What is the recommended course of budesonide (corticosteroid) for a patient with a flare-up of Ulcerative Colitis (UC)?

Budesonide Course for UC Flare-Up

For a flare-up of ulcerative colitis, use budesonide MMX 9 mg once daily for 8 weeks, taken in the morning with or without food, swallowing the tablet whole without crushing or chewing. 1

Treatment Duration and Dosing

• The standard course is 9 mg once daily for up to 8 weeks to induce remission in patients with mild to moderate active UC 2, 1
• The tablet must be swallowed whole and cannot be chewed, crushed, or broken to maintain the extended-release properties 1
• Once-daily morning dosing is recommended and is as effective as divided doses while causing less adrenal suppression 3

When to Use Budesonide MMX

Budesonide MMX is indicated as:

• First-line alternative therapy for patients with mild to moderate UC of any disease extent who prefer to avoid systemic corticosteroids 2, 4
• Second-line therapy after inadequate response to optimized 5-ASA therapy (oral mesalazine ≥2.4 g/day combined with topical therapy for 4-8 weeks) 4, 5
• Particularly effective for left-sided disease, though less effective for extensive colitis 4

Critical Monitoring Timeline

Evaluate for symptomatic response within 2 weeks to determine if therapy modification is needed 2, 4. This early assessment is crucial because:

• Failure to respond by 2 weeks should prompt consideration of escalating to advanced therapies (biologics or small molecules) 3
• The full 8-week course should only be continued if there is at least partial response at 2 weeks 4

Important Contraindications and Warnings

What NOT to Do:

• Never use budesonide for maintenance therapy - it is ineffective for maintaining remission and prolonged use causes significant adverse effects 2, 4
• Do not extend treatment beyond 8 weeks for induction therapy 1, 6
• Avoid abrupt discontinuation - taper gradually over 1-2 weeks after achieving remission to prevent symptom recurrence 4
• Avoid grapefruit juice during treatment as it inhibits CYP3A4 and increases systemic exposure 1

Special Monitoring Considerations:

• Patients with moderate to severe liver disease require closer monitoring for signs of hypercorticism 1
• If using concomitant CYP3A4 inhibitors (like ketoconazole), monitor closely for increased corticosteroid effects 1
• Patients transferring from systemic corticosteroids need careful tapering to avoid adrenal suppression 1

Efficacy Data

The evidence supporting this regimen is robust:

• Budesonide MMX 9 mg achieved 17.9% combined clinical and endoscopic remission versus 7.4% with placebo at 8 weeks 7
• Symptom resolution occurred in 28.5% of patients versus 16.5% with placebo 7
• The safety profile is favorable with adverse events similar to placebo, including minimal steroid-related side effects 7, 8

Treatment Algorithm Position

If budesonide MMX fails after 8 weeks or shows inadequate response at 2 weeks:

• Consider escalation to conventional oral corticosteroids (prednisolone 40 mg daily with tapering over 6-8 weeks) 3, 5
• For patients requiring two or more corticosteroid courses within a year, escalate to thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib 3, 5

Common Pitfalls to Avoid

• Do not mistake budesonide MMX for ileal-release budesonide - they have different indications and delivery systems 4
• Do not use for Crohn's disease - the ileal-release formulation is appropriate for ileocecal Crohn's, not budesonide MMX 4
• Do not continue beyond 8 weeks hoping for delayed response - if no improvement by 2 weeks, modify therapy rather than extending duration 4
• Do not use as maintenance therapy even if induction was successful - this exposes patients to unnecessary risks without benefit 2, 4