Steroid Management in Inflammatory Bowel Disease
Direct Recommendation
For moderate to severe IBD flares, initiate prednisolone 40 mg daily as a single morning dose, taper over 6-8 weeks, and never use steroids for maintenance therapy. 1
Initial Dosing Strategy
Ulcerative Colitis
- Start prednisolone 40 mg daily for moderate to severe disease, which achieves 77% remission within 2 weeks 1
- Doses of 60 mg/day increase adverse events without added benefit, making 40 mg optimal 1
- Combine oral and rectal steroids for superior efficacy compared to either alone 1
- Doses below 15 mg daily are ineffective for active disease 1
Crohn's Disease
- Use prednisone 0.5-0.75 mg/kg/day (higher dose for more severe disease) with tapering over 17 weeks, achieving 60% remission (NNT=3) 1
- Alternatively, prednisone 1 mg/kg/day achieves 83% remission over 18 weeks (NNT=2) 1
- For ileocecal Crohn's disease specifically, budesonide 9 mg daily is an appropriate first-line alternative with reduced systemic toxicity 1
Tapering Protocol
Standard Approach
- Taper prednisolone over 6-8 weeks once clinical response is achieved 1
- Administer as a single morning dose (before 9 am) to minimize adrenal suppression 2
- Too rapid reduction associates with early relapse 1
- Monitor closely as dose decreases below 15 mg, as this is when disease relapse commonly occurs 1
Critical Pitfall
Never taper too rapidly—the evidence consistently shows that rapid dose reduction leads to early relapse, yet doses must be reduced systematically to avoid prolonged steroid exposure 1, 3
Identifying Steroid Dependency
Escalate to steroid-sparing therapy if patients meet any of these criteria:
- Require ≥2 corticosteroid courses within a calendar year 1
- Disease relapses as steroid dose reduces below 15 mg 1
- Relapse within 6 weeks of stopping steroids 1
When steroid dependency is identified, initiate thiopurines (azathioprine 2-2.5 mg/kg/day or 6-mercaptopurine 1-1.5 mg/kg/day), anti-TNF therapy, vedolizumab, or tofacitinib rather than repeating steroid courses 1
Alternative Steroid Formulations
When to Use Low-Bioavailability Steroids
These agents provide topical anti-inflammatory effects with reduced systemic toxicity:
- Budesonide MMX 9 mg daily for mild to moderate ulcerative colitis (especially left-sided disease) when patients wish to avoid systemic steroids 1
- Beclomethasone dipropionate 5 mg daily for 4 weeks as an alternative for ulcerative colitis when 5-ASA fails 1
- Budesonide (Entocort) 9 mg daily for ileocecal Crohn's disease—slightly less effective than prednisolone but with better safety profile 1
Critical Safety Considerations
Adverse Events
- Approximately 50% of patients experience short-term adverse effects including acne, edema, sleep disturbance, mood changes, glucose intolerance, and dyspepsia 1
- Adverse events are significantly more frequent at 60 mg/day versus 40 mg/day without added benefit 1
Infection Risk Management
- High-dose steroids (≥20 mg prednisolone daily) significantly increase risk of respiratory tract infection, opportunistic infection, and septicemia 3
- Add PCP prophylaxis if >3 weeks of immunosuppression expected at doses >30 mg prednisone equivalent daily 3
- Start proton pump inhibitor for GI prophylaxis during corticosteroid use 3
Absolute Contraindication for Maintenance
Corticosteroids have NO role in maintenance therapy for either ulcerative colitis or Crohn's disease 1. This is a critical principle—steroids are purely for induction of remission. The goal from the outset must be complete withdrawal 1, 3.
If a patient cannot be weaned off steroids, this represents treatment failure requiring escalation to steroid-sparing agents (thiopurines, biologics, or small molecules), not continued steroid use 1.