What is the recommended steroid dose for a moderate to severe Crohn's (Crohn's disease) exacerbation?

Steroid Dosing for Crohn's Disease Exacerbation

For moderate to severe Crohn's disease exacerbations, use oral prednisone 40-60 mg/day to induce remission, with response assessment at 2-4 weeks. 1

Outpatient Oral Therapy

Moderate to Severe Disease

• Prednisone 40-60 mg/day is the recommended dose for moderate to severe Crohn's disease exacerbations 1, 2
• This represents a strong recommendation despite low-quality evidence, reflecting decades of clinical experience showing 60-83% remission rates 2
• Evaluate symptomatic response between 2-4 weeks to determine if therapy modification is needed 1, 3
• Taper gradually over 8 weeks after achieving remission, as more rapid reduction increases early relapse risk 3

Mild to Moderate Disease (Ileal/Right Colonic)

• Start with budesonide 9 mg/day as first-line therapy for disease limited to the ileum and/or right colon 1, 2
• Budesonide causes fewer corticosteroid-associated side effects (29% vs 48% with prednisolone) and less adrenal suppression 4
• However, budesonide is less effective than conventional steroids (53% vs 66% remission rates) 4
• Assess response at 4-8 weeks 1

Escalation After Budesonide Failure

• If moderate disease fails budesonide 9 mg/day, escalate to prednisone 40-60 mg/day 1
• This conditional recommendation acknowledges that budesonide failure may indicate more aggressive disease requiring systemic corticosteroids 1

Inpatient Intravenous Therapy

Severe Disease Requiring Hospitalization

• Use IV methylprednisolone 40-60 mg/day (typically 40 mg every 8 hours) for patients sick enough to require admission 1, 3
• IV administration ensures predictable drug delivery when gastrointestinal absorption may be compromised 3
• Evaluate response within 1 week to determine need for therapy modification or escalation to biologics 1, 3
• Transition to oral prednisone 40-60 mg/day once patient can tolerate oral intake and shows clinical improvement 3

Critical Pitfalls to Avoid

Never Use Steroids for Maintenance

• Corticosteroids are strongly contraindicated for maintenance therapy in Crohn's disease of any severity 1, 3
• Nearly half of patients who initially respond develop steroid dependency or relapse within 1 year 5, 6
• At 1 year after first steroid course: 44% remain steroid-responsive, 36% become steroid-dependent, and 20% become steroid-refractory 6

Recognize Steroid Dependency Early

• Multiple prior steroid courses and short intervals between treatments are risk factors for relapse 7
• For patients requiring repeated courses, immediately initiate steroid-sparing agents: thiopurines, methotrexate, or anti-TNF biologics 2, 3
• Budesonide 6 mg/day has some steroid-sparing effect but still causes adrenal suppression 6

Serious Adverse Effects

• Bone loss can develop even with short-term, low-dose therapy 5
• Other major toxicities include glucose intolerance, glaucoma, infections, hypertension, diabetes, osteonecrosis, myopathy, cataracts, and psychosis 5, 6
• Side effects during a 4-month tapering course are common: moon face (most common), acne, infection, ecchymoses, hypertension, hirsutism 6

When to Escalate Beyond Steroids

Steroid Failure or Dependency

• If no symptomatic response by 2-4 weeks (oral) or 1 week (IV), escalate to biologics 1, 3
• Anti-TNF therapy (infliximab, adalimumab) is recommended for moderate to severe disease failing corticosteroids 2, 3
• Vedolizumab or ustekinumab are alternatives for anti-TNF failures 3

High-Risk Features

• Patients with adverse prognostic factors (young age at diagnosis, perianal disease, extensive disease, deep ulcers, prior surgery) should be considered for early biologic therapy rather than prolonged steroid exposure 3