Corticosteroids for IBD

Points to remember

  • Steroids (corticosteroids) can effectively treat active inflammation in inflammatory bowel disease (IBD), but due to their side effects, they are not recommended to be used repeatedly or long-term. Other effective therapies can reduce the need for steroid medications.
  • You should not suddenly cease steroids on your own even if you are feeling better. You should reduce the dose over time (taper down) under the directions of your doctor.

Key points 

  • Steroids are usually used for a short time to get control over this disease while waiting for long-term medications to work. 
  • Steroids for IBD should not be confused with anabolic steroids which are used to build muscle. 
  • Depending on the type of steroid, you may take the medication as a tablet, enema or intravenously (directly into the veins).
  • Steroids have quite a few side effects which is why doctors aim to only use them for the short-term. Long-term use can cause cataracts, poor bone health (osteoporosis) and diabetes, to name a few.

What are steroids?

Steroids are hormones naturally produced in the body. Corticosteroids (or steroids) used to treat IBD are manufactured versions of these hormones. Steroids help to reduce inflammation during flares or worsening of disease. These should not be confused with anabolic steroids which are used to build muscle.

Why have I been prescribed steroids and how do they work?

Before you start thiopurines the IBD team may request blood tests including your full blood count, liver function tests, and “TPMT”. This is to check if it is safe to start taking a thiopurine medication. TPMT is an enzyme in the body that breaks down thiopurines and tells the IBD team if your dose of thiopurine needs to be altered.

You will also be screened to check you are up to date with your vaccinations and for certain infections before starting treatment.

Why have I been prescribed steroids and how do they work?

The immune system is important for fighting infections, but sometimes immune cells attack the body’s own tissues and can cause chronic inflammation (like that found in IBD). Excessive inflammation in the bowel can cause damage to intestinal lining, diarrhoea, and bleeding. Your doctor or nurse practitioner may prescribe a short course of steroid medication that is tapered overtime to get inflammation under control quickly or to control symptoms whilst waiting for other long-term therapies to work. Always inform your IBD team if you are prescribed steroid medication by another health practitioner and never self-initiate steroid therapy without medical advice.

How do I take steroids?

There are several different forms of steroids. The form that you need will depend on the type and location of your IBD and the severity of the inflammation. You may discuss these formulations with your IBD team.

Oral steroids

Oral steroids are best tolerated when taken with food to reduce any nausea, and in the morning as they can keep you awake.

Prednisolone

The most common oral steroid used is prednisolone. Prednisoloneis available in a 1mg, 5mg and 25mg tablet as well as a liquid. You will generally be given a higher dose of prednisolone to start with and then be asked to slowly decrease the dose (as instructed by your doctor) before stopping completely. Tapering down is a very important part of your treatment. You should not stop prednisolone on your own even if you are feeling better.

Budesonide

Budesonide is an oral steroid which was developed to reduce the side effects associated with conventional steroids. Budesonide works by releasing the medication directly at the site of inflammation in the bowel. There are 2 forms of oral budesonide.

•Enteric coated budesonide(3mg capsules), designed to release budesonide into the small bowel, is used in Crohn’s disease affecting the small bowel.

•Colonicrelease budesonide(9mg tablets) releases budesonide throughout the large bowel (colon) and is used to treat ulcerative colitis and colonic Crohn’s disease.

It may not be necessary to taper down budesonide; however, your doctor may give you a schedule for reducing the medication gradually.

Rectal steroids

Rectal steroids are used when inflammation is confined to the left side of the colon (enemas) or the rectum (suppositories) and work locally on the bowel, to reduce side-effects in the rest of the body. Rectal steroids deliver medication directly to the area where they are most needed.

Enemas come in foam or liquid form. Enemas use a special applicator that is inserted into the rectum and can deliver medication up into the colon. A foam enema can be better tolerated when the rectum is inflamed.

Suppositories are solid dosage forms of medication that are inserted into the rectum and dissolve over time. Rectal steroids include prednisolone suppositories and enemas, hydrocortisone enemas and budesonide enemas.

Your IBD team will give you advice on how to administer rectal treatments and address any concerns you may have.

Intravenous (IV) steroids

IV steroids such as hydrocortisone or methylprednisolone are administered directly into a vein in hospital for patients with severe ulcerative colitis or Crohn’s disease as they work very quickly. If you have been treated with IV steroids, you may be changed to a tapering course of oral steroidsafter a few days.

Pregnancy and breastfeeding

It is important to be well and stable on medication before becoming pregnant. Tell your doctor if you are thinking of becoming pregnant or find you are It is important to be well and stable on medication before becoming pregnant. Tell your doctor if you are thinking of becoming pregnant or find you are pregnant. Your IBD team may prescribe steroids for active inflammation during pregnancy as there may be a greater risk to the baby if the woman does not take treatment and is unwell with IBD. Steroids are generally considered to be safe during pregnancy and breastfeeding.

What are the possible side effects of steroids?

Although steroids are produced naturally by the body, giving extra steroids through medication can cause side effects. These effects can vary, depending on your dose, how long you have been on the medication, and how quickly you stop your steroid medication. In general, many of these are temporary and reversible with short courses. Side effects are less likely with budesonide and rectal preparations than prednisolone.

General side effects: These side effects can occur during any time of your therapy due to the body being exposed to higher than natural levels of steroids. They include: increased risk of infection, trouble sleeping, acne, fluid retention, puffy facial appearance, weight gain, mood changes (such as irritability, anxiety), growth of facial hair, stretch marks on the abdomen, reduced libido, and high blood sugar levels.

Side effects due to long term use: These side effects are more likely to occur when given at high doses for many months and include increased risk of infection, weight gain, cataracts, poor bone health (osteoporosis), thinning of skin, problems with blood supply to the top of the thigh bone, muscle weakness, diabetes, and high blood pressure. In babies, children and adolescents, steroids can affect growth.

Side effects due to coming off steroids too quickly: After many weeks on high dose steroid medication, your body produces less of its own natural steroid and therefore you cannot stop taking the steroid medication suddenly or too quickly, or you may become very unwell. Symptoms include fatigue, loss of appetite, weight loss, abdominal pain, nausea, vomiting, headache, joint pains, dizziness and fever. You should inform your IBD team if you experience any of these.

Will I need to take any special precautions while on steroids?

•You should inform all health care providers that you are currently on, or have been, taking steroids. If you become ill, require surgery or have an infection, the dose of steroid may need to be altered. This is because your body needs more steroids when exposed to physical stress.

•Avoid close contact with people with transmissible infections. Tell your doctor if you have come in contact with anyone who has an infectious condition such as chicken pox, shingles, whooping cough or measles.

•You should have the flu vaccine every year, and the COVID-19, pneumonia, and human papilloma virus (HPV) vaccines according to the recommended schedule. You should not have live vaccinations while taking steroids, and for some time after stopping them. Please refer to the Vaccinations and IBD information sheet for further information.

•Women should have regular cervical screening tests as recommended by your GP.

•You should use a strong sunscreen and protect your skin when outside. Annual skin checks are recommended.

•Always check with your IBD team before starting new medications to avoid unwanted interactions.

Contact the IBD team or your GP if you have an infection or persistent fever.

This information leaflet has been designed to provide you with some important informationabout steroids. This information is general and not intended to replace specific advice from your doctor or any other health professional. For further information please speak to your pharmacist, doctor or IBD nurse.

Acknowledgements:

This resource was developed in 2021 by the GESA IBD Patient Information Materials Working Group