Introduction Options in the treatment of acute severe ulcerative colitis have broadened with the recognition of the value of ciclosporin and infliximab, but corticosteroids remain the first-line treatment for active ulcerative colitis (UC) more than 50 years after the publication of the trial showing their benefit. But a standard regimen for drug, dose and duration has not been established. Patient intolerance, the side effects of corticosteroids – especially infection, and the availability of alternative drugs emphasises the importance of using corticosteroids in the most effective way.

Methods To assess variation in UK practice in preparation for a study to determine the optimal regimen for the use of corticosteroids in acute severe colitis. In January 2010, the authors surveyed all members of the inflammatory bowel disease section of the British Society of Gastroenterology on their use of corticosteroids in a typical patient with acute severe colitis, as defined by Truelove and Witts.

Results Responses were obtained from 94 hospitals out of the 174 Trusts/Health Boards treating acute severe UC in the UK.

Initial corticosteroid 76% of units use intravenous hydrocortisone 100 mg, 6 h as the initial regimen. 15% of units use a different regimen for intravenous hydrocortisone. Intravenous methyl-prednisolone or dexamethasone is preferred by 9%.

Transfer to oral corticosteroid 88% of units start prednisolone 40 mg daily when changing from intravenous administration. Possibly suboptimal dosing with prednisolone 30 mg daily is used by 4% units and 6% units use more than 40 mg when changing to oral steroid. Weight adjusted dosing (1 mg/kg) is used in only 2% of units.

Tapering of oral prednisolone 47% of units prescribe oral steroids for 8 weeks, but more than 40% taper over a longer period, up to 12 weeks. The remainder withdraws steroids in less than 8 weeks. The commonest interval for dose reduction was 5 mg per week but 60% of units used different doses or intervals.

Total exposure to oral steroids The total dose of prednisolone differed between units by more than threefold.

Conclusion The authors did not ask units to report their success rates. If efficacy is similar, then some units are exposing their patients to three times more corticosteroid than necessary, with the potential for more side effects and risks. Alternatively, if greater doses are more effective some units are denying their patients optimal treatment. In the era of evidence-based medicine the time is right for a formal investigation of dose and duration of corticosteroid in the treatment of acute severe colitis.