Do we know how to use corticosteroids in acute severe ulcerative colitis?

Options for the treatment of acute severe ulcerative colitis have broadened with the use of ciclosporin and infliximab, but corticosteroids remain first-line treatment. However, an optimum regimen for drug, dose and duration has not been established in the 57 years since Truelove and Witts first reported their value. In the absence of evidenced-based guidance this study sought to discover how gastroenterology units in the UK manage patients with acute severe colitis. In January 2010 a questionnaire was sent to all members of the inflammatory bowel disease section of the British Society of Gastroenterology enquiring about their use of corticosteroids in a typical patient with acute severe colitis. One hundred and two responses were obtained, representing more than 50% of the UK gastroenterology units. No consensus, and a wide variation in practice was found between these units. Over 70% of responders initially treat patients with intravenous hydrocortisone (400 mg/day), although some units prefer methylprednisolone and dexamethasone. On transfer to oral treatment, all units use prednisolone, most starting with 40 mg/day. There are no agreed national or international guidelines on the reducing regimen or duration of oral treatment-the area of greatest variation in our survey. Most units reduce prednisolone by 5 mg/week, but because of variations in the timing and magnitude of dose reduction, total exposure to prednisolone varies by 2.6-fold. To minimise harm from undertreatment or overtreatment of acute severe colitis a controlled study of prednisolone dose and duration is needed.