Systemic Corticosteroids for Inpatient Small Bowel Crohn's Disease
For an adult inpatient with acute small bowel inflammation due to Crohn's disease, initiate intravenous methylprednisolone 40–60 mg daily, with clinical response reassessed after 1 week to determine need for therapy escalation. 1, 2
Initial Inpatient Steroid Regimen
Intravenous methylprednisolone is the preferred formulation for hospitalized patients with moderate-to-severe small bowel Crohn's disease. 1, 2 The British Society of Gastroenterology strongly recommends systemic corticosteroids as initial treatment for moderate to severely active uncomplicated luminal Crohn's disease, with high-quality evidence supporting this approach. 3
Dosing Strategy
- Start IV methylprednisolone 40–60 mg daily as a continuous infusion or divided doses for hospitalized patients with severe disease. 1, 2
- Alternatively, IV hydrocortisone 300 mg/day achieves equivalent efficacy (88% response rate in hospitalized Crohn's patients). 4
- For patients who can tolerate oral intake, prednisolone 40 mg daily as a single morning dose is appropriate, though IV route is preferred for severe presentations requiring hospitalization. 5
Critical Timing Considerations
Reassess clinical response within 1 week of initiating IV steroids. 1, 2 Lack of improvement by 7 days mandates escalation to advanced therapy rather than continued steroid administration. 2 This early decision point is crucial because prolonged steroid exposure without response increases mortality risk without clinical benefit. 5, 2
Disease-Specific Considerations for Small Bowel Location
Budesonide has NO role in the inpatient setting for acute severe disease requiring hospitalization. 1 While budesonide 9 mg daily is appropriate for mild-to-moderate ileocecal disease in outpatients (achieving 51% remission vs 20% placebo), it lacks the potency needed for hospitalized patients. 1, 5
Budesonide is completely ineffective for disease confined to the distal small bowel or any colonic involvement and should be avoided in these distributions. 1
Concurrent Planning for Steroid-Sparing Therapy
When prescribing systemic corticosteroids, simultaneously establish a plan for advanced therapy (biologics or immunomodulators) to prevent steroid dependency. 1, 2 The European Crohn's and Colitis Organisation recommends considering early introduction of biological therapy for patients with extensive disease or poor prognostic features, even at initial presentation. 3
High-Risk Features Requiring Early Biologic Consideration
Patients with the following should receive biologics as a bridge rather than steroids alone: 3
- Extensive small bowel disease
- Structuring or penetrating disease at presentation
- Perianal fistulizing disease
- Age under 40 years at diagnosis
- Need for steroids to control the index flare
Tapering Protocol After Clinical Response
Once clinical improvement occurs, taper prednisolone over 6–8 weeks, reducing by 5 mg weekly. 5 Too rapid reduction associates with early relapse. 5
Monitor closely as the dose decreases below 15 mg daily, as this threshold is when disease relapse commonly occurs. 5 Doses below 15 mg are often ineffective for maintaining control. 5
Absolute Contraindications to Prolonged Use
Corticosteroids must NEVER be used for maintenance therapy in Crohn's disease due to toxicity and complete lack of efficacy. 3, 5 The British Society of Gastroenterology gives this recommendation 100% agreement with strong evidence. 3
Maximum treatment duration is 8 weeks. 2 Cumulative corticosteroid exposure exceeding 3000 mg prednisolone-equivalent per year is associated with significantly increased mortality. 5, 2
Identifying Treatment Failure Requiring Escalation
Steroid dependency signals treatment failure and mandates escalation rather than repeated courses. 5, 2 Dependency is defined as: 5
- Disease relapse when steroid dose reduces below 15 mg daily
- Relapse within 6 weeks of stopping steroids
- Requiring ≥2 corticosteroid courses within a calendar year
When dependency occurs, escalate to thiopurines (azathioprine 1.5–2.5 mg/kg/day), anti-TNF therapy, vedolizumab, or ustekinumab. 5 Repeated steroid courses should be avoided unless futility of other effective therapies has been established and surgical options are unavailable. 2
Safety Monitoring for Inpatients
Add PCP prophylaxis if >3 weeks of immunosuppression expected at doses >30 mg prednisone-equivalent daily. 5
Start proton pump inhibitor for GI prophylaxis during corticosteroid use. 5
High-dose steroids (≥20 mg prednisolone daily) significantly increase risk of respiratory tract infection, opportunistic infection, and septicemia. 5
Approximately 50% of patients experience short-term adverse effects including acne, edema, sleep disturbance, mood changes, glucose intolerance, and dyspepsia. 5