Excessive steroid dosing highlighted in inflammatory bowel disease

Researchers analysed steroid exposure in over 2000 outpatients with inflammatory bowel disease (IBD) and found that 15% of patients were receiving excessive steroid doses. In half of cases, steroid excess was judged to be avoidable.

'Looking at steroid prescribing for inflammatory bowel disease and trying to reduce steroid excess can be a powerful way to improve patient care and outcomes,' said lead author Christian P. Selinger, a consultant gastroenterologist at St James University Hospital in Leeds.

The study, published in Alimentary Pharmacology and Therapeutics, prospectively collected data from patients with IBD attending 19 UK outpatient clinics over 3 months between April and July 2017.

The researchers defined steroid dependency or excess in accordance with ECCO and UK guidelines as the presence during the 12 months preceding the clinic visit of 1 or more of: (a) the prescription of >1 steroid course or (b) inability to wean steroids below 10mg/day prednisolone or 3mg/day budesonide within 3 months of starting steroids or (c) disease flare within 3 months of stopping steroids.

Of the 2385 patients identified, 667 (28.0%) had received steroids in the preceding 12 months. Among these, 352 (14.8%) had steroid excess or dependency. 

Quality improvement

The rate of steroid excess was significantly lower at 'intervention centres' which had participated in a quality improvement programme (11.5%, vs 17.1% at centres that had not implemented such programmes; p<0.001). At these centres, rates of total steroid exposure fell from 30.0% in 2015 to 23.8% in 2017 (p=0.003) and rates of excessive steroid dosing decreased slightly from 13.8% to 11.5% (p=0.17). However, the authors pointed out that there was an accompanying trend towards a lower disease activity among patients seen at these centres.

All cases of steroid excess or dependency from the intervention centres, along with those from one centre in the non-intervention group, were subjected to in-depth review to determine the avoidability of excessive prescribing.

A total of 138 cases were reviewed. Those with steroid prescriptions for non-IBD indications, evidence of appropriate treatment attempting to avoid excess, or the absence of valid alternatives to steroids were excluded, leaving 70 cases (50.7%) in which excessive steroid dosing was deemed to be 'probably' or 'definitely' avoidable.

Of the 126 cases subjected to in-depth review where the source of the steroids was established, those where steroid prescriptions were all generated from secondary care were less likely to be classed as inappropriate excess than those cases where at least one prescription originated in general practice (43.0% vs 68.0%, p=0.04).

Factors independently associated with reduced steroid excess in Crohn's disease included maintenance treatment with anti-TNF agents, treatment in a centre with a multi-disciplinary team and treatment at an intervention centre. 

The researchers argue their findings strengthen the case for assessing steroid excess as a key performance indicator in IBD management.