Corticosteroids

Short course corticosteroids help calm active inflammation fast in Crohn’s disease and ulcerative colitis. The most used options are prednisone (whole‑body effect) and budesonide (gut‑targeted forms for specific locations). Steroids are for induction only, not long‑term control. The goal is to use the lowest effective dose for the shortest time, then transition to a steroid‑sparing maintenance therapy. (journals.lww.com)

Key takeaways

• Prednisone 40–60 mg daily induces remission, then taper over weeks; avoid courses longer than about 3 months. (journals.lww.com)

• Budesonide targets the gut and has fewer body‑wide effects, but only works where it is delivered. (drugs.com)

• Budesonide MMX 9 mg daily helps mild–moderate ulcerative colitis; controlled‑ileal‑release budesonide 9 mg helps ileocecal Crohn’s. (pubmed.ncbi.nlm.nih.gov)

• Steroids are not effective for maintenance; repeated or prolonged use increases serious risks. Aim for steroid‑free remission. (cochrane.org)

• Even short steroid bursts raise risks of sepsis, clots, and fractures. Use safety steps and plan a quick exit to a maintenance therapy. (pubmed.ncbi.nlm.nih.gov)

How steroids fit in IBD care

Corticosteroids rapidly suppress immune activity to provide symptom relief during a flare. In treat‑to‑target care, they are a bridge to maintenance medicines that keep inflammation off over time. Long‑term goals are symptom control and healing on endoscopy without ongoing steroid use. (pubmed.ncbi.nlm.nih.gov)

Prednisone (systemic)

• When used: Moderate to severe outpatient flares of UC or Crohn’s when faster relief is needed or 5‑ASA failed. Typical starting dose is 40–60 mg once daily. Clinical response is expected within about 5–7 days. (journals.lww.com)

• Taper: Hold the starting dose 1–2 weeks, then taper by about 5 mg per week to 20 mg, then by 2.5–5 mg weekly. Avoid total course lengths beyond roughly 3 months. There is no benefit to doses above 60 mg daily. (journals.lww.com)

• Hospital care for severe UC: Intravenous steroids (for example, methylprednisolone up to 60 mg/day) are first‑line; reassess at 3–5 days and move to rescue therapy if inadequate response. (journals.lww.com)

Budesonide (gut‑targeted)

Formulations are designed to release steroid where disease is located, which lowers whole‑body exposure.
- Budesonide MMX (tablet): Releases through the colon. Dose 9 mg daily for 8 weeks for mild–moderate ulcerative colitis. Trials show higher clinical and endoscopic remission vs placebo with a favorable safety profile. (pubmed.ncbi.nlm.nih.gov)
- Budesonide controlled‑ileal‑release (capsule): Targets terminal ileum and right colon. Dose 9 mg daily for up to 8 weeks for mild–moderate ileocecal Crohn’s; effective vs placebo but less potent than prednisone. Not effective for long‑term maintenance. (pubmed.ncbi.nlm.nih.gov)
- Rectal steroids: Budesonide foam or hydrocortisone enemas can treat proctitis or proctosigmoiditis when rectal 5‑ASA cannot be used or has failed. Budesonide foam improves remission and bleeding with minimal adrenal effects. (pubmed.ncbi.nlm.nih.gov)

Why steroids are short‑term only

Steroids induce remission but do not maintain it, and they are linked to important harms. ECCO recommends restricting courses to a maximum of about 3 months and starting a steroid‑sparing agent if relapse occurs on taper or if more than one course per year is needed. Treat‑to‑target emphasizes steroid‑free remission. (academic.oup.com)

Even brief oral courses are associated with higher short‑term risks of serious infection, venous thromboembolism, and fractures, with risks seen even at prednisone‑equivalent doses under 20 mg/day. (pubmed.ncbi.nlm.nih.gov)

Safety checks and monitoring

• Before and during a course

• Screen for infections that mimic flares when response is poor, including C. difficile and cytomegalovirus in UC. (pmc.ncbi.nlm.nih.gov)

• Monitor blood pressure, glucose, mood/sleep, and weight; consider eye and bone health if courses repeat. For people needing >3 months of systemic steroids or repeated courses, follow glucocorticoid‑induced osteoporosis guidance: ensure calcium and vitamin D and assess fracture risk, with medication for those at moderate to very‑high risk. (pubmed.ncbi.nlm.nih.gov)

• Vaccination

• Live vaccines are contraindicated during high‑dose systemic steroids, commonly defined as ≥20 mg/day prednisone for ≥14 days; give live vaccines at least 4 weeks before starting and delay after stopping as per guidance. Inactivated vaccines can be given. (pmc.ncbi.nlm.nih.gov)

• Drug interactions

• Budesonide levels rise with strong CYP3A4 inhibitors and grapefruit products; avoid these combinations. (drugs.com)

• Tapering and adrenal health

• Courses under 3–4 weeks generally do not need taper. Longer or repeated courses require a gradual taper and awareness of adrenal insufficiency; some patients need stress‑dose guidance during illness or procedures. (support.endocrine.org)

Quick comparison of common steroid options

When to pivot

• No response after 1–2 weeks of appropriate oral prednisone, or relapse during taper.

• Need for more than one systemic steroid course in a year.

• Steroid dependence (unable to taper below about 10 mg prednisone within 3 months, or relapse within 3 months of stopping).
  These are cues to start or optimize a steroid‑sparing agent such as a biologic or small‑molecule therapy. (academic.oup.com)

FAQs

Do steroids heal the bowel

They reduce symptoms quickly but are not reliable for mucosal healing or long‑term control. Maintenance therapies are needed for durable remission. (academic.oup.com)

Is budesonide “safer” than prednisone

Budesonide has lower systemic exposure and fewer body‑wide effects, but it only treats disease where the formulation releases. Safety also depends on dose, duration, and interactions. (drugs.com)

How long until steroids work

Prednisone usually shows improvement within 5–7 days. In severe UC treated in the hospital with IV steroids, response is reassessed by day 3–5. (journals.lww.com)