What is the initial management approach for a patient with steroid-induced colitis?

Management of Steroid-Induced Colitis

Switch immediately from oral to intravenous steroids when bowel edema is present, using IV methylprednisolone 60 mg every 24 hours or IV hydrocortisone 100 mg four times daily, as bowel edema severely impairs oral medication absorption. 1, 2

Initial IV Steroid Regimen

• Administer IV methylprednisolone 60 mg every 24 hours OR IV hydrocortisone 100 mg four times daily as standard dosing 3, 1, 2
• Higher doses provide no additional benefit, while lower doses are less effective 3, 2
• Bolus injection is as effective as continuous infusion 3
• Do not extend therapy beyond 7-10 days, as prolonged treatment carries no additional benefit and increases morbidity 3, 2

Mandatory Supportive Care

• Provide IV fluid and electrolyte replacement with potassium supplementation of at least 60 mmol/day to prevent hypokalemia and hypomagnesemia, which can precipitate toxic dilatation 1, 2
• Administer low-molecular-weight heparin for thromboprophylaxis, as inflammatory bowel disease flares significantly increase thromboembolism risk 3, 2
• Transfuse blood to maintain hemoglobin above 8-10 g/dL 3, 2
• Withdraw anticholinergics, antidiarrheals, NSAIDs, and opioids immediately, as these medications may precipitate colonic dilatation 3, 2

Day 3 Assessment: The Critical Decision Point

Assess response to IV steroids on day 3 of therapy—this is the critical timepoint for determining next steps. 1, 2

Failure Indicators on Day 3:

• More than 8 bowel movements per day 1, 2
• 3-8 bowel movements per day with C-reactive protein >45 mg/L 2
• Presence of mucosal islands or colonic dilatation on abdominal radiography 2
• Deep ulceration on flexible sigmoidoscopy 2

Rescue Therapy for Steroid-Refractory Disease

If inadequate response by day 3, initiate rescue therapy immediately rather than continuing ineffective steroids. 3, 2

Rescue Therapy Options:

• Infliximab 5 mg/kg IV at weeks 0,2, and 6 3, 2, 4
• Vedolizumab 300 mg IV at weeks 0,2, and 6 3, 2
• Cyclosporine 2 mg/kg/day IV for 7 days 3, 2, 4

Infliximab and vedolizumab appear equally effective, with choice based on patient-specific contraindications such as hematologic malignancies, severe congestive heart failure, or concurrent hepatitis 2. Cyclosporine achieves initial response in 65-85% of patients, though only 50% avoid colectomy over 5 years 4, 5.

Bridging to Long-Term Maintenance

• Add azathioprine 1.5-2.5 mg/kg/day immediately after response to rescue therapy to maintain remission and prevent relapse 2, 6
• Azathioprine maintenance reduces colectomy rates from 85% to 40% at 7 years compared to cyclosporine alone 5, 6
• Continue oral cyclosporine for 3-6 months if used as rescue therapy, then transition to azathioprine monotherapy 5, 6

Infection Screening Before Escalation

• Screen for C. difficile, CMV, and other enteric infections before escalating immunosuppression 1, 2
• If C. difficile positive, treat with oral vancomycin 500 mg every 6 hours for 10 days while continuing steroids 1, 2
• Immunosuppressive therapy should be stopped if possible when infection is detected, though this may not always be warranted 3

Surgical Consultation and Timing

• Involve colorectal surgery on day of admission—this is a mandatory multidisciplinary approach 3, 2
• Consider colectomy if no improvement following 4-7 days of rescue therapy 3, 2
• Do not attempt sequential rescue therapies, as only one attempt should be made before referral for colectomy 2
• Immediate surgical consultation is required if systemic toxicity, severe abdominal pain, or suspicion of toxic megacolon or perforation develops 2

Critical Pitfalls to Avoid

• Do not continue ineffective IV steroids beyond 7-10 days, as this increases morbidity and mortality associated with delayed surgery 3, 2
• Do not use oral steroids when bowel edema is present, as absorption is severely impaired 1, 2
• Do not delay rescue therapy beyond day 3 if failure indicators are present, as early intervention improves outcomes 1, 2
• Do not use antibiotics routinely unless infection is suspected or immediately prior to surgery, as controlled trials show no consistent benefit 3