What is the treatment for steroid-induced enteritis?

Treatment of Steroid-Induced Enteritis

For steroid-induced enteritis with bowel edema, immediately switch from oral to intravenous steroids (methylprednisolone 60 mg every 24 hours OR hydrocortisone 100 mg four times daily) and assess response by day 3—if inadequate improvement occurs, initiate rescue therapy with infliximab or vedolizumab rather than continuing ineffective steroids. 1, 2

Initial Management and Route Selection

When bowel edema is present, oral steroid absorption is significantly impaired, making IV administration essential 1. The standard dosing regimen consists of:

• IV methylprednisolone 60 mg every 24 hours, OR
• IV hydrocortisone 100 mg four times daily 2, 1

Higher doses provide no additional benefit, while lower doses are less effective 2. Bolus injection is as effective as continuous infusion 2.

Critical Supportive Care

Concurrent with IV steroids, provide:

• IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day (hypokalemia and hypomagnesemia can precipitate toxic dilatation) 2, 1
• Low-molecular-weight heparin for thromboprophylaxis, as inflammatory bowel disease flares significantly increase thromboembolism risk 2
• Blood transfusion to maintain hemoglobin above 8-10 g/dL 2
• Withdrawal of anticholinergics, antidiarrheals, NSAIDs, and opioids which may precipitate colonic dilatation 2

Day 3 Assessment: The Critical Decision Point

Response to IV steroids must be assessed on day 3 2, 1. Failure indicators include:

• More than 8 bowel movements per day, OR
• 3-8 bowel movements per day with C-reactive protein >45 mg/L 1
• Presence of mucosal islands or colonic dilatation on abdominal radiography 1
• Deep ulceration on flexible sigmoidoscopy 1

Rescue Therapy for Steroid-Refractory Disease

If inadequate response by day 3, initiate rescue therapy immediately rather than continuing ineffective steroids beyond 7-10 days 2, 1. Options include:

First-Line Rescue Options:

• Infliximab 5 mg/kg IV at weeks 0,2, and 6 2
• Vedolizumab 300 mg IV at weeks 0,2, and 6 2
• Cyclosporine 2 mg/kg/day IV (particularly useful in patients who must avoid steroids due to psychosis, severe osteoporosis, or poorly controlled diabetes) 2, 1

Choosing Between Biologics:

Infliximab and vedolizumab appear equally effective for steroid-refractory enteritis 2. The choice should be based on:

• Avoid infliximab in patients with hematologic malignancies (risk of rare lymphomas), severe congestive heart failure, or concurrent hepatitis 2
• Consider vedolizumab when gut-selective immunosuppression is preferred or when infliximab is contraindicated 2
• Response to biologics typically occurs within 1 week, much faster than in standard IBD treatment 2

Special Context: Immune Checkpoint Inhibitor-Related Enteritis

For ICI-related enteritis specifically:

• Grade 2-3: Start with corticosteroids 1-2 mg/kg/day prednisone equivalent 2
• If steroid-refractory after 72 hours: Add infliximab or vedolizumab 2
• Endoscopy is highly recommended for grade ≥2 to stratify patients for early biologic treatment based on endoscopic features 2
• Early introduction of biologics (within 14 days of steroid failure) results in higher resolution rates (94.4% vs 89.7%) 3

Critical Pitfalls to Avoid

Do not continue ineffective IV steroids beyond 7-10 days—this increases morbidity and mortality associated with delayed surgery 2. Patients remaining on ineffective medical therapy suffer high morbidity 2.

Only one attempt at rescue therapy should be considered before referral for colectomy 2. Sequential rescue therapy carries acceptable short-term outcomes (62.4% response rate) but increases adverse events (23% overall, 6.7% serious infections, 1% mortality) 2.

Early surgical consultation is mandatory—involve colorectal surgery on day of admission, particularly if systemic toxicity, severe abdominal pain, or suspicion of toxic megacolon develops 1. Perforation carries up to 50% mortality 2.

Infection Screening

Before escalating immunosuppression:

• Screen for C. difficile, CMV, and other enteric infections 1
• If C. difficile positive: Treat with oral vancomycin 500 mg every 6 hours for 10 days while continuing steroids 1
• Perform unprepared flexible sigmoidoscopy with biopsy to exclude CMV infection, which is associated with steroid-refractory disease 2