What is the recommended steroid treatment regimen for a patient with Crohn's disease?

Steroid Treatment in Crohn's Disease

For moderate to severe Crohn's disease, initiate prednisone 40-60 mg/day orally and evaluate response at 2-4 weeks; if hospitalization is required, use IV methylprednisolone 40-60 mg/day with response assessment within 1 week. 1, 2

Initial Steroid Selection Based on Disease Severity and Location

Mild to Moderate Disease (Ileal/Right Colon Only)

• Start with oral budesonide 9 mg/day for disease limited to the ileum and/or right colon 2, 3
• Budesonide causes significantly fewer corticosteroid-associated side effects (29% vs 48% with prednisolone, P=0.003) and less adrenal suppression 3
• However, budesonide is less effective than conventional steroids (relative risk 0.85,95% CI 0.75-0.97) 2

Moderate to Severe Disease or Disease Beyond Right Colon

• Use prednisone 40-60 mg/day orally as first-line therapy 1, 2
• This is a strong recommendation with low-quality evidence from the Canadian Association of Gastroenterology 1
• Expected remission rate is 60-83% with prednisone therapy 2

Severe Disease Requiring Hospitalization

• Switch to IV methylprednisolone 40-60 mg/day (typically 40 mg every 8 hours) 1, 2, 4
• IV administration ensures predictable drug delivery when gastrointestinal absorption may be compromised 4

Response Assessment Timeline

Oral Prednisone

• Evaluate symptomatic response between 2-4 weeks after starting therapy 1, 2
• Mean time to symptomatic remission is approximately 20-41 days 2
• Assess closer to 2 weeks for severe disease; patients with moderate symptoms can be assessed at 4 weeks 2
• Modify therapy if inadequate response is observed at this timepoint 1

IV Methylprednisolone

• Evaluate response within 1 week to determine need for therapy modification 1, 4
• This shorter assessment window reflects the severity of disease requiring hospitalization 1

Budesonide

• If no response after 4-8 weeks of budesonide, escalate to prednisone 40-60 mg/day 2

Steroid Tapering Strategy

• Taper prednisone gradually over 8 weeks after achieving remission 4
• More rapid tapering is associated with early relapse 4
• The specific tapering schedule should reduce from 40-60 mg/day down to discontinuation over this 8-week period 4

Critical Contraindication: Maintenance Therapy

Never use oral corticosteroids for maintenance therapy in Crohn's disease of any severity. 1, 2, 4

• This is a strong recommendation against their use from the Canadian Association of Gastroenterology 1
• Corticosteroids are completely ineffective for maintaining remission 5, 6
• Nearly half of patients who initially respond develop steroid dependency or relapse within 1 year 5, 6
• Long-term use causes serious adverse effects including osteoporosis, diabetes, infection, osteonecrosis, cataracts, glaucoma, and psychosis 6

Planning for Steroid-Sparing Maintenance

For Patients Who Respond to Steroids

• Plan transition to steroid-sparing maintenance therapy before completing the taper 2, 4
• Options include thiopurines (azathioprine/6-mercaptopurine), parenteral methotrexate, or anti-TNF biologics 1, 2

For Steroid-Dependent or Steroid-Refractory Patients

• Consider anti-TNF therapy (infliximab or adalimumab) as the next step 1, 4
• This is a strong recommendation with high-quality evidence for patients who fail corticosteroids 1
• Infliximab dosing: 5 mg/kg IV at weeks 0,2, and 6, then every 8 weeks 7
• Adalimumab dosing: 160 mg subcutaneous on day 1,80 mg on day 15, then 40 mg every other week starting day 29 8
• Evaluate anti-TNF response at 8-12 weeks; patients not responding by week 14 are unlikely to benefit from continued dosing 1, 7

For High-Risk Patients

• Consider anti-TNF therapy as first-line treatment instead of steroids for patients with poor prognostic factors (stricturing/penetrating disease, perianal fistulas, age <40 years, or need for steroids at diagnosis) 4
• This is a strong recommendation with moderate-quality evidence 4

Important Safety Precautions

Before Starting Steroids

• Avoid or use with extreme caution in patients with poorly controlled diabetes 2
• Avoid or use with extreme caution in patients with history of steroid-induced psychosis or depression 2
• Start calcium and vitamin D supplementation prophylactically to prevent bone loss 2

During Steroid Therapy

• Monitor for common adverse effects including moon face, acne, infection, hypertension, hirsutism, and metabolic complications 6
• The risk of serious infections increases with higher corticosteroid doses 7

Common Pitfalls to Avoid

• Do not use low-dose corticosteroids or alternate-day corticosteroids as steroid-sparing strategies—they are ineffective 6
• Do not continue steroids beyond the acute induction phase without a clear plan for transition to steroid-sparing maintenance 1, 5
• Do not use mesalamine (5-ASA) as a steroid-sparing agent—it is ineffective for this purpose 6
• Do not delay evaluation of steroid response—early assessment allows timely escalation to biologics if needed 1, 2