What is the recommended steroid treatment for active Crohn's disease?

Steroid Treatment for Active Crohn's Disease

For active Crohn's disease, systemic corticosteroids are recommended for colonic disease, while budesonide 9 mg daily for 8 weeks is the preferred first-line steroid treatment for mild-to-moderate ileocaecal Crohn's disease. 1

Location-Based Steroid Selection

Ileocaecal/Small Bowel Crohn's Disease:

• First-line: Budesonide 9 mg once daily for 8 weeks 1

  • As effective as prednisolone for mild-to-moderate disease
  • Significantly fewer side effects than systemic steroids
  • Once-daily dosing is as effective as 3 mg three times daily
  • Should be tapered over 1-2 weeks after remission is achieved

• For severe disease (CDAI >300):

  • Systemic corticosteroids (prednisolone) are superior to budesonide 1
  • Starting dose: 40 mg daily, tapering by 5 mg weekly

Colonic Crohn's Disease:

• Standard treatment: Systemic corticosteroids (prednisolone) 1

  • Starting dose: 40 mg daily, tapering by 5 mg weekly
  • Course duration: 8 weeks
  • Dosage should be tailored to disease severity and patient tolerance

• Note: Ileal-release budesonide has benefit only in proximal colonic disease, not distal colonic inflammation 1

Steroid-Sparing Alternatives

When steroids should be avoided or minimized:

1. Exclusive Enteral Nutrition (EEN):

   • Can be used to induce remission in mild to moderate disease 1
   • Particularly useful when avoidance of corticosteroids is desired
   • Requires strict adherence for up to 8 weeks
   • Minimum effective duration: 4-6 weeks
   • Can be taken orally or via nasogastric route if necessary

2. Immunomodulators for steroid-dependent disease:

   • Azathioprine (1.5-2.5 mg/kg/day) or mercaptopurine (0.75-1.5 mg/kg) 1, 2
   • Methotrexate (25 mg IM weekly for induction, then 15 mg weekly) 1, 2
   • Monitor FBC within 4 weeks of starting therapy and every 6-12 weeks thereafter

Steroid Dependency and Resistance Management

Steroid dependency is defined as:

• Relapse when steroid dose is reduced below 20 mg/day
• Relapse within 6 weeks of stopping steroids 1

Steroid-refractory disease is defined as:

• Active disease despite adequate dose and duration of prednisolone (>20 mg/day for >2 weeks) 1

For these patients:

1. Consider immunomodulators if surgery is not immediately indicated 1, 2
2. Consider biologic therapies after other options have been exhausted 1, 2

Important Considerations and Cautions

• Avoid long-term steroid use: Corticosteroids are not effective for maintenance therapy 1, 2
• Monitor for complications: Bone loss, metabolic complications, infections, hypertension, cataracts, and glaucoma 2, 3
• Response evaluation timeframes:
  • Prednisone: 2-4 weeks
  • Budesonide: 4-8 weeks 2
• Never abruptly discontinue steroids in patients already taking them (risk of adrenal crisis) 2
• Consider steroid-sparing agents for patients requiring two or more corticosteroid courses within a calendar year 2

Treatment Duration

• Standard steroid course: 8 weeks (including tapering) 1
• Longer courses do not appear to offer additional benefits for maintaining remission 4
• Approximately 50% of patients will either fail to respond or become steroid-dependent at 1 year 5

Steroids remain a cornerstone of Crohn's disease treatment despite their limitations, but their use should be optimized to minimize side effects while maximizing therapeutic benefit.