Meds & Biologics
If your gastroenterologist just prescribed prednisone for a Crohn's flare, you probably have two simultaneous reactions: relief that something strong is coming, and dread about what it will do to your body. Both reactions are valid. Corticosteroids remain the fastest way to knock down the acute inflammation driving your pain, bloody stools, and weight loss. But they come with real side effects, a taper that matters more than most patients realize, and an expiration date on how long they should be part of your treatment. This guide walks through what actually happens during a steroid course, what the side effects feel like week by week, how budesonide differs from prednisone, and what it means if you cannot get off steroids.
How Prednisone Works in a Crohn's Flare
Prednisone is a systemic corticosteroid, meaning it circulates through your entire body to suppress immune activity. In Crohn's disease, your immune system is attacking your own intestinal lining, creating ulcers, swelling, and narrowing. Prednisone dampens that immune response broadly and quickly. Most patients notice symptom improvement within days to a week.
A typical starting dose is 40 mg per day, taken in the morning to loosely mimic your body's natural cortisol rhythm. Your doctor will keep you at this dose for two to four weeks while your inflammation settles, then begin a gradual taper. The goal is always the same: get in, calm the flare, and get out. Prednisone is not a maintenance medication. The 2025 ACG Clinical Guideline for Crohn's disease strongly recommends limiting corticosteroid use to fewer than three months total per course.
The reason for that limit is straightforward. Prednisone does nothing to heal the underlying mucosal damage in your gut. It suppresses symptoms and visible inflammation, but once you stop it, the disease process picks up where it left off unless another therapy is holding things in check. That is why your GI team should already be discussing a steroid-sparing maintenance strategy before your taper is finished.
The Real Side Effects, Week by Week
Reading a list of side effects on a pharmacy handout is different from living through them. Here is what many Crohn's patients report during a standard prednisone course.
The first week hits fast. Insomnia is often the earliest and most disruptive side effect. You may feel wired at night even when exhausted. Appetite surges, sometimes dramatically, and many patients describe cravings they cannot control. Mood changes show up early too: irritability, anxiety, emotional swings that feel disproportionate to what is happening around you. Energy may spike during the day, creating a jittery, restless feeling.
Weeks two through four bring visible changes. Facial puffiness, commonly called moon face, develops as prednisone causes your body to redistribute fat to the face and midsection. Acne may flare. Water retention can make your hands and ankles feel swollen. Weight gain becomes noticeable, driven by both increased appetite and fluid shifts. Some patients develop elevated blood sugar or blood pressure even without a prior history of either.
During the taper, side effects begin to recede, but not all at once. Moon face often lingers for weeks after the dose drops. Fatigue can replace the earlier hyperactivity as your adrenal glands slowly resume natural cortisol production. Some patients feel worse during the taper than they did at full dose, because the body is adjusting to lower exogenous steroid levels while the adrenal axis catches up.
Why the Taper Schedule Matters
You cannot stop prednisone abruptly. At therapeutic doses, prednisone suppresses your adrenal glands, which normally produce cortisol on their own. Stopping suddenly can trigger adrenal insufficiency, a potentially dangerous condition with symptoms including severe fatigue, low blood pressure, nausea, and joint pain.
A standard taper for Crohn's disease follows a structured step-down. According to primary care guidelines for IBD corticosteroid use, experienced clinicians typically reduce by 5 mg per week from 40 mg down to 20 mg, then slow the taper to 2.5 mg per week from 20 mg to zero. The entire course runs roughly eight weeks. Some gastroenterologists adjust based on symptom response, slowing the taper if symptoms begin returning at a particular dose.
The taper is also a diagnostic tool. If your symptoms flare every time the dose drops below a certain threshold, that pattern has a name: steroid dependence. And it changes the treatment conversation significantly.
Steroid Dependence: A Signal, Not a Failure
Steroid dependence in Crohn's disease means you respond to steroids initially but cannot discontinue them without your symptoms returning. This is more common than many patients expect. It does not mean you did something wrong or that your disease is untreatable. It means the underlying inflammation is too active for your current maintenance therapy to control alone.
Current guidelines treat steroid dependence as a clear indication to escalate therapy. The 2025 ACG guidelines recommend against requiring failure of conventional therapy before starting advanced treatments like biologics. If you cannot taper off prednisone, your gastroenterologist should be discussing options like infliximab, adalimumab, ustekinumab, risankizumab, or upadacitinib, all of which are recommended by the AGA for moderate-to-severe Crohn's. These medications target specific pathways in the inflammatory process and can maintain remission without the systemic toxicity of long-term steroids.
If your doctor prescribes repeated steroid courses without discussing a steroid-sparing plan, ask directly: "Am I steroid dependent, and should we be talking about a biologic or immunomodulator?"
Budesonide: A Different Kind of Steroid
Budesonide, sold as Entocort EC, is a corticosteroid that works differently from prednisone in a way that matters for many Crohn's patients. The Entocort EC capsule uses a pH-dependent coating that dissolves in the ileum and ascending colon, delivering the drug directly to the areas most commonly affected by Crohn's disease. Because budesonide has approximately 90% first-pass metabolism in the liver, very little reaches the rest of your body. Its systemic bioavailability is roughly 11% compared to prednisone's much higher systemic exposure.
The clinical difference is meaningful. In head-to-head trials, budesonide induced remission in 53% to 60% of patients, compared to about 60% to 66% for prednisolone. The trade-off for that slightly lower remission rate was significantly fewer steroid side effects: less moon face, less insomnia, less adrenal suppression, and less mood disruption.
Budesonide works best for mild-to-moderate Crohn's disease affecting the ileum, the last section of the small intestine. The standard dose is 9 mg once daily for up to eight weeks, followed by 6 mg daily for maintenance if needed. If your Crohn's primarily affects the ileum and your flare is not severe, budesonide may be a reasonable first-line option worth discussing with your GI doctor. For more severe or widespread disease, prednisone's broader systemic reach may still be necessary.
Managing Side Effects While You Are on Steroids
You cannot eliminate prednisone's side effects entirely, but some strategies help.
For insomnia, take your dose first thing in the morning. This aligns the drug's peak activity with your natural cortisol cycle and gives levels time to drop before bedtime. Avoid caffeine after noon. Some patients find that melatonin helps, but check with your doctor before adding any supplement.
For appetite and weight gain, recognize that the hunger is pharmacological, not psychological. Keeping high-protein snacks available and eating structured meals can reduce the impulse to graze continuously. Weight gain from fluid retention will resolve after the course ends; weight gain from excess calories may not.
For mood changes, tell the people around you what is happening. Steroid-driven mood swings are well-documented and can range from irritability to full psychiatric symptoms at higher doses. If mood changes become severe, including depression, anxiety, or racing thoughts that interfere with daily function, contact your prescriber. Dose adjustments or short-term supportive medications can help.
What to Track During Your Steroid Course
The weeks on steroids are a window of data that matters for your long-term treatment plan. Your gastroenterologist needs to know how quickly your symptoms responded, at what dose during the taper symptoms began returning (if they did), and which side effects you experienced. This information shapes decisions about your next steps, whether that means staying on your current maintenance therapy, adding an immunomodulator, or starting a biologic.
Write down your daily symptoms: stool frequency, pain level, energy, sleep quality, and any side effects. Note the date and dose for each entry. When your doctor asks "how did the taper go," specific data is far more useful than a general impression. This kind of tracking turns a difficult medication experience into actionable clinical information that helps your care team calibrate what comes next.