Should I administer oral corticosteroids (oral steroids)?

Should I Give Oral Steroids?

The answer depends entirely on the underlying condition—oral corticosteroids are strongly recommended for moderate-to-severe inflammatory bowel disease (ulcerative colitis and Crohn's disease) and acute exacerbations of hypersensitivity pneumonitis, but should NOT be routinely prescribed for dysphonia (hoarseness) prior to laryngoscopy, and their use in other conditions requires specific clinical justification given significant adverse effects. 1

When Oral Steroids ARE Strongly Recommended

Inflammatory Bowel Disease

For ulcerative colitis:

• Moderate-to-severe disease: Prednisolone 40 mg daily, tapered over 6-8 weeks 1
• Mild-to-moderate disease failing 5-ASA therapy: Oral prednisolone is recommended as second-line therapy 1
• Single daily dosing is as effective as split-dosing and causes less adrenal suppression 1
• Approximately 50% of patients achieve remission, but 50% also experience short-term adverse events (acne, edema, sleep/mood disturbance, glucose intolerance, dyspepsia) 1

For Crohn's disease:

• Moderate-to-severe disease: Prednisone 40-60 mg/day to induce remission 1, 2
• Evaluate symptomatic response between 2-4 weeks to determine need for therapy modification 1, 2
• For hospitalized patients with severe disease: IV methylprednisolone 40-60 mg/day, with response evaluation within 1 week 1, 2
• Mild-to-moderate ileal/right colonic disease: Consider oral budesonide 9 mg/day as first-line (fewer systemic effects) 1

Hypersensitivity Pneumonitis (Acute Exacerbations)

• Prednisone starting at 40 mg daily for several weeks for acute non-fibrotic HP exacerbations 3
• Improvement in diffusion capacity (DLCO) documented after 1 month of treatment 3
• Resolution of radiographic abnormalities in up to 80% of treated patients 3
• Most effective in acute and subacute forms without established fibrosis 3

When Oral Steroids Should NOT Be Used

Dysphonia (Hoarseness)

Clinicians should NOT routinely prescribe corticosteroids for dysphonia prior to visualization of the larynx 1

• No studies support empiric use for acute or chronic laryngitis 1
• Risk of significant adverse events outweighs unproven benefits 1
• Laryngoscopy should be performed first to establish diagnosis 1

Maintenance Therapy in IBD

Oral corticosteroids should NEVER be used for maintenance therapy in ulcerative colitis or Crohn's disease 1, 2

• No significant reduction in relapse rates versus placebo 1
• Associated with serious infections (HR 1.57) and increased mortality (HR 2.14) 1
• No safe lower limit of dosing identified 1

Critical Adverse Effects to Monitor

Short-term use (even <21 days):

• Insomnia and gastrointestinal disturbances (most common) 1, 4
• Hyperglycemia, weight gain, mood disturbances 1, 3
• Sleep disturbances, facial flushing, fluid retention 1

Long-term use risks:

• Serious infections (HR 1.57), increased mortality (HR 2.14) 1
• Osteoporosis, hip/femur fractures (21-30% incidence) 1
• Cataracts, adrenal suppression, metabolic syndrome 1
• Cardiovascular disease, diabetes onset/progression 1
• Myopathy, particularly with high doses 5

Perioperative considerations:

• Preoperative corticosteroids (≥40 mg prednisolone) increase risk of postoperative infectious complications and anastomotic leaks in IBD surgery 1
• Prior to elective IBD surgery, corticosteroids should be stopped or dose minimized wherever possible 1

Important Drug Interactions and Contraindications

• Avoid in active infections (varicella, measles, systemic fungal infections, active tuberculosis, strongyloides) unless treating drug reactions 5
• Screen for hepatitis B before prolonged treatment—reactivation can occur 5
• Live vaccines are contraindicated during immunosuppressive doses 5
• Macrolide antibiotics significantly decrease corticosteroid clearance 5
• Fluoroquinolones increase tendon rupture risk, especially in elderly 5
• May require antidiabetic dose adjustments due to hyperglycemia 5

Key Clinical Pitfalls to Avoid

1. Never prescribe oral steroids empirically for dysphonia—always visualize the larynx first 1
2. Never use for IBD maintenance therapy—transition to steroid-sparing agents (thiopurines, anti-TNF, vedolizumab, tofacitinib) 1, 2
3. Patients requiring ≥2 courses of steroids per year need treatment escalation, not repeated steroid courses 1
4. Taper over 6-8 weeks—more rapid reduction associated with early relapse 1, 2
5. Monitor for steroid dependence—if patients cannot taper below 10-20 mg without symptom recurrence, escalate to steroid-sparing therapy 1