Are oral steroids, such as prednisone (corticosteroid), used in the treatment of pleurisy?

Oral Steroids in Pleurisy Treatment

Oral steroids are not routinely recommended for the treatment of pleurisy but may be used in specific cases depending on the underlying cause. 1

Use of Oral Steroids by Underlying Cause

Tuberculous Pleurisy

• Not recommended routinely 1, 2
• Multiple randomized controlled trials show conflicting results:
  • Some studies show faster resolution of symptoms and pleural effusion 3
  • Other studies show no significant benefit in long-term outcomes or residual pleural thickening 4, 5
• The American Thoracic Society/CDC/Infectious Diseases Society of America guidelines specifically state that based on randomized clinical trials and systematic reviews, there is no evidence to support routine use of adjunctive corticosteroids in patients with tuberculous pleurisy 1

Autoimmune-Related Pleurisy

• May be indicated in pleurisy associated with connective tissue diseases like Sjögren's syndrome 1
• For Sjögren's-related interstitial lung disease with pleurisy:
  • Moderate to severe symptoms: Moderate dose oral corticosteroids (typically prednisone up to 60 mg daily with a slow taper over weeks to months)
  • Rapidly progressive disease: High-dose steroids may be considered 1

Viral or Idiopathic Pleurisy

• Generally not indicated unless severe symptoms are present
• NSAIDs are typically first-line for symptom management 6

Dosing Considerations When Used

When oral steroids are indicated for pleurisy treatment:

• Typical dosing: Prednisone or prednisolone 0.5-1.0 mg/kg/day 1, 7
• Duration: Usually short-term (2-4 weeks) followed by tapering
• Tapering schedule: Typically reducing by 5 mg weekly until reaching 10 mg/day, then reducing by 2.5 mg weekly until reaching 5 mg/day 7

Important Cautions

• Tuberculosis must be ruled out before starting steroids for any pleurisy of unknown etiology
• Risk of adverse effects increases with dose and duration:
  • Short-term: Hyperglycemia, hypertension, mood changes
  • Long-term: Osteoporosis, adrenal suppression, increased infection risk
• Contraindications: Active untreated infections, poorly controlled diabetes, psychosis

Monitoring Recommendations

When oral steroids are used for pleurisy:

• Monitor blood pressure and glucose regularly
• Consider gastric protection with proton pump inhibitors
• For longer courses (>3 weeks), consider calcium and vitamin D supplementation
• Follow-up chest imaging to assess response

In summary, while oral steroids have a limited role in most cases of pleurisy, they may be beneficial in specific scenarios such as autoimmune-related pleurisy with significant symptoms or inflammation. The decision should be based on the underlying etiology, severity of symptoms, and potential risks of steroid therapy.