Can prednisone decrease the Mayo score in a patient with Ulcerative Colitis (UC)?

Can Prednisone Decrease the Mayo Score in Ulcerative Colitis?

Yes, prednisone effectively decreases the Mayo score in patients with moderate to severe ulcerative colitis, with approximately 77% of patients achieving remission within 2 weeks when treated with 40 mg daily. 1

Evidence for Mayo Score Reduction

Prednisone at 40 mg daily is the standard treatment for moderate to severe UC and directly improves all components of the Mayo score:

• Clinical improvement is defined as a reduction of baseline Mayo score by ≥3 points, which is the standard endpoint used in clinical trials 1
• Clinical remission is achieved when the overall Mayo score is ≤2 with no individual subscore >1 1
• In the pivotal Baron studies, 40 mg prednisolone was significantly more effective than 20 mg/day for inducing remission 1

Timeline of Mayo Score Improvement

Improvements in clinical and endoscopic disease activity can be seen within 2 weeks of treatment with oral prednisolone 40 mg/day:

• A study comparing oral prednisolone with prednisolone metasulphobenzoate demonstrated measurable improvements in both clinical symptoms and endoscopic findings within this timeframe 1
• Patients not responding after 2 weeks should be considered for treatment escalation to biologics or hospital admission, depending on systemic illness severity 1
• The Mayo score correlates with faecal calprotectin (r = 0.63; p < 0.0001), and this correlation strengthens when adding the endoscopic subscore (r = 0.90; p < 0.0001) 1

Specific Mayo Score Components Affected

Prednisone improves all four Mayo score components through its potent anti-inflammatory effects:

• Stool frequency subscore: Reduces bowel movements toward normal frequency 1
• Rectal bleeding subscore: Decreases visible blood in stool 1
• Endoscopic subscore: Improves mucosal appearance, reducing erythema, friability, and ulceration 1
• Physician's global assessment: Overall disease severity improves with treatment response 1

Optimal Dosing for Mayo Score Reduction

The recommended dose is prednisolone 40 mg daily with tapering over 6-8 weeks:

• Doses above 40-60 mg/day show no additional benefit and increase adverse effects 1
• Single daily dosing is as effective as split-dosing and causes less adrenal suppression 1
• Approximately 50% of patients experience short-term corticosteroid-related adverse events including acne, edema, sleep disturbance, mood changes, glucose intolerance, and dyspepsia 1

Response Rates and Clinical Outcomes

Historical data demonstrates consistent efficacy across severity levels:

• In patients with mild to moderate disease, oral prednisolone 40 mg daily induced remission in 77% within 2 weeks, compared to 48% with sulphasalazine 1
• For severe disease, remission rates are approximately 47% with colectomy rates of 42% 2
• For moderate disease, remission rates reach 80% with colectomy rates of 13% 2
• For mild disease, remission rates are 84% with colectomy rates of only 3% 2

Important Clinical Caveats

Several factors predict poor response and should trigger early treatment escalation:

• Prolonging treatment with high-dose oral corticosteroids has diminishing chance of achieving remission 1
• Patients with systemic symptoms (fever, severe pain, significant anemia) or those generally unwell should be admitted for inpatient management rather than continuing oral steroids 1
• Duration of oral corticosteroid therapy >14 days and hemoglobin ≤11.0 mg/dL are poor prognostic factors for response 3
• There is increasing risk of infective, metabolic, and surgical complications for deteriorating patients who may require emergency admission and colectomy 1

Steroid-Free Remission as the Ultimate Goal

While prednisone decreases the Mayo score, the therapeutic goal is achieving steroid-free remission:

• Patients requiring two or more corticosteroid courses within a calendar year require treatment escalation with thiopurines, anti-TNF therapy, vedolizumab, or tofacitinib 1
• Approximately 22% of patients become corticosteroid-dependent at 1 year 1
• Corticosteroids have no role in maintenance therapy for UC 1

Common Pitfall to Avoid

Do not continue oral corticosteroids beyond 2 weeks without response or improvement in Mayo score. Early recognition of steroid-refractory disease and timely escalation to biologics prevents complications and reduces colectomy risk 1. The Mayo score should be reassessed approximately 2-3 months after starting any new therapy to determine treatment success 1.