Inflammatory bowel disease (IBD), which includes Crohn’s disease (CD) and ulcerative colitis, causes chronic inflammation in the digestive tract and can cause symptoms like diarrhea and abdominal pain. Patients with IBD often use drugs called anti-inflammatory medications to:
- Help relieve the symptoms of active disease
- Help them to enter remission
- Help them to stay in remission longer1
Two types of anti-inflammatory drugs are commonly prescribed to people with IBD:
- Corticosteroids
- Aminosalicylates1
Some people with IBD may be advised to take both types of anti-inflammatories together for a certain amount of time, and in other cases people may take just one type or the other.
What are corticosteroids?
Corticosteroids, commonly called steroids, are drugs used in the treatment of inflammatory bowel diseases such as Crohn's disease and ulcerative colitis.1,2 Corticosteroids are anti-inflammatory medications that are used to help reduce inflammation in the digestive tract and relieve symptoms that it causes. For many people, corticosteroids have a powerful anti-inflammatory effect that starts working very quickly. However, some people do not respond to the effect of corticosteroids at all. Researchers are still not sure why some people respond while others do not.
Unlike other forms of anti-inflammatory drugs, corticosteroids are not used long-term to help patients to stay in remission. One of the reasons for this is that corticosteroids are not able to heal the damage to the lining of the intestines (called the “mucosa”) that IBD can cause. Instead, corticosteroid treatment for IBD is focused on:
- Short-term treatment to help relieve moderate or severe symptom flare-ups
- Helping the patient to enter remission more quickly2
Once a patient enters remission, the healthcare provider will help them to safely stop taking the medication by tapering off the dose gradually. Different types of medications can then be used to help lengthen the remission period.
Examples of corticosteroids used to treat Crohn's or UC
Common types of corticosteroids used in the treatment of IBD are:2
- Prednisone
- Methylprednisolone (brand name: Medrol)
- Hydrocortisone (brand names: Proctofoam, Cortenema)
- Budesonide (brand name: Entocort, Uceris)
Taking corticosteroids orally (in a tablet or capsule) is effective for many people. However, other people may need to take the medicine in a different type form, such as rectally (in a suppository, enema, or rectal foam) or through an intravenous (IV) line, which delivers the medication directly into a vein.
Prednisone, methylprednisolone, and hydrocortisone have been used for many years in treating patients who have moderate or severe active IBD. They can be taken in oral forms for people who can tolerate them.
Hydrocortisone and budesonide are also available in rectal forms for people who have active disease that affects the lower part of the colon or the rectum. This form of corticosteroid is different than the ones that are taken orally. The rectal forms specifically target the area affected by disease, without affecting a person’s entire body like the oral forms can do. This means that the rectal forms tend to be associated with fewer side effects than the oral forms. People with severe disease may need to have hydrocortisone or methylprednisolone delivered by an IV.
Budesonide is a type of oral corticosteroid that is suitable for some patients with mild or moderate disease that affects the end of the small intestine and the beginning of the large intestine.
How do corticosteroids work?
A substance called “cortisol” is produced by the body in the adrenal glands, which are located on top of the kidneys.2,3 One of the functions of cortisol is to naturally reduce the amount of inflammation in a person’s body. Corticosteroid medications are designed to copy the effect that cortisol has on the body. This means that at the correct dosage, corticosteroids can trigger the body’s response to fight inflammation more aggressively.
Corticosteroids can also have the effect of suppressing the body’s immune system. Current research suggests that there may be a link between IBD and overreaction of the body’s immune system, so it is thought that corticosteroid treatment may also be helpful in this way for people with IBD.
What are the possible side effects?
Many corticosteroids are called “systemic” medications because they affect the entire body, not just the area of inflammation.2,4 This means that a person might experience many different types of side effects, such as:
- High blood pressure
- High blood sugar or diabetes
- Weakened bones (osteoporosis)
- Thinning of the skin
- Weight gain
- Acne or stretch marks
- Rounding of the face
- Increased facial hair
- Insomnia
- Mood swings and other mental health symptoms
- Increased risk of infection2,5
- Ulcers
These are not all the possible side effects of corticosteroids. Patients should talk to their doctor about what to expect with treatment with corticosteroids.
Most side effects will resolve once a patient stops steroid use. To help counteract side effects, healthcare providers may advise patients to take calcium supplements and Vitamin D while they are taking corticosteroids to help prevent osteoporosis. Acid reducers (such as omeprazole) may also be prescribed to help prevent ulcers. A low-impact exercise routine can also be beneficial, if the patient is physically able (although exercising may be difficult for many patients).
Due to the number of side effects associated with corticosteroid use, many healthcare providers will attempt to treat a patient first with a different therapy, such as aminosalicylates, immunomodulators, and/or antibiotics, before recommending corticosteroids.
Why are corticosteroids used as short-term treatment for Crohn's or colitis?
Even though many patients find that corticosteroids can work very effectively and quickly to reduce symptoms, corticosteroids can cause effects in the body that can sometimes be harmful.2-3 One of those effects is called “steroid dependency.”
Steroid dependency happens because the body cannot tell the difference between natural cortisol and the corticosteroid delivered in the medicine. Taking too much corticosteroid medication over time can cause the person’s body to stop producing cortisol naturally, because of the amount of corticosteroid being provided by the medicine. As a result, the body becomes dependent on the medicine for all of its cortisol needs.
The hormone cortisol has an important function of affecting a person’s reaction to stress. This means that right after people stop taking a corticosteroid, it can make their reactions to stress a little bit different than it was before, because the body is not producing as much (or any) cortisol naturally. This effect usually goes away as the body’s own adrenal glands start producing the normal amount of cortisol again.
When this kind of dependency happens to a person with IBD, they may not be able to stop taking the corticosteroid medicine without experiencing a flare-up as a result. Healthcare providers can help patients who become dependent on steroids to transition to another type of medication for their symptoms.
Dependency on corticosteroids is more likely to occur if:
- Too high a dose is used
- The course of treatment is too long
- The courses of treatment are too frequent
For this reason, it is usually recommended that corticosteroids be taken at the smallest effective dose for the shortest amount of time possible. It is also important to stop taking corticosteroids gradually by tapering off the dosage slowly. This allows the body to start producing enough cortisol naturally again.