitis severity
5. Insufficient monitoring - patients require closer follow-up due to higher risk of complications

By maintaining the prednisone regimen while providing appropriate antibiotic therapy and close monitoring, you can optimize outcomes for patients who develop acute diverticulitis while on corticosteroid therapy.