What is the typical dose of prednisolone (corticosteroid) for ulcerative colitis flares?

Prednisolone Dosing for Ulcerative Colitis Flares

For moderate to severe ulcerative colitis flares, prescribe prednisolone 40 mg orally once daily as a single morning dose, then taper gradually over 6-8 weeks. 1, 2

Standard Dosing Regimen

• Initial dose: 40 mg daily as a single morning dose for moderate to severe UC flares 1, 3
• Single daily dosing is preferred over split-dosing because it is equally effective and causes less adrenal suppression 1, 3
• Duration: Taper over 6-8 weeks after achieving clinical response 1, 2

Evidence Base for 40 mg Dose

• The 40 mg dose is based on Baron's studies demonstrating superiority over 20 mg/day 1
• No additional benefit exists with doses above 40-60 mg/day, and higher doses increase adverse effects 1
• This represents a strong recommendation with high-quality evidence from the British Society of Gastroenterology 1

Treatment Response Timeline

• Assess response within 2 weeks of initiating prednisolone 40 mg/day 1, 3
• Clinical and endoscopic improvements may be seen within 2 weeks 1
• If no response after 2 weeks, consider treatment escalation to biologics or hospital admission depending on systemic symptoms 1, 3

Alternative Corticosteroid Options

For patients wishing to avoid systemic corticosteroids:

• Budesonide MMX 9 mg/day for 8 weeks (topically-acting oral corticosteroid) 2, 3
• Beclomethasone dipropionate 5 mg/day for 4 weeks (shown to be non-inferior to prednisolone in mild-moderate UC) 2, 3

Critical Safety Considerations

Expected Adverse Effects

• Approximately 50% of patients experience short-term adverse events including acne, edema, sleep disturbance, mood changes, glucose intolerance, and dyspepsia 1, 2, 3

When to Escalate Therapy

Patients requiring treatment escalation (not maintenance corticosteroids):

• Two or more courses of corticosteroids in the past year 1, 2, 3
• Corticosteroid-dependent disease (unable to taper off) 1, 2, 3
• Corticosteroid-refractory disease (no response after 2 weeks) 1, 3

Escalation options include: thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib 1, 2, 3

Common Pitfall to Avoid

Do not prolong high-dose oral corticosteroids beyond 2 weeks without response, as this has diminishing chance of achieving remission and increases risk of infective, metabolic, and surgical complications 1

Severe Disease Requiring Hospitalization

For patients with systemic symptoms (fever, severe pain, significant anemia, generally unwell):

• Admit for inpatient management rather than continuing oral therapy 1
• Intravenous options: methylprednisolone 60 mg IV daily or hydrocortisone 100 mg four times daily 3