How should new‑onset hypertension be evaluated and treated in a patient with inflammatory bowel disease, especially if they are receiving systemic glucocorticoids?

Management of New-Onset Hypertension in IBD Patients on Glucocorticoids

Patients with IBD who develop new-onset hypertension while receiving systemic glucocorticoids should have their blood pressure monitored regularly, and the hypertension should be treated with standard antihypertensive agents while simultaneously working to taper or discontinue the glucocorticoids as quickly as clinically feasible.

Initial Assessment and Monitoring

• Monitor blood pressure, glycemic control, and serum potassium in all patients on prolonged corticosteroids 1
• Recognize that glucocorticoid-induced hypertension is dose-dependent, with prednisolone ≥20 mg daily for ≥2 weeks significantly increasing cardiovascular risk 1
• Assess cardiovascular risk factors comprehensively, as IBD patients demonstrate a distinct cardiovascular risk profile compared to the general population, including higher rates of hypertension (OR 1.67), increased waist circumference (+4 cm), and elevated triglycerides (+0.6 mmol/L) 2
• Screen for other glucocorticoid-related complications including diabetes (incidence 12.6% in lupus patients on high-dose steroids), glucose intolerance, and cardiovascular disease 1

Treatment Strategy

Immediate Hypertension Management

• Treat the hypertension with standard antihypertensive medications according to general hypertension guidelines 1
• The choice of antihypertensive agent should follow standard cardiovascular risk assessment protocols, as there is no IBD-specific contraindication to any particular class 1
• Continue monitoring blood pressure throughout glucocorticoid therapy, as the effect on blood pressure is uncertain and variable 1

Glucocorticoid Management (Priority)

The primary therapeutic goal must be achieving corticosteroid-free remission to eliminate the underlying cause of hypertension 3. This takes precedence over simply treating the hypertension symptomatically.

• For Crohn's disease patients who are steroid-dependent: Transition to azathioprine/6-mercaptopurine (most reliable historically), infliximab, or methotrexate 4
• For ulcerative colitis patients who are steroid-dependent: Consider azathioprine/6-mercaptopurine or other steroid-sparing agents 4
• Implement a structured tapering protocol once remission is achieved, as patients on prolonged corticosteroids are at risk of adrenal suppression 1
• Avoid abrupt discontinuation without medical supervision, as this risks disease flare requiring hospitalization 5

Dose-Specific Considerations

• If the patient is on prednisolone ≥20 mg/day: This dose is associated with significantly increased infection risk (RR 1.67 for opportunistic infections) and cardiovascular complications 1
• Consider budesonide as an alternative when appropriate, as it has a better safety profile with lower systemic exposure, though some systemic adverse events including hypertension can still occur 3
• For doses ≥10 mg/day prednisolone: Recognize increased risk of all infectious events (RR 1.30) and intensify monitoring 1

Common Pitfalls to Avoid

• Do not ignore the hypertension while focusing solely on IBD management—cardiovascular disease occurs more frequently in IBD patients (OR 2.01), specifically coronary heart disease (OR 2.01) and heart failure (OR 2.02) 2
• Do not continue high-dose glucocorticoids indefinitely without actively pursuing steroid-sparing therapy, as approximately one-third of CD patients become steroid-dependent and one-fifth become steroid-resistant 6
• Do not underestimate cardiovascular risk using standard calculators like SCORE2, as these may underestimate risk in IBD patients due to their differing cardiovascular risk profile 2
• Do not overlook other glucocorticoid-related complications that may coexist with hypertension, including hyperglycemia, hypokalemia, and increased fracture risk 1

Long-Term Management

• Reassess the need for continued glucocorticoid therapy regularly, as every effort should be made to switch patients to less toxic medications given the numerous potential side effects 4
• Continue cardiovascular risk factor monitoring even after glucocorticoid discontinuation, as IBD itself is associated with increased ASCVD risk 2
• Consider that mucosal glucocorticoid receptor levels are decreased in IBD patients independently of treatment, which may contribute to steroid resistance and necessitate alternative immunosuppressive strategies 7