Hydrocortisone Suppository Dosing for Ulcerative Proctitis
Hydrocortisone suppositories should NOT be used as first-line therapy for ulcerative proctitis, but when used as second-line treatment after 5-ASA failure, the typical dose is 5 mg prednisolone suppositories (or equivalent hydrocortisone dose of approximately 20-25 mg) once daily, usually at night. 1
First-Line Treatment: 5-ASA, Not Corticosteroids
The evidence strongly favors 5-ASA over corticosteroid suppositories:
Rectal 5-ASA at 1 g daily is the recommended first-line therapy for mild to moderate ulcerative proctitis (GRADE: Strong recommendation, high-quality evidence). 1
Meta-analysis demonstrates that rectal 5-ASA is superior to rectal corticosteroids for inducing symptomatic remission, with an odds ratio of 1.65 (95% CI, 1.11–2.45; P = 0.01). 1
Suppositories are preferred over enemas for proctitis because they deliver medication specifically to the rectum and are better tolerated and retained. 1
When to Use Corticosteroid Suppositories
Corticosteroid suppositories are reserved as second-line therapy in specific circumstances:
For patients with incomplete response to 5-ASA suppositories: Switch to or add a corticosteroid suppository (e.g., 5 mg prednisolone) while continuing oral 5-ASA dose-optimized to 4-4.8 g daily. 1
Topical corticosteroids should only be used after patients have failed topical mesalazine, as they are less effective than topical 5-ASA. 1
Specific Dosing Regimens from Clinical Trials
Research studies provide these specific hydrocortisone dosing protocols:
Hydrocortisone foam 178 mg twice daily was used in comparative trials, though it proved less effective than mesalazine 500 mg suppositories twice daily. 2
Hydrocortisone enema 100 mg/day showed similar efficacy to low-dose 5-ASA (1 g/day) in mild to moderate distal ulcerative colitis, though 5-ASA showed a statistical trend toward better clinical activity. 3
Budesonide rectal foam 2 mg twice daily for 2 weeks, then once daily for 4 weeks achieved 38-44% remission rates versus 22-26% with placebo in ulcerative proctitis/proctosigmoiditis. 4
Critical Treatment Algorithm
Follow this stepwise approach:
- Start with 5-ASA suppository 1 g once daily (usually at night) 1
- If incomplete response: Add oral 5-ASA 2-3 g daily to the suppository regimen 1
- If still incomplete response: Switch to or add corticosteroid suppository (e.g., 5 mg prednisolone) and increase oral 5-ASA to 4-4.8 g daily 1
- If incomplete response to topical steroids: Escalate to oral prednisolone 40 mg once daily, tapering over 6-8 weeks 1, 5
Important Caveats and Pitfalls
Never use corticosteroids for maintenance therapy—this is an absolute contraindication for both ulcerative colitis and Crohn's disease. 5
Corticosteroid suppositories may be used as adjunctive therapy for troublesome rectal symptoms, but they are unlikely to be effective alone. 1
Before determining treatment failure, rule out proximal constipation (common and may contribute to poor response), co-existing irritable bowel syndrome, infection (including sexually transmitted), solitary rectal ulcer, psoriatic colitis, chemical colitis, and rectal prolapse. 1
Ensure adherence before escalating therapy—many patients require advice on proper suppository use. 1
Approximately 50% of patients on systemic corticosteroids experience short-term adverse effects including acne, edema, sleep disturbance, mood changes, glucose intolerance, and dyspepsia. 5
Maintenance Strategy
For patients who respond to corticosteroid suppositories:
Switch back to 5-ASA suppository 1 g daily for maintenance, as this is the most effective long-term therapy for proctitis. 1
Frequency can be reduced to every 2nd or 3rd day, or switch to oral 5-ASA to improve adherence. 1
Some patients with infrequent flares prefer to start suppositories only when symptoms begin rather than taking regular maintenance therapy—this is safe as colorectal cancer risk in proctitis is similar to the general population. 1