Should steroids be given for pneumonitis?

Steroid Management for Pneumonitis

Steroids should be given for pneumonitis, with the treatment regimen determined by the severity grade of pneumonitis. 1

Treatment Algorithm Based on Pneumonitis Severity

Grade 1 (Asymptomatic/Radiographic Only)

• Consider holding immune checkpoint inhibitor (ICI) therapy 1
• Oral steroids with prednisone 1 mg/kg daily or equivalent 1
• Monitor symptoms and oxygen saturation every 2-3 days with weekly clinic visits 1
• If imaging abnormalities resolve, consider resuming ICI treatment with close follow-up 1

Grade 2 (Symptomatic)

• Hold ICI therapy 1
• Consider hospitalization with pulmonary and infectious disease consultation 1
• Obtain bronchoscopy with bronchoalveolar lavage to rule out infection 1
• Initiate methylprednisolone 1 mg/kg/day (IV or oral equivalent) 1
• If symptoms improve to ≤ grade 1 after 2-3 days, begin slow steroid taper over >1 month 1
• If symptoms do not improve or worsen, treat as grade 3-4 1
• Consider drug re-challenge if symptoms and imaging abnormalities resolve 1

Grade 3-4 (Severe/Life-threatening)

• Permanently discontinue ICI therapy 1
• Hospitalize patient; consider ICU care 1
• Pulmonary consultation for bronchoscopy with bronchoalveolar lavage 1
• Initiate high-dose IV corticosteroids (methylprednisolone 2-4 mg/kg/day) 1
• If no clinical improvement after 2 days, add additional immunosuppressive strategies 1
• Options include infliximab, mycophenolate mofetil, or cyclophosphamide 1, 2
• Taper steroids very slowly and carefully over 6 weeks or more 1

Special Considerations

Non-infectious Pneumonitis (NIP)

• For mTOR inhibitor-induced pneumonitis, treatment interruption and dose reduction are generally effective for grade 2 symptomatic NIP 1
• Use systemic steroids and treatment discontinuation for grade 3 or greater toxicity 1

COVID-19 Pneumonitis

• Short-course low-dose steroids may be beneficial in early stages of COVID-19 pneumonitis 1
• Systematic corticosteroids (methylprednisolone <1-2 mg/kg body weight for 3-5 days) have been recommended for severe COVID-19 cases 1

Community-Acquired Pneumonia (CAP)

• Not recommended for routine use in non-severe CAP 1
• Not routinely recommended for severe CAP, though some meta-analyses show potential benefit 1
• Consider in severe CAP patients with septic shock refractory to fluid resuscitation and vasopressors 1
• Avoid in influenza pneumonia as mortality may increase 1

Steroid-Refractory Pneumonitis

• Occurs in approximately 18.5% of ICI-pneumonitis cases 3
• Additional immunosuppressive options include:
  • IVIG (appears to have better outcomes with 43% mortality) 3
  • Infliximab (higher mortality rates reported) 3, 4
  • Cyclophosphamide 5, 2
  • Mycophenolate mofetil 2
• Durable improvement with additional immunomodulators occurs in approximately 38% of cases 2

Important Considerations and Pitfalls

• Always rule out infection before initiating immunosuppressive treatment, especially in grade 2 or higher pneumonitis 1
• Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving ≥20 mg methylprednisolone or equivalent for ≥4 weeks 1
• Calcium and vitamin D supplementation is recommended with prolonged steroid use 1
• All patients with grade 2-4 pneumonitis receiving steroids should also be on proton pump inhibitor therapy for GI prophylaxis 1
• Monitor for steroid-related complications including hyperglycemia and increased risk of secondary infections 1
• Relapses of pneumonitis during steroid tapering have been reported, requiring careful monitoring 1