Corticosteroids

Corticosteroids such as prednisone and budesonide are fast acting medicines used to calm intestinal inflammation during IBD flares. They are very effective for short term symptom control, but they do not keep Crohn's disease or ulcerative colitis quiet long term and can cause serious side effects. This article explains how they work, typical courses, and why they serve as a bridge to safer maintenance therapies.

Key takeaways

• Prednisone and IV steroids are powerful options to control moderate to severe Crohn’s and ulcerative colitis flares, but only for short term use.

• Budesonide is a gut targeted steroid used for milder Crohn’s near the ileum and for some cases of mild to moderate UC, with fewer whole body side effects but the same rule: short courses only. (journals.lww.com)

• Guidelines are clear that steroids are for induction, not maintenance. Long term steroid use is a red flag and usually means maintenance therapy needs to change. (journals.lww.com)

• Side effects range from insomnia, mood changes, and weight gain to bone loss, diabetes, infections, and eye problems, especially if doses are high or courses are repeated. (eviq.org.au)

• Tapering slowly is essential after more than a brief course so the adrenal glands can recover and symptoms do not rebound.

• Anyone who becomes “steroid dependent” or “steroid refractory” usually needs a different long term plan with immunomodulators or biologics, not more steroids. (journals.lww.com)

What corticosteroids are

Corticosteroids are synthetic versions of cortisol, a hormone made by the adrenal glands. They strongly dampen the immune system and reduce inflammatory chemicals in the body.

In IBD, steroids are used as “rescue” drugs to quickly reduce gut inflammation when symptoms are moderate or severe. They work faster than most other IBD medicines, often within days.

There are two broad types used in IBD:

• Systemic steroids, which affect the whole body.

• Gut targeted steroids, which act mainly inside the intestine with lower bloodstream exposure.

Systemic steroids: Prednisone and IV steroids

Prednisone (or prednisolone) is the most common oral systemic steroid used for IBD:

• Often used for moderate to severely active Crohn’s or UC that is not controlled by milder medicines. (journals.lww.com)

• Typical outpatient courses start around 40 to 60 mg once daily, then slowly taper over about 8 to 12 weeks if there is a response. (femtomedicine.com)

• Symptoms usually improve within 5 to 7 days. If there is no response, care teams reassess the diagnosis or escalate therapy.

In hospital, people with acute severe ulcerative colitis or very severe Crohn’s may receive IV steroids (such as methylprednisolone). This is covered in more detail in the Acute Severe UC and Flares articles.

Systemic steroids are potent but travel everywhere in the body. That is why they have both strong benefit and significant risk.

Gut targeted steroids: Budesonide

Budesonide is a “second generation” steroid designed to concentrate its effect in the gut and then be rapidly broken down by the liver.

Key features:

• Formulations that release in the terminal ileum and right colon are used for mild to moderate Crohn’s disease in that region. (journals.lww.com)

• Budesonide MMX 9 mg daily releases throughout the colon and is recommended in guidelines for some people with mild to moderately active UC who do not respond fully to mesalamine. (journals.lww.com)

• Because more than 90% is inactivated on first pass through the liver, blood levels are lower and many systemic side effects are reduced, although not eliminated. (ncbi.nlm.nih.gov)

Despite this better safety profile, guidelines still treat budesonide as a short term induction medicine. It is not recommended for long term maintenance, and for Crohn’s should generally not be continued beyond about 3 to 4 months. (journals.lww.com)

When steroids are used in Crohn’s and UC

Induction of remission

“Induction” means getting active disease under control.

• In Crohn’s disease, oral corticosteroids or budesonide are recommended for short term induction in people with moderate to severe activity, especially when rapid symptom relief is needed. (journals.lww.com)

• In ulcerative colitis, oral systemic steroids are used to induce remission when 5‑ASA is not enough, and budesonide MMX is an option for some with mild to moderate disease. (mdcalc.com)

For both diseases, modern guidelines increasingly favor starting biologics or small molecules early, sometimes even avoiding systemic steroids if a fast acting advanced therapy is chosen from the start. (journals.lww.com)

Not for maintenance

Large guideline reviews show that systemic steroids do not keep remission going and cause many side effects when used long term. They are clearly recommended against for maintenance of remission in both Crohn’s and UC. (journals.lww.com)

If symptoms flare every time the dose is lowered, this is called steroid dependence. If symptoms never improve despite an adequate course, this is steroid refractory disease. Both situations signal the need for a different long term plan, not more steroids.

