Summary Background Corticosteroids remain important for managing inflammatory bowel disease (IBD) flares. Steroid excess, however, may be a marker of poor care. Patients access steroid prescriptions from primary (General Practitioners [GP]) or secondary care (hospital‐based). Sources of prescriptions and associated outcomes are not well described. Methods Patients attending IBD clinics with linked primary care information were included. We examined appropriateness and timeliness of treatment escalation and avoidability of steroid excess in relation to prescription sources. Results Of 2246 patients, 33% were exposed to steroids over 2 years. Primary care issued 28% of prescriptions. Secondary care prescriptions were more often of appropriate dose and duration (85% vs 41%, p < 0.001). Further flares occurred in 50% of patients prescribed steroids from primary care (vs 39%; p = 0.003). Steroid excess was observed in 15%. Patients with steroid excess who received prescriptions from primary care that were not communicated to secondary care less often received timely treatment escalation (49% vs 66%, p = 0.042) and steroid excess was more often avoidable (73% vs 56%, p = 0.022). Patients with steroid excess had higher risks of hospitalisation for IBD (OR = 12.33, 95% CI [8.89–17.11]), hospitalisation for infections (OR = 2.89, 95% CI [1.82–4.61]) and GP prescribed antibiotics (OR = 1.41, 95% CI [1.07–1.86]). Conclusion Patients commonly access steroids through primary care, but doses and durations are frequently inappropriate with patients more likely to flare. Steroid excess was associated with IBD admissions, admissions for infections and antibiotic prescriptions. Improved liaison between primary and secondary care is required to reduce steroid excess.

Acute severe ulcerative colitis is a medical emergency that warrants in-patient management. This is best served within a multidisciplinary team setting in specialised centres or with expert consultation. Intravenous corticosteroids remain the cornerstone in the management of ASUC and should be initiated promptly, along with general management measures and close monitoring of patients. Unfortunately, one-third of patients will fail to respond to steroids. Response to intravenous corticosteroid therapy needs to be assessed on the third day and rescue therapies, including cyclosporine and infliximab, should be offered to patients not responding. Choice of rescue therapy depends on experience, drug availability and factors associated with each individual patient, such as comorbidities, previous medications or contra-indications to therapy. Patients who have not responded within 7 days to rescue therapy must be considered for surgery. Surgery is a treatment option in ASUC and should not be delayed in cases of failure of medical therapy, because such delays increase surgical morbidity and mortality. This review summarises the current management of acute severe ulcerative colitis and discusses potential future developments.

During the COVID-19 pandemic many IBD units chose Budesonide MMX (Cortiment) as the first-line treatment for flares of ulcerative colitis (UC) in outpatients for its favourable side effect profile. This retrospective study of all UC patients treated with oral steroids between 1 March 2019–30 June 2019 and 1 March 2020–30 June 2020 aimed to compare Cortiment with Prednisolone in routine clinical practice. Outcomes included the need for hospitalisation for acute severe ulcerative colitis, symptoms at four weeks and end of treatment, and the need for rescue Prednisolone. The 2019 and 2020 cohorts did not differ at the baseline. Cortiment prescriptions rose from 24.5% in 2019 to 70.1% in 2020 (p < 0.001). At week four there were significant differences between 2019 and 2020 in mean bowel frequency (3.49 vs. 5.85, p = 0.001), rectal bleeding <50% (89.7% vs. 73.1% of patients, p = 0.039), and physician global assessment (PGA) (39.2% vs. 19.8% in remission, p = 0.045). There was no significant difference in hospital admissions, rectal bleeding, and PGA at week eight. Rescue Prednisolone was required in 10% of Cortiment patients in 2019 vs. 31.3% in 2020 (p = 0.058). Active IBD is associated with worse COVID-19 outcomes prompting the careful evaluation of the choice of first-line steroid for UC, as Cortiment was associated with worse outcomes at four weeks.

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LINKED CONTENT This article is linked to Rosiou et al papers. To view these articles, visit https://doi.org/10.1111/apt.17039 and https://doi.org/10.1111/apt.17137