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& Inflammatory Bowel Disease (IBD)

Corticosteroids

KEY POINTS:

  • Corticosteroids are very useful drugs that have been used for at least 60 years to treat inflammatory diseases including IBD.

  • Also referred to as “steroids”, though they are different from the “muscle building” steroids.

  • Corticosteroids are used both for Crohn’s disease and ulcerative colitis.

  • They can be used for treatment of moderate-to severe symptoms of IBD which are not responding to other agents when rapid improvement in symptoms is desired.

  • Corticosteroids suppress the immune system and reduce inflammation.

  • Corticosteroids are used with caution because of concerns about side effects which can occur with long term use.

  • They are not used for maintenance of remission or response.

  • Corticosteroids are not effective in treating fistulas in patients with Crohn’s disease.

 

Oral Medicines (pill form)

  • Common pill forms are prednisone, prednisolone (or methylprednisolone), and Budesonide.

  • Prednisone is the most common pill form (in dose ranges from 1mg to 50mg). Dosing is variable and depends on severity. When symptoms are severe, you may need to take between 40 and 60 mg per day. Once symptoms have settled, your doctor will usually gradually taper the dose, often by 5 to 10 mg a week until you are no longer taking it.

  • Budesonide (Entocort) is not quite as effective as prednisone but has fewer of the side effects of other corticosteroids. It is used in pill form to treat Crohn’s disease affecting the end of the small bowel (ileum) and/or the right colon.

  • Budesonide-MMX (Uceris,Cortiment) (pill form) is effective in treating ulcerative colitis.

  • Tapering is used with oral corticosteroids to reduce withdrawal effects as well as prevent rapid rebound in IBD-related symptoms.

  • Duration - a full course of corticosteroids, including the taper, may take 2-3 months to complete.

  • There are some diseases where oral corticosteroids like prednisone are prescribed for a very short period (i.e. one week, as in the case of asthma) or for prolonged periods (i.e. months or even indefinitely, as in the case of organ transplantation) but these are not the optimal approaches for corticosteroid use in IBD.

 

Enema Form

  • Enemas are used for active Crohn’s disease or ulcerative colitis involving the rectum and/or sigmoid colon where 5-ASA medications were not effective or have caused problem side effects.

  • They are usually taken once daily.

  • One form of corticosteroid enema is in a foam base instead of liquid base (Cortifoam). This can make it easier for the user to hold in the rectum.

  • Budesonide in enema format is used to treat ulcerative colitis limited to the lower colon and rectum.

  • Betamethasone is formulated as an enema (Betnesol) and can also be used in treating ulcerative colitis.

  • Some patients are prescribed both 5-ASA and corticosteroid enemas (one type in the morning and the other in the evening).

 

 

Intravenous Form (given only in hospital)

  • Are used for severe symptoms of Crohn’s disease or ulcerative colitis when:

    • Symptoms and/or disease activity has not improved on other medications including oral corticosteroids.

    • Using pills is not tolerated due to severe nausea or being unable to eat due a bowel obstruction.

  • Methylprednisolone doses range between 50 to 100mg per day, hydrocortisone doses range between 200mg to 300mg day.

 

 

 

How well do they work?

  • When treating moderate to severe Crohn’s disease or ulcerative colitis up to 80% of persons may achieve a good response.

  • Some patients become “steroid-dependent”. This means that they achieve a good response to using the corticosteroids and feel much improved but they cannot taper down on the corticosteroid dose because with dose reduction their symptoms flare.

  • Some patients become “steroid-resistant”. This refers to patients who at one time may have had a good response to suing corticosteroids but with the current dosing they are not responding and will need another treatment to get symptoms to settle.

 

Side Effects

  • Side effects are one factor that doctors and patients consider in choosing treatments. Even though corticosteroids have possible side effects, doctors and patients often choose them because they are rapidly effective and the anticipated benefit outweighs the potential side effects.

  • Side effects vary depending on the medicine, the dose, characteristics of the person (such as other health conditions), how long it is taken, and how quickly the dose is increased or decreased.

  • Because side effects increase with prolonged use your doctor will try to use steroids for as limited a duration as possible. Further, if repeated courses of steroids are needed your doctor will consider other immune modulating drugs to maintain remission to avoid further steroid courses.

  • Early side effects include irritability, mood swings, trouble sleeping, weight gain. Irritability and mood swings are more common among people who have a tendency toward anxiety or depression. Trouble sleeping and weight gain are very common such that most people using corticosteorids may experience these side effects. Early side effects can occur within days to weeks of starting steroids.

  • Later side effects include a rounding of facial features, acne, depression, high blood pressure, high blood sugar levels, and increased risk for infection. Acne, depression, high blood pressure and high blood sugars are more likely to occur in persons with a tendency to those conditions. In particular, people who already have a diagnosis of diabetes and who get a course of corticosteroids are at risk of having very erratic and/or high blood sugars. Rounding of facial features is common to all who use corticosteroids for a prolonged period. Late side effects can occur with weeks to months of starting steroids.

