When is budesonide (corticosteroid) used?

When to Use Budesonide

Budesonide is primarily used for inducing remission in mild-to-moderate Crohn's disease limited to the ileum and/or ascending colon, and for controlling persistent asthma in children and adults. 1

Crohn's Disease (Oral Formulations)

Primary Indication

• Use budesonide 9 mg/day for active mild-to-moderate Crohn's disease involving the ileum and/or ascending colon 1
• This represents a strong recommendation based on moderate-quality evidence showing budesonide is superior to placebo (RR: 1.93; 95% CI: 1.37–2.73) for inducing clinical remission at 8 weeks 1

When NOT to Use Budesonide in Crohn's Disease

• Do not use for severe presentations or exacerbations - switch to systemic corticosteroids (prednisolone 40-60 mg/day) instead 1
• Do not use for maintenance therapy - budesonide is ineffective for maintaining remission and prolonged use causes significant adverse effects 2
• Avoid in patients with obstructive symptoms 1

Timing of Assessment

• Evaluate for symptomatic response between 4-8 weeks to determine if therapy modification is needed 2
• If no improvement by 2-4 weeks, consider escalating to systemic corticosteroids 1

Advantages Over Conventional Steroids

• Budesonide has high topical anti-inflammatory activity with low systemic absorption (11% bioavailability), resulting in fewer glucocorticoid-related side effects than prednisolone 1, 3
• Moon face occurs significantly less frequently with budesonide compared to prednisolone (p = 0.0005) 4
• Adrenal suppression is less common than with prednisolone (p = 0.0023) 4

Ulcerative Colitis (Oral Extended-Release Formulations)

Primary Indication

• Use budesonide MMX 9 mg/day as an alternative to conventional steroids for mild-to-moderate ulcerative colitis with inadequate response to mesalazine 2, 5
• Particularly effective for left-sided disease, but less effective for extensive colitis 2

Efficacy Data

• 8-week combined clinical and endoscopic remission: 20.3% vs 3.2% for placebo 2
• Endoscopic healing: 27.6% vs 17.1% for placebo 2

Treatment Duration

• Use for 8 weeks maximum for induction 2
• Do not use for maintenance therapy - corticosteroids are ineffective for maintenance and cause significant adverse effects with prolonged use 2
• Taper over 1-2 weeks after achieving remission rather than abrupt discontinuation 2

Asthma (Inhaled Formulations)

Primary Indications

• Long-term maintenance control of persistent asthma in children aged 12 months to 8 years (inhalation suspension) 6
• Treatment of mild-to-moderate persistent asthma in adults and adolescents (dry powder inhaler) 7, 8

Dosing Considerations

• Children with persistent asthma: 0.5-2 mg/day via nebulizer significantly reduces symptom scores and beta2-agonist requirements compared to placebo 7
• Adults with persistent asthma: up to 8 mg/day via nebulizer or 200-400 mcg/day via dry powder inhaler for mild disease 7, 9
• Once-daily dosing is as effective as twice-daily in mild-to-moderate asthma and may improve compliance 8

Special Populations

• Preschool children with severe persistent asthma: 2 mg/day significantly reduces exacerbations and systemic corticosteroid requirements 7
• Preterm very low birthweight infants: 1 mg/day appears to reduce need for mechanical ventilation and decrease overall corticosteroid usage 7

When NOT to Use

• Do not use to treat sudden asthma symptoms or acute attacks - always have a short-acting beta2-agonist (rescue inhaler) available 6

Croup (Inhaled Suspension)

• Single doses of 2-4 mg are as effective as oral dexamethasone 0.6 mg/kg for alleviating croup symptoms and reducing hospitalization 7

Important Contraindications and Precautions

Absolute Contraindications

• Allergy to budesonide 6
• As sole therapy for acute severe disease requiring systemic intervention 1, 6

Use with Caution

• Active or recent tuberculosis, untreated fungal/bacterial/viral/parasitic infections, or ocular herpes simplex 6
• Patients at risk for decreased bone mineral density (family history of osteoporosis, poor nutrition, long-term bone-thinning medications) 6
• Poorly controlled diabetes, history of steroid-induced psychosis, avascular necrosis, or severe osteoporosis 1
• Liver problems (budesonide undergoes extensive first-pass hepatic metabolism) 6

Monitoring Requirements

• Growth velocity in children - corticosteroids may reduce growth; close monitoring required 6
• Regular eye examinations - long-term use increases risk of cataracts and glaucoma 6
• Bone mineral density in at-risk patients 6
• Adrenal function if transferring from systemic corticosteroids - taper slowly to avoid adrenal insufficiency 6

Common Pitfalls to Avoid

• Using budesonide for maintenance therapy in IBD - this is ineffective and exposes patients to unnecessary risks 2
• Failing to escalate therapy within 2-4 weeks of non-response - delays necessary treatment modifications 1, 2
• Using budesonide for severe Crohn's disease or extensive ulcerative colitis - systemic corticosteroids are required 1, 2
• Abrupt discontinuation after remission - taper over 1-2 weeks to prevent symptom recurrence 2
• Expecting immediate results - maximum benefit may take 4-6 weeks in asthma 6