Optimal use of corticosteroids in gastroenterology and hepatology

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Date: April-June 2014
Publisher: Medknow Publications and Media Pvt. Ltd.
Document Type: Report
Length: 4,073 words
Lexile Measure: 1850L

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Byline: Xavier. Verhelst, Martine. Vos, Hans. Vlierberghe

Although they have been introduced a long time ago, corticosteroids are still extensively used for the treatment of several gastroenterological and hepatological diseases. The goal of this review is to provide an overview of current indications for the optimal use of corticosteroids in this field. For a growing number of indications, budesonide can be an interesting alternative for systemic corticosteroids due to its rapid first-pass hepatic metabolism. Furthermore, topical corticosteroids are increasingly used, e.g., for the treatment of eosinophilic esophagitis and selected patients with inflammatory bowel disease. We conclude that corticosteroids remain of great importance in gastroenterology and hepatology, but the balance between benefit and side-effects use should be evaluated cautiously."

Introduction

Although, many new molecules have emerged for the treatment of gastroenterological and hepatologic diseases, corticosteroids are currently still extensively used. The goal of this paper was to provide an overview of current indications for corticosteroids in the field of gastroenterology and hepatology. Corticosteroids include conventional systemic corticosteroids (e.g., prednisone, methylprednisolone), nonsystemic corticosteroids (e.g., budesonide) and topical corticosteroids (e.g., budesonide enemas).

Gastroenterology

Inflammatory bowel disease

Crohn's disease (CD) and ulcerative colitis (UC) are inflammatory diseases of the gastrointestinal tract. CD can affect any portion of the gastrointestinal tract, while UC is confined to the colon. The choice of treatment should be guided by the severity and the site of the disease and the balance between potency and potential side-effects. Although a variety of drugs is available, conventional, and nonsystemic glucocorticoids remain an appropriate choice for many patients. Recommendations are mainly based upon the evidence-based guidelines from the European Crohn's and Colitis Organization. [sup][1],[2]

Crohn's disease

In mildly active localized ileocecal CD, budesonide (9 mg daily) is the treatment of choice [sup][1] and induces remission in 50-70% of patients over 8-10 weeks. [sup][3],[4],[5],[6] Budesonide with controlled ileal release (CIR) is preferred due to the high first-pass metabolism in the liver via the cytochrome P450-3A4 (CYP3A4) pathway, which enables maximal antiinflammatory effects in the ileocecal region and minimizes (but not excludes) systemic steroid-related side-effects. [sup][7] However, it should be kept in mind that budesonide can inhibit the hypothalamic-pituitary-adrenal axis. [sup][3],[7] In moderately active localized ileocecal CD, budesonide (9 mg daily) or systemic corticosteroids can be used. [sup][1] Although corticosteroids are the mainstay for induction of remission, [sup][8],[9] they are a bad choice for maintaining remission due to a lack of an efficiency [sup][10],[11] and the well-known multiple side-effects. Other immunomodulatory drugs like azathioprin or antitumor necrosis factor agents will need to be introduced early to minimize steroid exposure. [sup][1] For severely active localized ileocecal CD, the initial treatment will be based upon systemic corticosteroids, administered in oral or intravenous form. Lack of response will rapidly lead to the introduction of biological agents or even evaluation for surgery. [sup][1] In patients with infrequent relapses, corticosteroids can be restarted, in combination with immunomodulatory therapy. In active colonic CD, remission can be induced, but not maintained with systemic corticosteroids. In patients with infrequent relapses, steroids can be...

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Gale Document Number: GALE|A394585222