By Léon Van Wouwe, Clinical Innovation Director, Volv Global

In Inflammatory Bowel Disease (IBD), a steroid burst is often considered a routine necessity, something to “overcome the inflammatory flare.” But repeated, systemic steroid exposure is one of the clearest, most measurable red flags, or signals, that a care pathway is failing.

Between 2023 and 2025, the U.S. IBD landscape added new mechanisms and new delivery options: oral JAK1 for Crohn’s Disease, oral S1P for ulcerative colitis (UC), expansion of IL-23 agents across UC and Crohn’s, and subcutaneous maintenance formulations for established biologics.

However, the rise of new treatment options have not reduced the challenge or difficulty in managing this complex set of conditions. If anything, they increased the complexity of how to manage it.

The American Gastroenterological Association (AGA) living guidelines (for UC in 2024; and Crohn’s in 2025) and the ACG 2025 updates emphasise earlier use of advanced therapies for appropriate patients, treat-to-target with objective assessment, and minimising systemic steroid exposure.

This means: we are raising the bar for sequencing and risk stratification.

Disclaimer: This article represents expert commentary and is intended for informational purposes only; it does not constitute medical advice.

The Care Gap We Keep Normalising

IBD is not one disease. It’s a syndrome-level label – most commonly UC and Crohn’s disease, with additional complexity including cases which are IBD-unclassified (IBD-U) and phenotypes that evolve over time. That heterogeneity is precisely why “one-size-fits-all” escalation doesn’t work.

So, despite the advances in available treatment options that add new mechanisms of actions and new delivery options across the USA, one pattern stubbornly persists: steroids keep showing up as the default answer to uncertainty. Not because clinicians don’t know the risks, and not because patients want them long-term, but because steroids are fast, familiar, and often the path of least resistance when:

• objective inflammation isn’t being measured consistently
• risk is not stratified early enough
• access and sequencing decisions are delayed
• “temporary” steroid use becomes recurring care.

Patient education materials from the Crohn’s & Colitis Foundation put it plainly: steroids are best suited for short-term control, and the need for repeated courses often indicates the underlying regimen is insufficient and should be reassessed [1]. This is not a moral judgment, but a system signal.

What the Evidence Actually Shows

Steroids still have an appropriate role in IBD, particularly for short-term induction in select scenarios. But the evidence base and modern guideline direction converge on a consistent theme: steroid dependence/excess is a red flag, not a treatment strategy.

• Treat-to-target frameworks (e.g., STRIDE-II) emphasise moving beyond symptom control toward objective targets (biomarkers/endoscopy) and durable disease control [2].
• The AGA living guideline for moderate-to-severe UC explicitly treats outcomes like corticosteroid-free remission as important – because needing ongoing steroids is a marker of uncontrolled disease and suboptimal sequencing [3].
• A 2025 narrative review in Clinical Gastroenterology and Hepatology highlights that while corticosteroids remain widely used, there is a “notable risk of overuse and misuse,” alongside meaningful adverse effects and special-population considerations [4].
• Observational evidence links excess systemic corticosteroid exposure with worse downstream outcomes, supporting the idea that steroid burden correlates with avoidable harm and potentially preventable escalation delays [5].

You don’t need a perfect dataset to act on this. Steroid exposure is already visible in claims, electronic health records, pharmacy data, and patient histories. That’s what makes it such a powerful lever: it’s measurable, trackable, and actionable.

Why This Keeps Happening (Root Causes Across Functions)

Steroid happens when multiple parts of the pathway drift out of alignment and is rarely about one “bad decision.”

For patients and families:

• Steroids can feel like the only thing that works quickly, especially when symptoms are severe and daily life is on hold.
• Many patients are not given a clear steroid “exit plan,” or they don’t know what questions to ask after the flare settles.

For clinicians (gastrointestinal primary care and urgent care):

• Time pressure, fragmented records, and inconsistent access to objective inflammation measures can drive short-term decisions.
• Care often spans multiple sites, where a steroid prescription may be issued without full visibility into cumulative exposure.

For health systems and payers:

• Pathways can unintentionally reward “cheap, fast fixes” over proactive treatment optimisation.
• Step-therapy and administrative friction can delay appropriate sequencing, even when a patient’s pattern clearly signals high risk.

For pharma and life-science partners:

• The field has advanced therapies, but identifying who is truly high-risk, who is misclassified, who is undertreated, and when to intervene is still uneven in the real world.
• Trial design and real-world evidence strategies can struggle with “noisy” endpoints if the underlying pathway is inconsistent.

This is where IBD’s syndromic complexity matters: if we don’t differentiate the patient and their trajectory early, uncertainty persists … so steroids fill the gap.

What Winning Looks Like (Practical Path Forward)

If steroids are the canary in the coalmine, then “winning” is not zero steroids. Rather, it’s steroid stewardship: using steroids appropriately, briefly, and with a deliberate plan to prevent recurrence.

