Can IV Steroids Cause GI Bleeding? Risks and Prevention

Overview of IV Steroids and Their Link to GI Bleeding

Intravenous (IV) corticosteroids are commonly used to treat ulcerative colitis flares. These potent anti-inflammatory drugs can rapidly improve symptoms. However, IV steroids are also linked to an increased risk of gastrointestinal (GI) bleeding.

Understanding when IV steroids may be appropriate and learning about their potential side effects can help anyone with ulcerative colitis have an informed discussion with their doctor about treatment options.

What Are IV Steroids?

Corticosteroids like prednisone, methylprednisolone, and hydrocortisone are potent anti-inflammatory medications. They help suppress the immune system and reduce inflammation in the body.

Oral corticosteroids are frequently used to treat moderate to severe ulcerative colitis flares. IV forms of these steroids allow for faster absorption and quicker symptom relief.

Some of the IV steroid medications used for ulcerative colitis include:

• Methylprednisolone
• Hydrocortisone
• Prednisolone

These medications are typically given in the hospital when rapid treatment is needed to bring a severe flare under control quickly.

Why Are IV Steroids Used for Ulcerative Colitis?

IV steroids offer a few advantages over oral steroids for treating ulcerative colitis flares:

• Faster onset of action - IV steroids take effect within hours while oral steroids can take days to start working.
• Higher blood concentrations - IV administration leads to higher peak blood levels of the drug than oral dosing.
• Less variability - IV dosing avoids variability in absorption from the gut.
• Lower total doses may be needed - The ability to administer higher blood concentrations upfront means lower total doses may control symptoms.

Due to these advantages, IV steroids are most commonly used for:

• Severe ulcerative colitis flares
• Hospitalized patients unable to take oral medications
• Patients not responding adequately to oral steroids

IV steroids can help rapidly calm inflammation, control symptoms like diarrhea and bleeding, and avoid the need for emergency colectomy in some cases.

Side Effects of IV Steroids

While IV steroids offer rapid, potent treatment, they also come with a risk of side effects. Some potential side effects include:

• Increased appetite
• Mood changes
• Insomnia
• Acne
• High blood sugar

Of particular concern is the link between IV steroids and GI bleeding in ulcerative colitis patients.

IV Steroids and GI Bleeding Risk

Multiple studies have shown IV steroids increase the risk of lower GI bleeding in people with ulcerative colitis. However, the exact mechanism behind this increased risk is still being investigated.

Some theories about why IV steroids may promote bleeding include:

• Inhibition of wound healing - Steroids may prevent proper healing of inflamed intestinal tissue.
• Thinning of intestinal lining - Steroids could negatively impact the protective mucus lining of the colon.
• Changes in clotting factors - Steroids may alter levels of clotting proteins, impairing ability to form clots.
• Altered gut microbiome - Steroids may allow harmful bacteria to propagate and damage the intestinal lining.

Regardless of the mechanism, multiple clinical studies have consistently shown IV steroids increase the odds of lower GI bleeding in ulcerative colitis. The rate of bleeding events in various studies has ranged from 10-30%.

Those at highest risk include patients with more extensive colonic involvement, a history of colonic bleeding, and active bleeding at the time treatment is initiated.

Timing of Bleeding Risk

The risk of bleeding is not evenly distributed during IV steroid treatment. Research shows most major bleeding events happen during the second week of treatment.

The reasons for this timeline are not entirely clear. Proposed explanations include:

• Early damage to the intestinal lining builds up over the first week.
• The anti-inflammatory effects of steroids take time to kick in.
• Cumulative thinning of the protective mucus layer in the colon.

Regardless of the cause, the data indicates the end of the first week and start of the second week of IV steroids pose the greatest bleeding risk.

Risk Factors

Not every ulcerative colitis patient treated with IV steroids will experience GI bleeding. However, certain factors appear to increase the odds of bleeding:

• Extensive colon involvement - Left-sided colitis or pancolitis have higher risks than only rectal inflammation.
• Severe active inflammation - High CRP levels and 10 or more stools per day prior to treatment.
• Existing colonic ulcerations - Identified by colonoscopy before treatment.
• History of colonic bleeding - Previous hospitalization or transfusion due to colonic hemorrhage.
• Intravenous heparin use - Concurrent treatment with IV blood thinners like heparin.
• High IV steroid doses - Greater than 60 mg/day methylprednisolone equivalent dosing.

Talk to your doctor about your individual risk factors prior to treatment with IV steroids.

Preventing Steroid-Related GI Bleeding

While IV steroids do carry an increased risk of lower GI bleeding, there are things that can be done to help minimize this risk:

Careful Patient Selection

IV steroids may not be the best option for all patients. Oral steroid formulations or other rapid-acting treatments like infliximab can be considered for patients at high risk of bleeding.

Lowest Effective Dosing

Using the smallest IV steroid dose necessary to induce remission helps reduce bleeding risk. Doses above 60 mg/day of methylprednisolone equivalent appear to confer greater risks.

Shorter Treatment Duration

Limiting IV steroids to 7 days or less is preferable when possible. Much of the bleeding risk arises in the second week of treatment.

Combination Therapy

Adding treatments like infliximab helps taper steroids faster. Quickly transitioning from IV to oral steroid dosing may lower overall bleeding risk.

Close Monitoring

Frequent assessment for signs of bleeding allows rapid intervention if hemorrhage occurs. Key signs include dropping hemoglobin, bloody stools, and tachycardia.

Ulcer Prevention

Medications to decrease stomach acid like proton pump inhibitors may help prevent ulcer formation and damage to the intestinal lining.

Anticoagulant Avoidance

Holding other drugs that impair clotting like heparin for several days before and during IV steroid treatment can help avoid bleeding.

Treatment If GI Bleeding Occurs

If significant GI bleeding develops during IV steroid treatment for ulcerative colitis, rapid treatment is essential. Steps include:

• Holding IV steroids - Immediately discontinuing steroids if active bleeding develops.
• Fluid resuscitation - Giving IV fluids if bleeding is severe.
• Blood transfusion - Transfusing blood or platelets if indicated by labs.
• Treating anemia - Giving iron supplements or erythropoietin to help restore red blood cell levels.
• Endoscopic evaluation - Performing colonoscopy to locate and treat bleeding sites.
• Surgery - Colectomy if medical management cannot control hemorrhage.

Thankfully, most cases of bleeding can be managed medically with holding steroids, transfusions, and endoscopic treatment. However, surgery may be urgently needed in cases of uncontrolled hemorrhage.

Bottom Line

IV corticosteroids like methylprednisolone are very effective for gaining rapid control of severe ulcerative colitis flares. However, these intravenous medications do come with an increased risk of lower GI bleeding of around 10-30%.

Those at highest risk of bleeding include patients with extensive colonic disease, prior colonic bleeding, and high severity of inflammation. Most major bleeding events occur in the second week of IV steroid therapy.

Careful patient selection, conservative dosing, combination treatment, close monitoring, and ulcer prevention help reduce chances of bleeding. Even with preventive measures, all patients on IV steroids need to stay vigilant for any signs of GI hemorrhage.

With prompt holding of steroids and supportive care, many bleeding episodes can be effectively managed. However, urgent colectomy may be required in cases of uncontrolled hemorrhage. Having a discussion about the risks and benefits of IV steroids with your doctor can help determine if this treatment option is appropriate for your individual situation.

Disclaimer: This article is for informational purposes only and does not constitute medical advice. Always consult with a healthcare professional before starting any new treatment regimen.