Oral Corticosteroid Dosing for Pulmonary Fibrosis

Corticosteroids are not recommended for idiopathic pulmonary fibrosis (IPF) except during acute exacerbations, where high-dose therapy is used. 1

Recommendations for Corticosteroid Use in Pulmonary Fibrosis

Corticosteroid therapy is not recommended for routine treatment of IPF as no survival benefit has been demonstrated in controlled trials 1
Long-term corticosteroid monotherapy is associated with substantial morbidity without proven benefit 1
Low-dose oral prednisone (up to 10 mg daily) may sometimes be used to alleviate incapacitating cough in IPF patients 1
For acute exacerbations of IPF, high-dose corticosteroid therapy is recommended 1

Pulse therapy with methylprednisolone 1,000 mg per day for 3 days, followed by oral prednisolone 40-60 mg per day 2
After initial high-dose therapy, a gradual taper is typically implemented 1

When treatment is deemed necessary, the following regimen has been suggested historically 1:

Prednisone starting at 0.5 mg/kg lean body weight daily for 4 weeks
Reduced to 0.25 mg/kg lean body weight daily for 8 weeks
Then tapered to 0.125 mg/kg daily or 0.25 mg/kg every other day 1
Often combined with immunomodulatory agents such as azathioprine (2-3 mg/kg/day) or cyclophosphamide (2 mg/kg/day) 1, 3

Prednisone should be administered in the morning prior to 9 am to minimize adrenal suppression 4
For multiple daily doses, administer at evenly spaced intervals throughout the day 4

Response to therapy should be assessed after 3-6 months 1
If no improvement is seen after 6 months, therapy should be stopped or changed 1
For patients who show improvement, therapy may be continued with the same doses 1

Corticosteroid monotherapy is associated with substantial long-term morbidity 1
Common adverse effects include glucose metabolism abnormalities, cataracts, growth retardation in children, and increased susceptibility to infections 1
In adults with pulmonary fibrosis, there is particular concern for development of osteoporosis and diabetes 1

For symptom management only: Low-dose prednisone (up to 10 mg daily) may help alleviate severe cough in IPF 1
Newer antifibrotic medications are now preferred over corticosteroids for IPF management 1
For non-IPF pulmonary fibrosis (such as those associated with connective tissue diseases or hypersensitivity pneumonitis), corticosteroids may still play a role in management 1

If long-term therapy is implemented, gradual withdrawal rather than abrupt discontinuation is recommended 4
Alternate-day therapy (twice the usual daily dose given every other morning) may help minimize adverse effects during long-term treatment 4

Avoid using corticosteroids as monotherapy for IPF as they provide no survival benefit and cause significant side effects 1
Do not continue corticosteroid therapy indefinitely without objective evidence of continued improvement or stabilization 1
Always consider the risk-benefit ratio, especially in older patients (>70 years) or those with comorbidities such as diabetes, obesity, or osteoporosis 1
Monitor for adverse effects regularly, including blood glucose, blood pressure, bone density, and signs of infection 4