What is the recommended steroid regimen for controlling acute flares of Ulcerative Colitis (UC) and Crohn's Disease (CD)?

Steroid Management for UC and Crohn's Disease Flares

For ulcerative colitis flares, start prednisolone 40 mg daily as a single morning dose and taper over 6-8 weeks; for Crohn's disease, use prednisone 0.5-1 mg/kg/day with the higher dose for more severe disease, tapering over 17-18 weeks. 1

Initial Dosing for Ulcerative Colitis

Outpatient Management:

• Start prednisolone 40 mg daily as a single morning dose, which achieves 77% remission within 2 weeks 1
• Do NOT use 60 mg/day—this increases adverse events without added benefit 2, 1
• Combining oral and rectal steroids is superior to either alone 1
• Doses below 15 mg daily are ineffective for active disease 1

Inpatient Management (Moderate-Severe Flares):

• Use methylprednisolone 40-60 mg IV every 24 hours OR hydrocortisone 100 mg IV three times daily 3
• If patients fail to respond after 3-5 days of IV corticosteroids, consider rescue therapy with cyclosporine 2 mg/kg IV or infliximab 5 mg/kg IV 4
• Patients who fail oral steroids can still respond to IV steroids (75% initial response rate), but 35% develop steroid-dependency long-term 5

Initial Dosing for Crohn's Disease

Standard Approach:

• 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

Ileocecal Disease:

• Budesonide 9 mg daily is an appropriate first-line alternative with reduced systemic toxicity for ileocecal Crohn's disease 1
• Budesonide is slightly less effective than prednisolone but has a better safety profile 2, 1

Tapering Protocol

Critical Tapering Principles:

• Taper prednisolone over 6-8 weeks once clinical response is achieved 1
• Most commonly, reduce by 5 mg/week, though practice varies widely 6
• Too rapid reduction associates with early relapse 1
• Monitor closely as dose decreases below 15 mg—this is when disease relapse commonly occurs 1

Common Pitfall: Reducing steroids too quickly or below 15 mg without adequate monitoring leads to early relapse 2, 1

Discharge Planning After Hospitalization

Discharge Criteria:

• Discharge when rectal bleeding has resolved (Mayo subscore 0-1) AND/OR stool frequency has returned to baseline (Mayo subscore 0-1) 3
• Discharge on prednisone 40 mg after observing patients for 24 hours to ensure stability 3

Post-Discharge Follow-Up:

• Clinical follow-up within 2 weeks 3
• Lower endoscopy within 4-6 months after discharge 3

Identifying Steroid Dependency and Escalation

Escalate to steroid-sparing therapy if: 1

• Patients require ≥2 corticosteroid courses within a calendar year
• Disease relapses as steroid dose reduces below 15 mg
• Relapse occurs within 6 weeks of stopping steroids

Steroid-Sparing Options:

• Initiate thiopurines (azathioprine 2-2.5 mg/kg/day or 6-mercaptopurine 1-1.5 mg/kg/day), anti-TNF therapy, vedolizumab, or tofacitinib 1
• For anti-TNF-naive UC patients being discharged after hospitalization, start anti-TNF therapy after discharge 3
• For anti-TNF-exposed UC patients, start vedolizumab or ustekinumab for all patients, or tofacitinib for those with low risk of adverse events 3

Critical Safety Considerations

Adverse Effects:

• Approximately 50% of patients experience short-term adverse effects including acne, edema, sleep disturbance, mood changes, glucose intolerance, and dyspepsia 1
• High-dose steroids (≥20 mg prednisolone daily) significantly increase risk of respiratory tract infection, opportunistic infection, and septicemia 1

Prophylaxis:

• 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

Absolute Contraindication

Corticosteroids have NO role in maintenance therapy for either ulcerative colitis or Crohn's disease—never use steroids for maintenance. 2, 1