Treatment and Medication

Corticosteroids, or steroids, are hormones produced naturally in the adrenal glands located above your kidneys. Steroid medications used in the treatment of IBD are analogues of these hormones but they are made synthetically. 

However, health care providers choose to prescribe corticosteroids sparingly due to side effects. They tend to use other medications whenever possible instead. These other drugs can help reduce the need for corticosteroids.

Examples of corticosteroids include prednisone, hydrocortisone, and budesonide. Corticosteroids are available as an oral medication or intravenously, or even as an enema. More specifically, the various formulations of steroid medications for IBD treatment are often as follows:

• Intravenous (e.g. in hospitals): methylprednisolone (Solumedrol™️).

• Oral: prednisone, budesonide (Entocort™️, Cortiment™️). The advantage of oral budesonide is that it does not have as many side effects because it gets broken down quickly in the body after being absorbed and therefore it has less time to circulate and cause a lot of side effects. Even though budesonide is not quite as potent (effective) as prednisone, it is better tolerated than the latter. In fact, budesonide was created to provide the benefits of steroid as a medication with fewer of the associated side effects. 

• Rectal enemas, suppositories, foams: hydrocortisone, budesonide, prednisolone. 

Steroids inhibit the immune system. In the gastrointestinal system, they stop the movement of inflammatory cells (cells causing inflammation) to the intestine and they decrease the expression of inflammatory chemicals called cytokines. As such, they cause activated white blood cells to die and this reduces inflammation in the body.

Corticosteroids have dramatic effects in IBD. They act as a broad way of reducing inflammation but they are associated with significant long-term toxicity. There are two kinds of steroid medications:

• Glucocorticoids - they are used to reduce inflammation and these are the type of steroids used in the treatment of Crohn's and colitis.

• Mineralocorticoids - they affect the balance of fluids and electrolytes in your body, e.g. how much fluid you retain.

​All steroids have a bit of both effects and this is why the glucocorticoids used in the treatment of IBD also cause fluid retention. 

Steroid medications in IBD are intended to be short-term treatment options for cases of moderate to severe Crohn's and colitis. For example, oral prednisone is often prescribed at a high dose (about 40 mg to 60 mg per week) for a couple of weeks before gradually decreasing the dose over time (to usually 5 mg per week). In contrast, oral budesonide could be prescribed at the same dose (e.g. 9 mg) for the course of 8 weeks without the need to reduce the dose. 

Healthcare providers try their best to avoid extended and repeated treatment with steroids because of the side effects. Hence, they do not consider corticosteroids to be a maintenance therapy.

Here is a summary of the effectiveness of corticosteroids for the management of IBD:

• In general, corticosteroids are effective at inducing remission in active ulcerative colitis.

• Corticosteroids are effective at inducing remission in active Crohn's disease.

• ​Standard corticosteroids such as prednisone tend to be more effective than budesonide at inducing remission in active Crohn's disease.

• The corticosteroid budesonide is NOT effective at preventing relapse in inactive Crohn's disease. 

Corticosteroids are well known to have significant short-term side effects. These can be categorized as follows:

• Cosmetic - e.g. acne, redness on the face, Cushingoid faces (‘chubby cheeks’), a tendency to bruise easily, fluid retention, weight gain, and striae (stretch marks). 

• Psychological - e.g. mood swings, depression, and psychosis (loss of touch with reality).

• Musculoskeletal Health - e.g. skeletal myopathy or muscle weakness, osteonecrosis (reduced blood flow to the joints, especially the hip), and osteoporosis or bone weakness.

• Metabolic - e.g. infection, diabetes mellitus, hypertension (higher blood pressure than normal), cataracts (cloudy eye lens), glaucoma (damage to the optic nerve that can cause vision loss), increased appetite, growth retardation.

​The side effects of steroids worsen the more you take them and this is why healthcare providers try to get people off them as soon as possible. However, if you have been on steroids for a long time, your body gets used to it. From there, your body stops making its own steroids (natural hormones) because it got used to getting the steroids delivered in the form of medication. You then lose the ability to produce steroids on your own. At this point, people feel unwell, achy, and experience muscle pain.

If you are taking corticosteroids, you should avoid getting live vaccines from three weeks before starting this type of drug.

You should not have vaccines during the time you are on corticosteroids, up until three to six months after stopping. You should also avoid anyone who has recently had live vaccine, and avoid the nasal flu vaccine.

Here a few tips on how to reduce your use of steroid medications in IBD:

• Before starting a treatment with steroids, always check if other types of medications could be taken instead. 

• Use steroids only for a short and defined period of time with a scheduled and gradual dose reduction and/or complete discontinuation at the end.

• Consider adding or changing your maintenance therapy to better control the disease and to prevent further use of steroids. To do so, talk to your healthcare provider about the changes that can be made to your treatment plan. 

Video: Steroids and Inflammatory Bowel Disease

Watch this video (7 min) to learn more about steroids used in the treatment of Crohn's disease and ulcerative colitis, including how these medications work in IBD, what they are used for, which types of patients can access steroids, potential benefits, side effects, and risks and minimizing steroid use.

Speaker: 

Dr. John K. Marshall (MD, MSc, FRCPC, CAGF, AGAF), Professor of Medicine, Director, Division of Gastroenterology, McMaster University.