Steroid Dosing and Duration for Crohn's Disease
For moderate to severe Crohn's disease, use oral prednisone 40-60 mg/day to induce remission, evaluate response at 2-4 weeks, then taper gradually over 8 weeks—never use steroids for maintenance therapy. 1
Initial Steroid Selection and Dosing
Mild to Moderate Disease (Ileal/Right Colon)
- Start with budesonide 9 mg/day orally as first-line therapy for mild to moderate disease limited to the ileum and/or right colon 1, 2
- Evaluate response between 4-8 weeks to determine if therapy modification is needed 1
- If budesonide fails, escalate to prednisone 40-60 mg/day 1
Moderate to Severe Disease
- Use prednisone 40-60 mg/day orally as the standard induction regimen 1, 2
- This achieves remission in 60-83% of patients 2
- Evaluate symptomatic response between 2-4 weeks 1, 3
Severe Disease Requiring Hospitalization
- Use IV methylprednisolone 40-60 mg/day (typically 40 mg every 8 hours) 1, 3
- Evaluate response within 1 week to determine need for therapy modification 1, 3
- Transition to oral prednisone 40-60 mg/day once patient responds and can tolerate oral intake 3
Steroid Tapering Protocol
Taper prednisone gradually over 8 weeks after achieving remission—more rapid tapering is associated with early relapse 3. While specific tapering schedules vary, the evidence supports a minimum 4-week taper, with 8-12 weeks being optimal 4, 3.
Critical Pitfall to Avoid
- Never use corticosteroids for maintenance therapy in Crohn's disease of any severity 1, 3
- Steroids are ineffective for maintaining remission and carry significant long-term toxicity risks 5, 6
When Steroids Fail or Dependency Develops
Steroid-Dependent Patients (36% at one year)
If patients relapse during tapering or require repeated courses 6:
- Initiate anti-TNF therapy (infliximab or adalimumab) as the most effective option 1, 2, 7
- Consider thiopurine monotherapy for selected patients who achieved remission on steroids 1
- Consider parenteral methotrexate for steroid-dependent/resistant disease 1
Steroid-Refractory Patients (20% at one year)
If no response by 2-4 weeks for oral steroids or 1 week for IV steroids 1:
- Switch to anti-TNF therapy (infliximab or adalimumab) 1, 2
- For patients with risk factors for poor prognosis, anti-TNF should be considered first-line instead of steroids 1
Risk Factors for Steroid Relapse
Patients at higher risk for relapse after steroid withdrawal include those with 4:
- Multiple courses of steroid treatment in the previous 3 years
- Short time interval since previous steroid treatment
Anti-TNF Dosing When Transitioning from Steroids
Infliximab
- 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks for maintenance 8
- Evaluate response between 8-12 weeks 1
Adalimumab
- 160 mg subcutaneous on Day 1 (single dose or split over 2 days), 80 mg on Day 15, then 40 mg every other week starting Day 29 9
- Higher induction dosing (160/80 mg) is associated with better steroid discontinuation rates 7
Monitoring and Safety Considerations
- Aminosalicylates and corticosteroids may be continued during anti-TNF initiation 9
- Patients who do not achieve corticosteroid-free remission within 12-16 weeks on thiopurines or methotrexate should have therapy modified 1
- Long-term steroid use carries risks of osteoporosis, diabetes, infection, hypertension, and psychosis 6