1.5.2 Corticosteroids

Steroids are the most appropriate treatment for acute disease but do not prevent relapse.

The link with peptic ulceration and standard formulation of prednisolone is weak and therefore enteric coated and soluble tablets offer no additional benefit.

Systemic corticosteroids see section 6.3 Corticosteroids.

Clipper®

(Beclometasone dipropionate)

  • Modified release tablets 5mg (£52.79)

Indications

  • Adjunct to aminosalicylates in acute mild to moderate ulcerative colitis

Dose

  • 5mg in the morning; maximum duration of treatment 4 weeks

Notes

  1. For initiation by a Consultant Gastroenterologist only
Budesonide
  • Budenofalk® capsules containing e/c granules 3mg (£63.04 = 3x3mg daily)
  • Entocort® CR capsules containing e/c m/r granules 3mg (£83.16 = 9mg once daily)
  • Budesonide rectal foam, one metered application contains 2mg budesonide (£57.11 = 14 application canister)

Indications

  • Budenofalk capsules and Entocort CR capsules are licensed for the induction of remission in patients with mild to moderate Crohn's disease affecting the ileum and/or ascending colon for up to 8 weeks. In theory it has steroid sparing benefits in patients requiring frequent courses, but this has not been demonstrated in clinical trials.
  • Budesonide rectal foam is licensed for active colitis affecting the sigmoid colon and the rectum.

Dose

  • Budenofalk three capsules once daily or one capsule three times daily, for up to 8 weeks; reduce dose for the last 2 weeks of treatment
  • Entocort CR 9mg once daily in the morning for up to 8 weeks; reduce dose for the last 2–4 weeks of treatment
  • Budesonide rectal foam: one metered application once daily for up to 8 weeks

Notes

  1. Prescribe oral preparations by brand.
  2. Consider budesonide rectal foam as a second line alternative to hydrocortisone foam enema
Hydrocortisone
  • Foam enema 10% (£9.33 = 14-application canister)

Indications

  • Ulcerative colitis, proctitis, proctosigmoiditis

Dose

  • Foam enema: initially 1 metered application once or twice daily for 2–3 weeks, then once on alternate days

Notes

  1. Hydrocortisone foam enema is appropriate initial treatment for relapse, but if the symptoms have not resolved within two weeks specialist advice should be sought. Hydrocortisone foam enema is useful for patients who cannot tolerate the liquid prednisolone enema.
Prednisolone
  • Retention enema 20mg in 100ml (£14.95 = 7 enemas)
  • Suppositories 5mg (£80.39 = 10 suppositories)

Indications

  • Ulcerative colitis
  • Crohn's disease

Dose

  • By rectum – enema: initially 20mg at bedtime for 2–4 weeks, continued if good response
  • By rectum – suppositories: 5mg inserted night and morning after a bowel movement

Notes

  1. Oral corticosteroid dosages and durations advised by consultant gastroenterologists in South Devon and Torbay NHS Foundation Trust for the management of active colitis are: Severe disease (More than 6 bloody stools per 24 hours, systemic symptoms e.g. pyrexia, tachycardia,) requires in-patient treatment with intravenous steroids
  2. Moderate disease (4-6 bloody stools per 24 hours) or step-down from intravenous treatment: Prednisolone 40mg daily for 1 week, then 30mg daily for 1 week, then 20mg daily for 1 month then review by a gastroenterologist
  3. Mild disease (less than 4 bloody stools per 24 hours): Prednisolone 20mg daily for four weeks and then review
Budesonide prolonged release (Cortiment®)

The routine commissioning of budesonide 9mg prolonged release multi-matrix tablets used for up to 8 weeks treatment is not accepted in Devon for induction of remission in adults with mild to moderate active ulcerative colitis where 5-aminosalicylic acid (5-ASA) treatment is not sufficient (see Commissioning Policy for more details). The policy indicates that in exceptional circumstances the Trust-Managed Individual Patient Treatments process can be used for this indication.

 

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