  • Side effects which can occur with prolonged use: development of cataracts and osteoporosis (thinning of bones). Osteoporosis is painless, but may lead to an increased risk of bone fracture. There is some debate about whether corticosteroid use can lead to blood flow problems to the bones called avascular necrosis or osteonecrosis. It is possible that this complication occurs in selected persons with very active disease.

  • Early and late side effects tend to improve with lower doses or stopping the medication. Side effects from prolonged use may not be as easily reversible, especially cataracts which will only be cured by surgery.

  • Because side effects are a concern with corticosteroid use, doctors use corticosteroids sparingly and use other medicines which reduce the need for corticosteroids.

  • Infection - corticosteroids are not be used when there is an active infection.

  • Adrenal suppression - Our adrenal glands make our own circulating corticosteroids. When people take corticosteroid treatments it acts to suppress the adrenal glands from making their own corticosteroids. If corticosteroids are withdrawn too quickly after prolonged use the adrenal glands may remain suppressed for an extended period until they rebound on their own. Symptoms of adrenal suppression (otherwise known as symptoms of steroid withdrawal) include fatigue, generalized achiness, joint pains, feeling faint. When recognized this is treated with small doses of replacement corticosteroids and a slow taper to allow for the adrenal glands to slowly recover. This is why after several weeks of use corticosteroids are not simply abruptly stopped. Withdrawal from steroids that is too rapid can lead to fatigue, lethargy, joint pains, nausea.

References

Brassard P, Bitton A, Suissa A, Sinyavskaya L, Patenaude V, Suissa S. Oral corticosteroids and the risk of serious infections in patients with elderly-onset inflammatory bowel diseases. American Journal of Gastroenterology. 2014;109(11):1795-1802.

Burger D, Travis S. Conventional medical management of inflammatory bowel disease. Gastroenterology. 2011;140(6):1827-1837.

Cohen RD, Dalal SR. Systematic Review: Rectal Therapies for the Treatment of Distal Forms of Ulcerative Colitis. Inflammatory Bowel Diseases. 2015;21(7):1719-1736.

Ford AC, Bernstein CN, Khan KJ, Abreu MT, Marshall JK, Talley NJ, Moayyedi P. Glucocorticosteroid therapy in inflammatory bowel disease: systematic review and meta-analysis. American Journal of Gastroenterology 2011;106(4):590-599.

Greenberg GR, Feagan BG, Martin F, Sutherland LR, Thomson AB, Williams CN, Nilsson LG, Persson T. Oral budesonide for active Crohn's disease. Canadian Inflammatory Bowel Disease Study Group. New England Journal of Medicine1994;331(13):836-841.

Lichtenstein GR Budesonide multi-matrix for the treatment of patients with ulcerative colitis. Digestive Diseases and Sciences 2016;61(2):358-370.

Otley A, Steinhart AH. Budesonide for induction of remission in Crohn's disease. Cochrane Database Systematic Reviews 2005;(4):CD000296.

Talley NJ, Abreu MT, Achkar JP, Bernstein CN, Dubinsky MC, Hanauer SB, Kane SV, Sandborn WJ, Ullman TA, Moayyedi P, American College of Gastroenterology IBD Task Force. An evidence-based systematic review on medical therapies for inflammatory bowel disease. American Journal of  Gastroenterology 2011;106 Suppl 1:S2-25.

Targownik LE, Nugent Z, Singh H, Bernstein CN. Prevalence of and outcomes associated with corticosteroid prescription in inflammatory bowel disease. Inflammatory Bowel Diseases. 2014;20(4):622-630.

Weber NK, Bruining DH, Loftus EV Jr, Tremaine WJ, Augustin JJ, Becker BD, Kammer PP, Harmsen WS, Zinsmeister AR, Pardi DS. Comparative outcomes of younger and older hospitalized patients with inflammatory bowel disease treated with corticosteroids. Inflammatory Bowel Diseases 2013;19(12):2644-2651.

Last reviewed: October 2018

For more information and fact sheets about IBD and its treatment please visit: http://www.crohnsandcolitis.ca

Disclaimer: This information is provided for educational purposes only. Always consult a qualified health care professional for your specific care.

Source: This summary provides scientifically accurate information.  It was prepared in a research review by researchers with the IBD Clinical and Research Centre, University of Manitoba with assistance from colleagues in Canada and internationally. 

Acknowledgement: Preparation of this material was supported by funding from the Canadian Institutes of Health Research. 

©2016 Charles N. Bernstein, John R. Walker on behalf of Manitoba IBD Clinical and Research Centre. This work is licensed under a Creative Commons Attribution-NoDerivatives 4.0 International License. You are free to copy and distribute this material in its entirety as long as it is not altered in any way (no derivative works).