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A 25-year-old woman with Crohn's disease presents to your office with recurrent abdominal pain and diarrhea. She has been taking mesalamine 4 grams per day for the last year. Last fall, after developing diarrhea and pain, she was placed on prednisone 60 mg daily. She had a complete remission and, after a 3-month tapering of the prednisone, suffered a relapse. Prednisone was restarted 2 months ago at 60 mg daily, and now as the dose has decreased to 20 mg per day, the diarrhea has recurred. She is having 6 to 8 water stools per day, crampy pain, and some weight loss. What would be the best next step?
(A) Restart the prednisone and plan to maintain the dose at 40-60 mg indefinitely
(B) Restart the prednisone with 6-mercaptopurine and plan on prednisone taper in 2 months
© Stop the prednisone and add cyclosporine
(D) Admit to the hospital and give high-dose intravenous steroids to induce remission
(E) Stop the mesalamine and add methotrexate
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B, cannot stop predisolone acutely, because the HPA axis is on vacation.
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I this time prednisolone has already been tapered to 20 ...so wudnt worry about adrenal crisis...
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u have to taper 5 mg every week till a minimum dose(5 or 10, im not sure,but 20 is high enough to create crisis) and moreover steroid sparing is usually with 6-MC or azathioprine rather than cyclosporine.
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Restart the prednisone with 6-mercaptopurine and plan on prednisone taper in 2 months
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(B) Restart the prednisone with 6-mercaptopurine and plan on prednisone taper in 2 months
Explanation:
Prednisone is effective in treating active Crohn's disease for short durations (3-6 months). Long-term use for maintenance is not indicated. 6-Mercaptopurine and azathioprine are steroid-sparing medications used to limit the need for prednisone. Prednisone, like other corticosteroids, has numerous side effects and should only be used for treating active flares of disease, not maintenance of remission. Cyclosporine and methotrexate have limited roles in the management of Crohn's disease.
