What is the appropriate management of a patient with inflammatory bowel disease on high‑dose systemic prednisone (40‑60 mg daily) who presents with a hypertensive urgency (blood pressure ≥180/120 mmHg without acute target‑organ damage)?

Management of Hypertensive Urgency in IBD Patients on High-Dose Steroids

Immediately reduce the steroid dose using rapid tapering (10 mg/week) while initiating oral antihypertensive therapy and transitioning to steroid-sparing agents, as high-dose corticosteroids (≥20 mg prednisolone daily) are a well-established risk factor for hypertension and serious complications. 1, 2

Immediate Steroid Management

• Implement rapid steroid taper of 10 mg per week to minimize ongoing cardiovascular risk while balancing against disease flare 1, 2
• Do not abruptly discontinue steroids without medical guidance, as this can precipitate adrenal crisis 1
• Target getting below 20 mg prednisolone daily as quickly as possible, since doses ≥20 mg significantly increase infection risk, hypertension, and other serious complications 1, 3
• Consider switching to budesonide 9 mg daily if the patient has ileocecal Crohn's disease, as this provides equivalent efficacy with reduced systemic exposure and fewer cardiovascular effects 1, 2, 4

Blood Pressure Management

• Start oral antihypertensive therapy immediately (typically an ACE inhibitor or calcium channel blocker) to achieve gradual BP reduction over 24-48 hours 5
• Hypertensive urgency (BP ≥180/120 without end-organ damage) requires oral agents, not IV therapy 5
• Monitor BP closely during steroid taper, as blood pressure should improve as steroid dose decreases 3, 5

Transition to Steroid-Sparing Therapy

Patients requiring high-dose steroids (40-60 mg daily) who develop complications like hypertensive urgency meet criteria for immediate escalation to steroid-sparing agents rather than continued steroid exposure. 2, 4

• Initiate azathioprine (1.5-2.5 mg/kg/day) or anti-TNF therapy (adalimumab or infliximab) immediately to facilitate complete steroid withdrawal 6, 7
• This patient is steroid-dependent by definition (requiring high-dose steroids with complications) and needs advanced therapy 2, 4
• Do not attempt repeated steroid courses, as this perpetuates the cycle of toxicity 2, 4

Critical Monitoring During Transition

• Assess disease activity objectively with fecal calprotectin and CRP, not symptoms alone 6
• Monitor for disease flare as steroids taper below 15 mg, the threshold where relapse risk increases 2
• Continue VTE prophylaxis with subcutaneous low molecular weight heparin during any hospitalization, as IBD patients on steroids have markedly elevated thrombotic risk 1

Additional Risk Mitigation

• Start proton pump inhibitor for GI prophylaxis during corticosteroid use 2
• Consider PCP prophylaxis if total steroid exposure >3 weeks at >30 mg prednisone equivalent daily 2
• Patients on ≥20 mg prednisolone daily should observe enhanced infection precautions 1

Common Pitfalls to Avoid

• Do not continue high-dose steroids beyond 2 weeks without clinical improvement, as this delays necessary treatment escalation and increases complication risk 4
• Do not use steroids for maintenance therapy under any circumstances, as they are ineffective long-term and associated with infections, osteoporosis, cataracts, and increased mortality 4, 8
• Approximately 50% of patients experience short-term adverse effects (acne, edema, sleep disturbances, mood changes, glucose intolerance, hypertension) even with appropriate dosing 4, 3
• Prolonged high-dose corticosteroid therapy yields diminishing therapeutic returns while exponentially raising the likelihood of infectious, metabolic, and cardiovascular complications 4, 3