Managing Corticosteroid Therapy

Introduction to Budesonide Therapy

• The British Society of Gastroenterology and the Canadian Association of Gastroenterology recommend budesonide for mild to moderate ileocaecal Crohn's disease for 8-week treatment courses, with symptomatic response evaluated between 4-8 weeks to determine if therapy modification is needed 1, 2
• Budesonide is not recommended for maintenance therapy in Crohn's disease, as most evidence suggests it is not more effective than placebo for maintenance of remission in patients with quiescent Crohn's disease, according to the Canadian Association of Gastroenterology (conditional recommendation, low-quality evidence) 2

Discontinuation and Tapering Guidelines

• To minimize adrenal suppression risks and optimize treatment outcomes, discontinue budesonide 9mg daily for at least 1-2 weeks before receiving a cortisone injection, and taper over 1-2 weeks when remission is achieved, as recommended by the British Society of Gastroenterology 1
• A tapering regimen may include reducing budesonide from 9mg to 6mg for 3-4 days, then to 3mg for 3-4 days, before complete discontinuation at least 7-10 days before the planned injection 1
• Never stop budesonide suddenly as this may precipitate adrenal crisis or disease flare, according to the British Society of Gastroenterology 3

Timing of Cortisone Injection and Restarting Budesonide Therapy

• If possible, schedule the cortisone injection at least 2 weeks after complete budesonide discontinuation for optimal safety, as recommended by the British Society of Gastroenterology 1
• If budesonide needs to be restarted after injection, wait at least 1 week after the cortisone injection, according to the British Society of Gastroenterology 1

Patient Monitoring and Communication Between Providers

• Monitor patients for signs of disease flare (increased abdominal pain, diarrhea) and symptoms of adrenal insufficiency (fatigue, weakness, dizziness) during the discontinuation period 1
• Ensure the provider administering the cortisone injection is aware of recent budesonide use to minimize risks and optimize treatment outcomes, as emphasized by the British Society of Gastroenterology 3

Special Considerations

• For children, budesonide can be tapered within 10-12 weeks after induction therapy 4
• For eosinophilic esophagitis in adults, induction treatment with orodispersible budesonide should be given for 6-12 weeks, with potential for maintenance therapy up to 48 weeks in patients who respond to induction therapy, and maintenance treatment with orodispersible budesonide showed persistent remission in 73.5-75% of patients over 48 weeks compared to 4.4% with placebo 5
• For autoimmune hepatitis, budesonide may be used in non-cirrhotic patients intolerant of prednisolone, with treatment continuing for at least 2 years and for at least 12 months after normalization of transaminases 6
• Prolonged use of budesonide increases the risk of corticosteroid-related adverse events, including cutaneous symptoms and bone health issues such as osteopenia and osteoporosis, and DEXA bone mineral density scans should be performed before or shortly after commencing treatment and at 1-2 yearly intervals, with calcium and vitamin D supplementation provided and bisphosphonates given to patients with osteopenia or osteoporosis 2, 6

Treatment Outcomes

2, 5