New steroids for inflammatory bowel disease

: The antiinflammatory effects of glucocorticosteroids (GCS) in inflammatory bowel disease (IBD) are unsurpassed by those of any other type of drug, but the beneficial effects are often offset by troublesome, and sometimes irreversible, systemic side effects. Improved GCS have been developed with the aim of obtaining improved topical action, with reduced systemic side effects. A high tissue uptake and a high affinity for the GCS-receptor in combination with a rapid and extensive biotransformation in the liver are key prerequisites. Budesonide appears to be the most promising of the new topical GCS for IBD. In enema form it is already in clinical use for active distal ulcerative colitis (UC), with efficacy similar to that of conventional GCS but with no appreciable impact on adrenal gland function. Oral, slow release preparations of budesonide are efficacious in the treatment of active ileocecal Crohn's disease (CD), causing less suppression of endogenous plasma cortisol levels than does oral prednisolone, and giving rise to fewer, and less severe, side effects. Budesonide may also have a role for prevention of clinical relapse in certain groups of patients with CD, and is currently under evaluation for extensive and left-side UC. Long-term studies addressing issues such as impact on bone metabolism are currently in progress. Future development of GCS for IBD includes factors such as improved topical delivery systems, enhanced tissue uptake, and even more extensive first pass metabolism.