Is IBD "Steroid-Loving" Disease?
No, IBD is not "steroid-loving" disease—it is "steroid-responsive" for acute flares but steroids are ineffective for maintenance therapy and should be avoided for long-term use. 1
Steroids Are Effective for Induction, Not Maintenance
Corticosteroids successfully induce clinical remission in moderate to severe IBD flares but have no role in preventing relapse. 1 The British Society of Gastroenterology guidelines explicitly state that corticosteroids, including budesonide, are not effective for maintaining remission in Crohn's disease. 1
Acute Treatment Efficacy
- Oral prednisolone 40 mg daily is appropriate for moderate to severe Crohn's disease or mild-moderate disease that failed mesalazine. 1
- Intravenous steroids (hydrocortisone 400 mg/day or methylprednisolone 60 mg/day) are appropriate for severe disease. 1
- Budesonide 9 mg daily is effective for isolated ileocecal Crohn's disease with moderate activity, though marginally less effective than prednisolone. 1
The Problem: Steroid Dependency and Excess
Steroid dependency occurs in approximately 15% of IBD patients and represents a failure of appropriate disease management, not a therapeutic goal. 1 Steroid-dependent disease is defined as inability to wean below 10 mg prednisolone within 3 months of starting, or disease flare within 3 months of stopping steroids. 1
Steroid excess (two or more courses over 1 year) is associated with increased mortality, particularly in Crohn's disease. 1 Prolonged steroid use (>3 months) causes numerous complications including increased infection risk, osteoporosis, hypothalamic-pituitary-adrenal axis suppression, diabetes, weight gain, and cardiovascular disease. 1, 2
The Correct Approach: Steroid-Sparing Strategies
When patients require steroids more than once per year or cannot be weaned off steroids, immunomodulation with azathioprine, mercaptopurine, or methotrexate should be initiated. 1
First-Line Steroid-Sparing Agents
- Azathioprine 1.5-2.5 mg/kg/day or mercaptopurine 0.75-1.5 mg/kg/day are first-line agents for steroid-dependent disease. 1
- Methotrexate 25 mg IM weekly for 16 weeks followed by 15 mg weekly is effective for chronic active disease. 1
Biologics for Steroid-Refractory Disease
Infliximab 5 mg/kg should be reserved for patients with moderate to severe disease who are refractory to or intolerant of steroids, mesalazine, azathioprine/mercaptopurine, and methotrexate, where surgery is inappropriate. 1
Practical Steroid Management
Tapering Protocol
Prednisolone should be reduced gradually over 8 weeks according to severity and patient response—more rapid reduction is associated with early relapse. 1 During the COVID-19 pandemic, rapid tapering (10 mg/week) was recommended when necessary, though this must be balanced against risks of extending overall steroid exposure. 1
Avoiding Steroid Excess
Steroids should be avoided if possible, and when necessary, alternative formulations should be considered: 1
- Budesonide MMX 9 mg/day for 8 weeks or beclometasone 5 mg/day for 4 weeks for flaring ulcerative colitis
- Exclusive enteral nutrition for flaring Crohn's disease
- Budesonide 9 mg/day for 8 weeks for active small bowel and ileocecal Crohn's disease
Common Pitfalls
Primary care prescriptions are frequently inappropriate in dose and duration, with only 41% meeting standards compared to 85% from secondary care. 3 Patients receiving steroids from primary care without communication to secondary care are less likely to receive timely treatment escalation (49% vs 66%) and steroid excess is more often avoidable (73% vs 56%). 3
Patients with steroid excess have 12-fold higher risk of IBD-related hospitalization and nearly 3-fold higher risk of infection-related hospitalization. 3
Bottom Line
IBD responds to steroids acutely but this response should trigger escalation to steroid-sparing immunomodulators or biologics, not continued steroid use. 1 The term "steroid-loving" is a dangerous misnomer that could perpetuate harmful long-term steroid exposure. The goal is steroid-free remission through appropriate use of maintenance therapies.