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Inflammatory bowel disease (IBD) encompasses gastrointestinal tract disorders, including Crohn’s disease and ulcerative colitis. These disorders are common, affecting almost 1 million persons in the United States and Europe. Their presentation is varied, and a number of complications can occur. To help develop a more consistent care plan, the American Gastroenterological Association Institute issued a clinical position statement on corticosteroids, immunomodulators, and infliximab (Remicade) use in managing IBD.
Corticosteroids

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Corticosteroids are used for treating patients with a moderate to severe relapse of IBD. Topical agents like suppositories or foam have been used to treat proctitis, and enemas have been effective for patients with disease up to the splenic flexure. Budesonide (Rhinocort), which has limited bioavailability and is poorly absorbed, can provide therapeutic benefit with reduced toxicity in patients with ileocecal Crohn’s disease.
RECOMMENDATIONS
For patients with mild to moderate IBD, ileal-release forms of budesonide can be used to treat ileal and right-sided colonic Crohn’s disease; however, they are not effective in treating ulcerative colitis. Conventional corticosteroids (e.g., prednisone) typically are used only in patients with moderate to severe IBD who do not respond to other first-line treatments (e.g., mesalamine [Rowasa] for ulcerative colitis, budesonide for Crohn’s disease). For distal colonic inflammation, a topical solution of hydrocortisone or budesonide is effective.
For patients with moderate to severe IBD, corticosteroids are effective in managing Crohn’s disease and ulcerative colitis; however, they are not effective in treating perianal fistulas.
Hospitalization for parenteral corticosteroids is needed for patients with severe and fulminant IBD who do not respond to oral corticosteroids and for those with severe IBD with Crohn’s disease or ulcerative colitis.
Conventional corticosteroids are not effective for use as maintenance therapy in patients with Crohn’s disease or ulcerative colitis. Budesonide is effective as a maintenance therapy in patients with mild to moderate ileocecal Crohn’s disease who are in short-term (three months) remission; it is not effective for long-term (one year) remission.
For the initiation of remission, a prednisone (or equivalent medication) dosage ranging from 40 to 60 mg per day or 1 mg per kg per day is effective. Induction of response can average seven to 14 days. Gradually tapering the dosage by 5 mg per week to a dose of 20 mg per day and then tapering the dosage again by 2.5 to 5.0 mg per week until the dosage is below 20 mg per day is recommended. Budesonide also can be tapered gradually from the initial dose of 9 mg to 6-mg and 3-mg doses. Budesonide suppresses the adrenocortical axis, so physicians should monitor patient symptoms and evaluate for adrenal insufficiency. If a corticosteroid dose cannot be tapered, antimetabolite or infliximab therapy is needed. If a patient does not respond to therapy with high doses of prednisone (or equivalent medication) in seven to 14 days, parenteral corticosteroids are indicated; the dosage usually ranges from 40 to 60 mg per day of methylprednisolone (Medrol) or 200 to 300 mg per day of hydrocortisone.
Patients taking corticosteroids are at an increased risk of infectious complications and should be monitored for glucose intolerance and other metabolic abnormalities. Occasional bone mineral density assessment and yearly ophthalmologic examinations also are recommended for patients on long-term (more than three months) corticosteroid therapy. Those who have taken corticosteroids in the past year have a higher risk of adrenal insufficiency; stress-dose corticosteroids may be needed if the patient undergoes surgery.
Azathioprine and 6-Mercaptopurine
Azathioprine (Imuran) and 6-mercaptopurine (6-MP; Purinethol) are immunomodulators; azathioprine is converted to 6-MP nonenzymatically. They often are used to withdraw the corticosteroids and maintain remission in corticosteroid-dependent patients who have Crohn’s disease or ulcerative colitis. Some studies show that azathioprine and 6-MP are effective in reducing clinical and endoscopic postoperative recurrence of Crohn’s disease.
RECOMMENDATIONS
While azathioprine and 6-MP doses are being adjusted, a complete blood count with differential should be taken at least every other week. Once the doses stabilize, a complete blood count should be performed at least once every three months for as long as it is clinically appropriate. Periodic measurement of liver-associated chemistries also is recommended. Currently, the U.S. Food and Drug Administration recommends that, to avoid adverse effects, all persons should have a thiopurine methyltransferase (TPMT) genotype or phenotype assessment before undergoing azathioprine or 6-MP therapy. Persons with intermediate or normal TPMT activity also will need frequent complete blood count measurements because of the possibility of developing myelosuppression.