Typical course and taper

Steroid courses are individualized, but common patterns include:

• Oral prednisone for 8 to 12 weeks in outpatient flares, with the dose stepped down gradually once symptoms improve. (journals.lww.com)

• Budesonide 9 mg daily for about 8 weeks, sometimes followed by a short lower dose period, then stopped. (pubmed.ncbi.nlm.nih.gov)

A taper allows the body’s own cortisol production to recover and reduces the risk of adrenal crisis, a medical emergency that can occur if high dose steroids are stopped suddenly after several weeks. (eviq.org.au)

During the taper, care teams usually start or optimize steroid sparing maintenance therapy such as thiopurines, methotrexate, biologics, JAK inhibitors, or S1P modulators.

Side effects: Why steroids are short term only

Steroids can affect almost every organ system. Risk increases with higher doses, longer use, and repeated courses.

Common short term effects

Often appear within days to weeks:

• Difficulty sleeping, restlessness, or anxiety

• Mood swings, euphoria, or irritability, and in some people depression or psychosis

• Increased appetite and rapid weight gain

• Puffy face, fluid retention, and higher blood pressure

• High blood sugar, especially in those with diabetes or prediabetes

• Stomach irritation or heartburn

• Higher infection risk and slower wound healing (eviq.org.au)

Long term and cumulative effects

More likely with months of treatment or multiple bursts:

• Osteoporosis and fractures

• Cataracts and glaucoma

• Type 2 diabetes or worsening glucose control

• Thinning skin, easy bruising, and muscle weakness

• Persistent weight gain and changes in body fat

• Infections, including serious ones like pneumonia or shingles (eviq.org.au)

Because budesonide has much lower systemic exposure, these long term problems are less common but can still occur, especially at higher doses or with interacting medicines. (academic.oup.com)

Budesonide vs prednisone: “Safer,” but still a steroid

Compared with prednisone:

• Budesonide delivers more drug directly to the intestinal wall and is largely inactivated on first pass through the liver.

• Clinical trials in ileocecal Crohn’s show similar remission rates with fewer classic steroid side effects for budesonide, although it may be slightly less potent for very severe inflammation. (pubmed.ncbi.nlm.nih.gov)

However:

• Budesonide can still suppress the adrenal glands, affect bone, and increase infection risk. (academic.oup.com)

• It is still recommended only for induction, not for long term maintenance. (journals.lww.com)

So budesonide is often a preferred short term option in eligible patients, not a free pass to stay on steroids indefinitely.

Tapering and monitoring

Safe steroid use usually includes:

• Planning a clear stop date, usually within 8 to 12 weeks for systemic steroids. (journals.lww.com)

• Regular checks of blood pressure, blood sugar, and weight.

• Considering bone protection (calcium, vitamin D, and in high risk cases bone density scans and specific medications).

• Watching for mood changes, sleep problems, or signs of infection and reporting them promptly.

Repeated or prolonged steroid use is a strong signal to review the overall treatment plan and consider more effective maintenance options.

FAQs

Are steroids always necessary during a flare?

Not always. For some people with mild disease, 5‑ASA, budesonide, or rapid acting advanced therapies can control flares without systemic prednisone. For many moderate to severe flares, though, a short steroid course is still used while longer acting treatments take effect. (journals.lww.com)

What if symptoms return every time steroids are lowered?

This pattern is called steroid dependence. It usually means underlying inflammation is still active and that the maintenance regimen is not strong enough. Guidelines recommend shifting to steroid sparing treatments rather than continuing or repeating steroids. (journals.lww.com)

Is budesonide mild enough to skip monitoring?

No. Budesonide has fewer systemic effects than prednisone, but it is still a corticosteroid. Monitoring for blood pressure, blood sugar, bone health, adrenal suppression, and infections remains important, especially with repeated courses or other interacting medicines. (academic.oup.com)