How do steroids affect Crohn's disease in a patient?

How Steroids Affect Crohn's Disease

Systemic corticosteroids are highly effective for inducing remission in moderate to severe Crohn's disease but should be limited to 8 weeks maximum and are not recommended for maintenance therapy due to significant adverse effects and lack of long-term efficacy. 1

Efficacy for Induction of Remission

Corticosteroids effectively induce clinical remission in active Crohn's disease with remission rates of 60-83% compared to 30-38% with placebo. 1, 2

• Systemic corticosteroids (prednisolone 40-60 mg/day) are suggested for moderate to severe disease, with treatment duration not exceeding 8 weeks 1
• For mild ileocaecal Crohn's disease, budesonide 9 mg once daily for 8 weeks is as effective as prednisolone (51% vs 52.5% remission) with significantly fewer side effects 1
• Budesonide is inferior to prednisolone in severe disease (CDAI >300), achieving only 52% of the efficacy of conventional steroids 1
• Clinical and biomarker response (fecal calprotectin) should be assessed at 2 weeks to determine if escalation to advanced therapy is needed 1

Complete Ineffectiveness for Maintenance

Corticosteroids are not recommended for maintenance of remission in Crohn's disease—they simply do not work for this purpose. 1

• Among patients initially responding to corticosteroids, 36% become steroid-dependent and 20% are steroid-refractory within one year 3
• Budesonide 6 mg/day has shown some short-term maintenance benefit but lacks long-term efficacy and should not be used beyond 12 weeks 1, 4
• Low-dose corticosteroids, alternate-day regimens, and prolonged courses are ineffective for maintaining remission 3

Adverse Effects and Safety Concerns

Corticosteroids cause significantly more adverse events than placebo (RR 4.89) or low-dose 5-ASA (RR 2.38), with risks increasing substantially with prolonged use. 2, 5

Short-term adverse effects (occurring during 4-month tapering):

• Moon face, acne, infection, ecchymoses, hypertension, hirsutism, petechial bleeding, and striae 3

Serious long-term complications (with courses >6-8 weeks):

• Osteoporosis and osteonecrosis (can develop even with short-term, low-dose therapy) 6, 1
• Hypertension, diabetes mellitus, and glucose intolerance 6, 3
• Increased infection risk (potentially lethal) 6
• Glaucoma and cataracts 3
• Myopathy and psychosis 3
• Suppression of hypothalamic-pituitary-adrenal axis 1
• Increased mortality with prolonged use (>3000 mg prednisolone equivalent per year) 1

Critical Management Principles

Whenever prescribing systemic corticosteroids, simultaneously consider whether initiation or change of advanced therapy (biologics, immunomodulators) is required. 1

Steroid-sparing strategy:

• Repeated courses of steroids should be avoided unless futility of other effective therapies has been established and surgical options are unavailable 1, 5
• Consider immunomodulators (azathioprine 2-2.5 mg/kg/day, 6-mercaptopurine 1-1.5 mg/kg/day, or methotrexate 15-25 mg IM weekly) for patients requiring two or more steroid courses within a calendar year 1
• Anti-TNF therapy (infliximab, adalimumab) is recommended for moderate to severe disease failing corticosteroids 1
• Azathioprine/6-mercaptopurine enables corticosteroid withdrawal in 55% of steroid-dependent patients, methotrexate in 39%, and infliximab in approximately 75% 4, 3

Steroid dependency definitions:

• Inability to wean below 10 mg prednisolone (or 3 mg budesonide) within 3 months of starting 1
• Disease flare within 3 months of stopping steroids 1
• Relapse when steroid dose reduced below 15-20 mg/day 1

Steroid excess definition:

• Two or more courses over one year 1
• Continuous therapy for more than 3 months 1

Disease-Specific Considerations

For colonic Crohn's disease, systemic corticosteroids (prednisolone 40 mg tapering by 5 mg weekly) are effective, but budesonide has no evidence of benefit in distal colonic inflammation. 1

For hospitalized patients with severe disease, intravenous methylprednisolone 40-60 mg/day is suggested, with response assessment within 1 week to determine need for therapy modification. 1

Common Pitfalls to Avoid

• Do not continue corticosteroids beyond 8 weeks without reassessing for alternative immunosuppressive therapy 1, 5
• Do not use corticosteroids for maintenance—they are ineffective and harmful for this purpose 1
• Do not prescribe repeated courses without establishing a steroid-sparing strategy 1
• Do not delay assessment of response—evaluate at 2 weeks clinically and with biomarkers to enable timely escalation 1
• Do not ignore bone health—assess bone mineral density in patients receiving prolonged or repeated courses 1