Budesonide n = 22
Prednisolone n = 26a
p-value
Moon face
5
15
0.01
Buffalo hump
0
1
NS
Acne
1
7
0.033
Hirsutism
2
3
NS
Skin striae
0
1
NS
Bruising easily
1
1
NS
Swollen ankles
0
1
NS
Hair loss
1
3
NS
Mood swings
3
2
NS
Depression
2
1
NS
Insomnia
5
4
NS
Any such signb
11
20
0.030
A retrospective review of six prepubertal children with Crohn disease showed linear growth to be subnormal (2 cm/year) during budesonide maintenance treatment [28]. It remains unclear, however, whether impaired growth in these children (with PCDAI’s of 15–27.5, indicating active disease) was due only to budesonide treatment or to ongoing mucosal inflammation.
Maintenance Treatment in Crohn Disease
Maintenance treatment with budesonide has not been studied prospectively in children. Systemic corticosteroids, however, have not been shown to be effective in prolonging clinical remission. A Cochrane review based on four placebo-controlled randomized trials in adults with Crohn disease [23, 29–31] concluded that maintenance treatment with oral budesonide at 6 mg/day is not effective in preventing relapses of Crohn disease in adults [32]. In addition, a recent meta-analysis demonstrated that there is no statistically significant benefit of oral budesonide over placebo in the prevention of relapse in adults with quiescent Crohn disease, while GCS-related side effects were significantly more common with budesonide [33]. ln view of this evidence, and the concerns on longitudinal growth in children, maintenance treatment with budesonide should not be recommended.
Budesonide Enemas in Ulcerative Colitis
Conclusion
Corticosteroids have been the first-line treatment in Crohn disease for many years. Disfiguring acute and serious long-term side effects, such as growth retardation and bone demineralization limit their use. The current trend in pediatric as well as adult Crohn disease is to minimize and avoid repeated corticosteroid use by introducing immunomodulators early in the course of disease. In Europe, primary treatment of active Crohn disease by a 6–8 week course of enteral nutrition is favored over remission induction by prednisolone. Systemic or topical corticosteroids are not effective as maintenance treatment.
Adrenal suppression is less during budesonide treatment compared to prednisolone, and GCS-associated side effects such as acne and moon face occur less frequently. Budesonide, however, seems to be less effective, and is only indicated in localized ileocecal disease with mild to moderate disease activity.
Corticosteroids do not heal the mucosa, do not prevent relapse and do not alter the course of the disease. In the current era, confidence with early immunomodulator and biological treatment is growing, with a tendency towards step-down instead of step-up treatment. While this strategy needs to be substantiated by prospective studies, it is clear that corticosteroids are losing their position as first-line treatment of pediatric IBD.
References
1.
2.
3.
Barnes PJ, Adcock IM. How do corticosteroids work in asthma? Ann Intern Med. 2003;139(5 Pt 1):359–70.PubMed
4.
5.
6.
Heuschkel RB, Menache CC, Megerian JT, Baird AE. Enteral nutrition and corticosteroids in the treatment of acute Crohn’s disease in children. J Pediatr Gastroenterol Nutr. 2000;31(1):8–15.PubMedCrossRef
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