What is the role of prednisone in treating Crohn's disease?

Prednisone for Crohn's Disease

Prednisone 40-60 mg/day is the recommended treatment for inducing remission in moderate to severe Crohn's disease, but it should never be used for maintenance therapy due to ineffectiveness and significant toxicity risk. 1

Indications and Dosing

When to Use Prednisone

• Use prednisone 40-60 mg/day for moderate to severe Crohn's disease to induce complete remission 1
• Use prednisone 40-60 mg/day for moderate disease that has failed budesonide 9 mg/day 1
• For hospitalized patients with severe disease requiring IV therapy, use methylprednisolone 40-60 mg/day 2

Dosing Strategy

• Start with prednisone 40-60 mg/day (or 0.5-1 mg/kg/day, with higher doses for more severe disease) 1
• Evaluate response between 2-4 weeks to determine if therapy modification is needed 1
• Taper gradually over 8 weeks after achieving remission, as rapid reduction causes early relapse 2
• Doses below 15 mg/day are ineffective for active disease 1

Efficacy

Prednisone demonstrates strong efficacy for induction of remission:

• 60-83% remission rate in moderate to severe Crohn's disease compared to 30-38% with placebo (NNT = 2-3) 1, 3
• One study showed 92% remission within 7 weeks using prednisone 1 mg/kg/day without tapering 1

Critical Limitations

No Role in Maintenance Therapy

Corticosteroids are strongly contraindicated for maintenance therapy in Crohn's disease of any severity due to:

• Complete ineffectiveness at maintaining remission 1
• High risk of serious adverse effects with prolonged use 4
• Nearly 50% of initial responders develop steroid dependency or relapse within 1 year 4

Steroid-Sparing Strategy Required

Initiate steroid-sparing agents for patients who:

• Require two or more corticosteroid courses within a calendar year 1
• Have disease that relapses as steroid dose is reduced below 15 mg 1
• Experience relapse within 6 weeks of stopping steroids 1

Options for steroid-sparing maintenance include:

• Thiopurines (azathioprine 2-2.5 mg/kg/day or 6-mercaptopurine 1-1.5 mg/kg/day) for selected patients 1
• Parenteral methotrexate for steroid-dependent/resistant disease 1
• Anti-TNF therapy (infliximab, adalimumab) for patients failing corticosteroids 3, 2

Adverse Effects and Monitoring

Common Toxicities

Prednisone carries significant risks that worsen with duration:

• Bone loss (can develop even with short-term, low-dose therapy) 4
• Metabolic complications including glucose intolerance and diabetes 4
• Increased intraocular pressure and glaucoma 4
• Potentially lethal infections 4
• Suppression of pituitary-adrenal function 5

Monitoring Requirements

• Evaluate symptomatic response at 2-4 weeks for oral prednisone 1
• Evaluate within 1 week for IV methylprednisolone in hospitalized patients 2
• Monitor for corticosteroid-associated side effects throughout treatment 5

Alternative Considerations

Budesonide as First-Line for Mild-Moderate Disease

• For mild to moderate ileal and/or right colonic disease, use budesonide 9 mg/day first before escalating to prednisone 1, 3, 2
• Budesonide has significantly fewer glucocorticoid-associated side effects and less pituitary-adrenal suppression than prednisone 5
• Budesonide is slightly less effective than prednisolone (53% vs 66% remission rate) but with better tolerability 5

Clinical Pitfalls to Avoid

• Never use prednisone for maintenance therapy - it is ineffective and harmful 1
• Do not taper too rapidly - this causes early relapse 1, 2
• Do not continue prednisone beyond induction without initiating steroid-sparing agents in patients at risk for dependency 1
• Do not use doses below 40 mg/day for moderate to severe disease - they are subtherapeutic 1
• Do not delay evaluation of response - assess at 2-4 weeks to avoid prolonged ineffective therapy 1