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Budesonide ICI Colitis — SCE Medical Oncology MCQ

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ModerateImmunotherapy & Targeted TherapyBudesonide ICI ColitisSCE Medical Oncology

A 58-year-old woman on ICI for melanoma develops grade 2 immune-related colitis that improves with oral budesonide. She wants to understand the rationale for budesonide over systemic prednisolone for mild-moderate colitis. What is the advantage?

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Correct answer: D — Budesonide has high topical gut anti-inflammatory activity with approximately 90% first-pass hepatic metabolism — providing local anti-inflammatory effect with minimal systemic steroid exposure, potentially preserving ICI anti-tumour efficacy better than systemic steroids

Oral budesonide (9 mg/day) has high topical activity in the gut (particularly ileum and right colon) with ~90% first-pass hepatic inactivation, minimising systemic corticosteroid exposure. For mild-moderate (grade 1-2) ICI colitis, budesonide provides local anti-inflammatory action while theoretically better preserving systemic anti-tumour immunity compared with systemic prednisolone. Limitations: budesonide primarily acts on the proximal colon and may be less effective for distal colitis. Grade 3+ colitis requires systemic corticosteroids ± infliximab/vedolizumab.

Reference: ESMO 2024 irAE Management; BNF Budesonide