Here are five practical actions that patient groups, clinicians, and partners can take now:

1. Make steroid exposure a visible metric (not a hidden variable).
   Track cumulative systemic steroid courses, tapers, and bursts over 6–12 months. If a patient has repeated bursts, treat it as a trigger for pathway review, not business-as-usual.
2. Pair every steroid start with a steroid exit plan.
   Patients should be told:
   • why steroids are being used now,
   • how tapering will work, and
   • what the next decision point will be if symptoms recur.
     (This is especially important because abrupt stopping can be unsafe; tapering is often required.) [1]
3. Re-anchor decisions to objective inflammation – not symptoms alone.
   Symptoms matter, but they can mislead. Treat-to-target strategies emphasise objective assessment (biomarkers/endoscopy/imaging where appropriate) to reduce “false reassurance” and prevent slow-motion failure [2].
4. Define “steroid recurrence” as a risk-stratification event.
   A patient with repeat steroid exposure isn’t just “flaring again.” They may be signalling higher-risk disease, delayed optimisation, adherence challenges, comorbidity complexity, or access barriers. The point isn’t to blame; it’s to classify the pattern.
5. Use real-world data to find the high-risk populations we keep missing.
   This is the biggest factor to unlock, because steroid burden is one of the clearest pathway signals that can be surfaced at scale. With the right analytics and clinical input, we can:
   • identify “repeat steroid” cohorts,
   • characterise what predicts recurrence, and
   • design decision support that helps clinicians act earlier and more confidently.

Call to Action: Partner With Volv Global

If you’re a patient organisation, a U.S. healthcare team, or a clinician leader trying to reduce avoidable steroid exposure, you don’t have to start with a moonshot. Start with a pilot.

At Volv Global, we partner on claims/EHR-driven feasibility and real-world evidence work to identify hidden high-risk populations, quantify care gaps, and translate pathway signals – like repeated steroid exposure – into practical clinical decision support. Our approach is designed to be transparent and explainable, and structured to work within real-world data constraints.

If you want to build a steroid stewardship “early warning system” for IBD – one that helps answer: who is truly high-risk, who needs earlier targeted therapy consideration, and where pathway friction is driving preventable harm – let’s discuss a pilot project.

About the author

Léon van Wouwe has 20+ years’ global experience in clinical development and operations, uniting data science with pharma and research. He drives cross-functional collaboration to advance innovative treatments.

References

1. Crohn’s & Colitis Foundation (2020) Corticosteroids [Fact Sheet]. New York: Crohn’s & Colitis Foundation. Available at: https://www.crohnscolitisfoundation.org/sites/default/files/2020-03/corticosteroids.pdf (Accessed: March 2026).

2. Turner, D., Ricciuto, A., Lewis, A., D’Amico, F., Dhaliwal, J., Griffiths, A.M., Bettenworth, D., Sandborn, W.J., Sands, B.E., Reinisch, W., Schölmerich, J., Bemelman, W., Danese, S., Mary, J.Y., Rubin, D., Colombel, J.-F., Peyrin-Biroulet, L., Dotan, I., Abreu, M.T. and Dignass, A. on behalf of the International Organization for the Study of IBD (2021) ‘STRIDE-II: An Update on the Selecting Therapeutic Targets in Inflammatory Bowel Disease (STRIDE) Initiative of the International Organization for the Study of IBD (IOIBD): Determining Therapeutic Goals for Treat-to-Target Strategies in IBD’, Gastroenterology, 160(5), pp. 1570–1583. doi: 10.1053/j.gastro.2020.12.031.

3. Singh, S., Loftus, E.V., Jr, Limketkai, B.N., Haydek, J.P., Agrawal, M., Scott, F.I. and Ananthakrishnan, A.N. on behalf of the AGA Clinical Guidelines Committee (2024) ‘AGA Living Clinical Practice Guideline on Pharmacological Management of Moderate-to-Severe Ulcerative Colitis’, Gastroenterology, 167(7), pp. 1307–1343. doi: 10.1053/j.gastro.2024.10.001.

4. Feuerstein, J.D., Rubin, D.T., Aberra, F.N., Yarur, A.J. and Malter, L. (2025) ‘Appropriate Use and Complications of Corticosteroids in Inflammatory Bowel Disease: A Comprehensive Review’, Clinical Gastroenterology and Hepatology, 23(12), pp. 2068–2082. doi: 10.1016/j.cgh.2025.05.019.

5. Rosiou, K., Carbonell, J., Dolby, V., Monfared, N., Raine, T. and Selinger, C.P. (2022) ‘Sources of excess steroid prescriptions and clinical adverse outcomes associated with steroid excess in patients with inflammatory bowel disease: the Leeds IBD Steroids study’, Alimentary Pharmacology & Therapeutics, 56(3), pp. 501–509. doi: 10.1111/apt.17039.

Links:

• Volv Global: We find patients earlier
• Volv Global: We find eligible patients

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