Is there evidence to support the concomitant use of pulse-dose corticosteroids (steroids) in patients with Interstitial Lung Disease (ILD) while treating an infection?

From the Guidelines

The use of pulse-dose corticosteroids in patients with Interstitial Lung Disease (ILD) while treating an infection is conditionally recommended, with careful consideration of the severity of both conditions and close monitoring for infection progression, as supported by the 2023 American College of Rheumatology (ACR)/American College of Chest Physicians (CHEST) guideline 1.

Key Considerations

• The decision to use pulse-dose corticosteroids should be individualized based on the severity of both ILD and the infection.
• Lower steroid doses (prednisone 0.5-1mg/kg/day) are often preferred when infection is present, as high-dose steroids can worsen outcomes by suppressing immune function.
• Empiric antimicrobial coverage should be initiated before steroids when infection is suspected, and infectious disease consultation is advisable for complex cases.
• The 2021 consensus guidelines for evaluation and management of pulmonary disease in Sjögren's suggest a dose of corticosteroids not to exceed 60 mg daily of prednisone, with a slow taper over weeks-months, and consideration of pulse dose IV corticosteroids or high-dose oral corticosteroids in rapidly progressive ILD or acute respiratory failure 1.

Treatment Approach

• When infection is present but ILD is rapidly progressing, clinicians may consider methylprednisolone 500-1000mg daily for 3 days with concurrent broad-spectrum antibiotics and antifungals tailored to the suspected pathogens.
• Close monitoring for infection progression is essential, and the treatment approach should balance the need to control inflammatory lung damage while managing infection risk.
• The use of nintedanib, an antifibrotic, may be considered in certain cases of ILD, such as systemic sclerosis-associated ILD, but its use is not recommended as a first-line treatment option for other types of ILD, including Sjögren's-associated ILD 1.

From the Research

Use of Pulse-Dose Corticosteroids in ILD Patients with Infections

• The use of pulse-dose corticosteroids in patients with Interstitial Lung Disease (ILD) while treating an infection is supported by several studies 2, 3, 4, 5, 6.
• Corticosteroids are a mainstay of therapy for many forms of ILD, and their use has been shown to be effective in improving lung physiology, exercise capacity, and quality of life in patients with ILD 2, 4, 5.
• In patients with connective tissue disease-related ILD, the use of pulse-dose methylprednisolone followed by low-dose prednisone and tacrolimus has been shown to be well-tolerated and effective in improving lung function and exercise capacity 5.
• The use of high-dose corticosteroids (> 1.0 mg/kg prednisolone) has been shown to improve outcomes in patients with acute exacerbation of non-IPF ILD, but not in patients with IPF 6.
• The treatment of acute exacerbations of ILD with corticosteroids is a common practice, and the choice of dose and duration of treatment depends on the severity of the exacerbation and the underlying disease subtype 3, 6.

Specific ILD Subtypes and Corticosteroid Use

• In patients with ILD associated with idiopathic inflammatory myopathies, the use of combination therapy with corticosteroids, intravenous cyclophosphamide pulse, and calcineurin inhibitors has been shown to be effective in improving lung function and reducing disease activity 3.
• In patients with anti-aminoacyl-tRNA synthetase (ARS) positive ILD, the use of corticosteroids alone or in combination with other immunosuppressive agents has been shown to be effective in improving lung function and reducing disease activity 3.
• In patients with connective tissue disease-related ILD, the use of pulse-dose corticosteroids followed by low-dose prednisone and tacrolimus has been shown to be effective in improving lung function and exercise capacity 5.