What is the recommended steroid treatment for a Crohn's (Crohn's disease) flare?

Steroid Treatment for Crohn's Disease Flare

For moderate to severe Crohn's disease flares, use oral prednisone 40-60 mg/day to induce remission, with response assessment at 2-4 weeks; for mild to moderate disease limited to the ileum and/or right colon, use budesonide 9 mg/day as first-line therapy. 1

Disease Severity-Based Steroid Selection

Mild to Moderate Disease (Ileal/Right Colonic)

• Start with oral budesonide 9 mg/day as first-line therapy for patients with disease limited to the ileum and/or ascending colon 1, 2
• Budesonide offers comparable efficacy to conventional steroids with significantly fewer glucocorticoid-associated side effects (29% vs 48% of patients experienced side effects, p=0.003) and less suppression of the hypothalamic-pituitary-adrenal axis 3
• Evaluate symptomatic response between 4-8 weeks to determine if therapy modification is needed 1
• If patients fail to respond to budesonide 9 mg/day, escalate to prednisone 40-60 mg/day 1

Moderate to Severe Disease

• Use oral prednisone 40-60 mg/day to induce complete remission - this is a strong recommendation despite low-quality evidence 1
• Prednisone induces remission in 60-83% of patients with moderate to severe Crohn's disease 2
• Evaluate response between 2-4 weeks to determine need for therapy modification 1
• Patients who do not respond within this timeframe should have their treatment escalated rather than continuing ineffective therapy 1

Severe Disease Requiring Hospitalization

• Use intravenous methylprednisolone 40-60 mg/day (typically administered as 40 mg every 8 hours) for patients whose disease severity requires hospitalization 1, 4
• Assess response within 1 week - this is critical as non-responders need rapid therapy modification 1, 4
• IV administration ensures predictable drug delivery when gastrointestinal absorption may be compromised 4

Steroid Tapering and Duration

• Taper prednisone gradually over 8 weeks - more rapid reduction is associated with early relapse 4
• The duration of steroid therapy does not significantly impact long-term remission rates; both 7-week and 15-week regimens show similar relapse rates (53% vs 37%, p=NS) 5
• Multiple previous steroid courses and short intervals since last steroid treatment are risk factors for relapse 5

Critical Maintenance Considerations

• Never use oral corticosteroids for maintenance therapy - this is a strong recommendation across all disease severities 1, 4
• Corticosteroids are ineffective at maintaining remission and carry high risks of serious adverse effects including bone loss, metabolic complications, glaucoma, and potentially lethal infections 6
• Nearly 50% of patients who initially respond to corticosteroids develop steroid dependency or relapse within 1 year 6

Steroid-Sparing Strategy

For Patients Requiring Repeated Steroid Courses

• Consider anti-TNF therapy (infliximab, adalimumab) as first-line for patients with moderate to severe disease and risk factors for poor prognosis - this is a strong recommendation with moderate-quality evidence 1, 2
• Anti-TNF therapy is strongly recommended for patients who fail to achieve remission with corticosteroids 1, 2
• Infliximab dosing: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks for maintenance 7

Alternative Maintenance Options

• For selected patients who achieve remission on steroids, consider thiopurine monotherapy to maintain remission 1, 2
• Parenteral methotrexate can be used for corticosteroid-dependent/resistant disease and subsequent maintenance 1, 2
• Evaluate response to immunosuppressants within 12-16 weeks; modify therapy if corticosteroid-free remission is not achieved 1

Common Pitfalls to Avoid

• Do not continue steroids beyond induction - the evidence clearly shows no benefit for maintenance and significant harm 1, 6
• Do not delay escalation in non-responders - patients who fail to respond by week 2-4 (oral steroids) or week 1 (IV steroids) need immediate therapy modification 1
• Do not use budesonide for maintenance - even this better-tolerated steroid should not be used long-term 1
• Avoid long-term opioid use for pain management as it is associated with poor outcomes in IBD patients 4