What is the recommended dosage and treatment protocol for prednisone (corticosteroid) in managing colitis?

Prednisone Dosing and Treatment Protocol for Colitis

For moderate to severe ulcerative colitis, start prednisone 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 with 40 mg prednisone daily for moderate to severe disease—this achieves 77% remission within 2 weeks and is the optimal dose 2, 1, 3
• Doses of 60 mg/day increase adverse events without added benefit, making 40 mg the ceiling dose 1, 3
• For mild to moderate disease that fails 5-ASA therapy, use the same 40 mg daily regimen as second-line treatment 2
• Administer as a single morning dose rather than divided doses—equally effective with less adrenal suppression 3
• Combining oral and rectal steroids is superior to either alone 1
• Doses below 15 mg daily are ineffective for active disease 1

Crohn's Disease

• For moderate to severe Crohn's disease, use prednisone 40 mg daily (or 0.5-0.75 mg/kg/day for weight-based dosing) 2, 1
• For more severe presentations, consider 1 mg/kg/day which achieves 83% remission over 18 weeks (NNT=2) 1
• For isolated ileocecal disease, budesonide 9 mg daily is an appropriate first-line alternative with reduced systemic toxicity, though marginally less effective than prednisolone 2, 1

Severe/Hospitalized Disease

• Use intravenous hydrocortisone 400 mg/day or methylprednisolone 60 mg/day for severe colitis requiring hospitalization 2, 3
• Add concomitant intravenous metronidazole as it may be difficult to distinguish active disease from septic complications 2

Tapering Protocol

• Reduce prednisolone gradually over 6-8 weeks once clinical response is achieved 2, 1, 3
• Most commonly, reduce by 5 mg/week, though the evidence base for specific tapering schedules is weak 4
• Too rapid reduction associates with early relapse 2, 1
• Monitor closely as dose decreases below 15 mg—this is when disease relapse commonly occurs 1
• Assess response within the first 2 weeks to determine if therapy modification is needed 3

Alternative Steroid Formulations

When patients wish to avoid systemic steroids or have contraindications:

• Budesonide MMX 9 mg daily for 8 weeks for mild to moderate ulcerative colitis (especially left-sided disease) 2, 1, 3
• Beclomethasone dipropionate 5 mg daily for 4 weeks—non-inferior to prednisolone in mild to moderate ulcerative colitis 1, 3
• Budesonide (Entocort) 9 mg daily for ileocecal Crohn's disease—slightly less effective than prednisolone but with better safety profile 2, 1

Identifying Steroid Dependency and Escalation

Escalate to steroid-sparing therapy if patients meet any of these criteria:

• Require ≥2 corticosteroid courses within a calendar year 1
• Have disease relapse 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) 1
• Anti-TNF therapy 1
• Vedolizumab 1
• Tofacitinib 1

Critical Safety Considerations

Common Adverse Effects

• Approximately 50% of patients experience short-term adverse effects including acne, edema, sleep disturbance, mood changes, glucose intolerance, and dyspepsia 2, 1, 3
• Adverse events are significantly more frequent at 60 mg/day versus 40 mg/day without added benefit 1

Infection Risk

• High-dose steroids (≥20 mg prednisolone daily) significantly increase risk of respiratory tract infection, opportunistic infection, and septicemia 1
• Add PCP prophylaxis if >3 weeks of immunosuppression expected at doses >30 mg prednisone equivalent daily 1
• Start proton pump inhibitor for GI prophylaxis during corticosteroid use 1

Long-term Complications

• Long-term use associates with cataracts, osteoporosis, myopathy, and susceptibility to infections 2
• In Crohn's disease patients, prednisone therapy was associated with increased risk of serious infections (hazard ratio 1.57) and increased mortality (hazard ratio 2.14) 2

Absolute Contraindication

Corticosteroids have NO role in maintenance therapy for either ulcerative colitis or Crohn's disease—they are ineffective for this indication and their prolonged use is associated with significant adverse effects that outweigh any benefits 2, 1, 3