What is the recommended dosing regimen for oral prednisone (corticosteroid) to treat a flare-up of Crohn's disease in a patient with a history of autoimmune hepatitis?

Oral Prednisone Dosing for Crohn's Disease Flare

For a moderate to severe Crohn's disease flare, start prednisone 40-60 mg orally once daily in the morning (before 9 AM), continue for 2-4 weeks to assess response, then taper by 5 mg per week over 8-12 weeks if remission is achieved. 1, 2, 3

Initial Dosing Strategy

• Start with prednisone 40-60 mg/day orally as a single morning dose for moderate to severe Crohn's disease flares 1, 2
• Administer before 9 AM to align with the body's natural cortisol rhythm and minimize adrenal suppression 3
• Take with food or milk to reduce gastric irritation 3
• The 40 mg dose is optimal for outpatient management, as 60 mg/day shows no added benefit but significantly more adverse events 1

When to Use Budesonide Instead

• Reserve budesonide 9 mg/day only for mild-to-moderate disease strictly limited to the ileum and/or ascending colon 1, 2
• Budesonide is significantly less effective than prednisone (RR 0.85,95% CI 0.75-0.97) and should not be used for moderate-to-severe disease or disease beyond the right colon 2
• If a patient fails budesonide after 4-8 weeks, escalate to prednisone 40-60 mg/day 2, 4

Response Assessment Timeline

• Evaluate clinical response at 2-4 weeks after starting prednisone to determine if therapy modification is needed 2, 4
• Expect remission in 60-83% of patients with moderate-to-severe disease 1, 2
• Mean time to symptomatic remission is approximately 20-41 days 2
• Assess earlier (closer to 2 weeks) for severe disease; patients with moderate symptoms can be assessed at 4 weeks 2

Tapering Protocol

• Once remission is achieved, taper prednisone by 5 mg per week over 8-12 weeks 1
• The initial dose should be maintained until a satisfactory response is noted before beginning the taper 3
• Avoid tapering below 15 mg/day too rapidly, as this is associated with early relapse 1
• Never stop prednisone abruptly—gradual withdrawal is essential to prevent adrenal insufficiency 3

Critical Contraindications in Your Patient

Your patient's history of autoimmune hepatitis requires special consideration:

• Prednisone is actually the standard treatment for autoimmune hepatitis, typically used in combination with azathioprine 5, 6
• The combination regimen of prednisone and azathioprine is preferred for autoimmune hepatitis because it reduces corticosteroid-related side effects 5
• Monitor liver enzymes closely during prednisone therapy, as there is a theoretical risk of hepatitis flare, though prednisone itself is hepatoprotective in autoimmune hepatitis 5, 6
• Be aware that if you later consider infliximab for steroid-refractory Crohn's disease, infliximab can paradoxically induce autoimmune hepatitis in patients with Crohn's disease 7

General Precautions During Therapy

• Start calcium and vitamin D supplementation immediately when initiating prednisone to prevent bone loss 2
• Consider antacids between meals to prevent peptic ulcers when using higher doses 3
• Avoid use or use with extreme caution in patients with poorly controlled diabetes or history of steroid-induced psychosis 2
• Prednisone increases risk of serious infections (HR 1.57,95% CI 1.17-2.10) and mortality (HR 2.14,95% CI 1.55-2.95) with long-term use 1

When Oral Therapy Fails

• Switch to IV methylprednisolone 40-60 mg/day (typically 40 mg every 8 hours) if disease severity requires hospitalization 2
• Evaluate response to IV therapy within 1 week to determine if escalation to biologics is needed 2

Maintenance Therapy Planning

• Do NOT use prednisone for maintenance therapy—this is a strong recommendation against corticosteroid use for maintaining remission 1, 2
• Corticosteroids are ineffective for maintaining remission and have no role in long-term management 1
• Plan for steroid-sparing maintenance therapy using thiopurines (azathioprine 2-2.5 mg/kg/day), methotrexate, or anti-TNF biologics 1, 2, 4
• Consider thiopurines for patients requiring two or more corticosteroid courses within a calendar year, or those who relapse as steroids are tapered below 15 mg 1
• Nearly half of patients who initially respond to corticosteroids develop steroid dependency or relapse within 1 year 8

Common Pitfalls to Avoid

• Do not use doses below 40 mg/day for moderate-to-severe disease—doses of 15 mg/day or less are ineffective for active disease 1
• Do not continue prednisone beyond 12 weeks without a clear exit strategy to steroid-sparing maintenance therapy 1, 8
• Do not use budesonide for disease extending beyond the right colon—it is significantly less effective than prednisone for this indication 1, 2