Recommended Steroids for Crohn's Disease Exacerbation
For Crohn's disease exacerbation, oral prednisone 40-60 mg/day is recommended as the first-line steroid therapy for moderate to severe disease, while budesonide 9 mg/day is recommended for mild to moderate disease limited to the ileum and/or right colon. 1
Steroid Selection Based on Disease Severity and Location
Mild to Moderate Disease
- For mild to moderate ileal and/or right colonic Crohn's disease, oral budesonide 9 mg/day is suggested as first-line therapy to induce remission 1
- Budesonide should be evaluated for response between 4-8 weeks to determine need for therapy modification 1
- Budesonide has fewer systemic side effects compared to conventional corticosteroids due to its high first-pass metabolism in the liver 2
Moderate Disease After Budesonide Failure
- In patients with moderate Crohn's disease who have failed to respond to oral budesonide 9 mg/day, prednisone 40-60 mg/day is suggested to induce complete remission 1
Moderate to Severe Disease
- For moderate to severe Crohn's disease, oral prednisone 40-60 mg/day is strongly recommended to induce complete remission 1
- Response to prednisone should be evaluated between 2-4 weeks to determine need for therapy modification 3
- Prednisone has been shown to induce remission in 60-83% of patients with moderate to severe Crohn's disease 1
Severe Disease Requiring Hospitalization
- For patients with active Crohn's disease severe enough to require hospitalization, intravenous corticosteroids (e.g., methylprednisolone 40-60 mg/day) are suggested to induce symptomatic remission 4
- Patients with severe disease should be evaluated for response to IV methylprednisolone within 1 week 5
Important Considerations and Limitations
Duration of Therapy
- Steroids should be used for short-term induction of remission only 5
- Approximately 50% of patients will either fail to respond (steroid-resistant) or become steroid-dependent at 1 year 4
- Steroids are not effective for maintenance of remission in Crohn's disease of any severity 2
Side Effects and Monitoring
- Corticosteroid-associated side effects include moon face, acne, infection, hypertension, glucose intolerance, osteoporosis, and psychiatric disturbances 6
- Budesonide has significantly fewer corticosteroid-associated side effects compared to prednisolone (33% vs 55%) 2
- Morning plasma cortisol concentrations are less suppressed with budesonide compared to prednisolone 2
Steroid-Sparing Strategies
- For patients requiring repeated courses of steroids, consider steroid-sparing agents such as thiopurines, methotrexate, or biologics 6
- In selected patients who achieve remission on corticosteroids, thiopurine monotherapy or methotrexate may be used to maintain remission [@16@, @18@]
- Anti-TNF therapy (infliximab, adalimumab) is recommended for patients with moderate to severe disease who fail to achieve remission with corticosteroids [@21@]
Common Pitfalls to Avoid
- Avoid using steroids for maintenance therapy as they are ineffective and associated with significant long-term adverse effects 2
- Do not use doses of prednisolone less than 15 mg/day for active disease as they are ineffective 1
- Avoid too rapid reduction of steroid dose as this can be associated with early relapse 1
- Do not continue ineffective steroid therapy without reassessment - evaluate response within the recommended timeframes and modify therapy if needed 3, 5