Which systemic steroid is preferred, budesonide or prednisolone?

Budesonide vs. Prednisolone: Systemic Steroid Selection

Budesonide is preferred over prednisolone as a systemic steroid due to its superior safety profile with comparable efficacy for specific indications such as mild-to-moderate Crohn's disease limited to the ileum and/or ascending colon.

Comparative Efficacy

• Budesonide is highly effective for inducing remission in mild-to-moderate Crohn's disease limited to the ileum and/or ascending colon, with a 93% higher likelihood of achieving clinical remission compared to placebo 1
• Prednisolone demonstrates greater overall efficacy for moderate-to-severe Crohn's disease, with controlled-release budesonide being inferior to systemic corticosteroids for inducing remission (20% higher failure rate) 1
• For microscopic colitis, budesonide shows a 152% higher likelihood of achieving clinical remission compared to no treatment 1

Safety Profile Comparison

• Budesonide causes significantly fewer glucocorticoid-associated side effects than prednisolone (29 vs. 48 patients in comparative trials) 2
• Morning plasma cortisol levels remain significantly higher with budesonide compared to prednisolone (200 nmol/l vs. 98 nmol/l after 8 weeks), indicating less adrenal suppression 3
• After 5 days of administration, budesonide in both clinical (9 mg/day) and high doses (15 mg/day) affects plasma cortisol less than a moderate dose (20 mg/day) of prednisolone 4

Disease-Specific Recommendations

Crohn's Disease

• For mild-to-moderate Crohn's disease limited to the ileum and/or ascending colon, budesonide 9 mg/day is strongly recommended as first-line therapy 1, 5
• For moderate-to-severe Crohn's disease or disease extending beyond the ascending colon, prednisolone is more effective and should be used 1
• Neither budesonide nor prednisolone is recommended for maintenance therapy in Crohn's disease 1

Microscopic Colitis

• Budesonide is the first-line treatment for symptomatic microscopic colitis 1
• Prednisolone should only be considered when budesonide therapy is not feasible due to cost or other factors 1

Ulcerative Colitis

• Budesonide MMX formulation is recommended for mild-to-moderate ulcerative colitis, particularly for left-sided disease 5, 6
• Prednisolone is preferred for moderate-to-severe or extensive ulcerative colitis 6

Dosing Considerations

• Standard budesonide dosing for Crohn's disease and microscopic colitis is 9 mg once daily for 8 weeks, followed by tapering over 1-2 weeks 5, 6
• Prednisolone is typically started at 40-60 mg daily (or 1 mg/kg) with gradual tapering over 6-8 weeks 1, 6
• Response to budesonide should be evaluated between 4-8 weeks to determine the need for therapy modification 5, 6

Important Clinical Considerations

• Cost may be a determining factor in treatment selection, with prednisolone being considerably less expensive than budesonide 1
• Budesonide should not be used for maintenance therapy as it is ineffective for this indication and prolonged use is associated with significant adverse effects 5
• In pediatric patients, budesonide shows less impact on growth and adrenal function compared to prednisolone, making it particularly valuable in this population 1, 3

Treatment Algorithm

1. For localized disease (ileum/ascending colon): Start with budesonide 9 mg daily 1, 5
2. For extensive or severe disease: Use prednisolone 40-60 mg daily 1
3. For microscopic colitis: Budesonide 9 mg daily is first-line; consider prednisolone only if budesonide is not feasible 1
4. For patients with growth concerns or at high risk for steroid side effects: Prefer budesonide when the disease location allows 3
5. For maintenance therapy: Avoid both steroids and transition to steroid-sparing agents 1, 5