What is the typical steroid regimen for treating interstitial lung disease (ILD) in an inpatient setting?

Steroid Regimen for Interstitial Lung Disease (ILD) in Inpatient Setting

For inpatient treatment of interstitial lung disease, the recommended steroid regimen includes pulse dose IV methylprednisolone (1000 mg daily for 3 days) followed by moderate-dose oral prednisone (up to 60 mg daily) with a slow taper over weeks to months, alongside appropriate steroid-sparing agents. 1

Initial Steroid Approach Based on ILD Type and Severity

Moderate to Severe Symptomatic ILD

• For non-SSc SARD-ILD (Sjögren's, RA, myositis, MCTD): Moderate dose oral corticosteroids (up to 60 mg daily prednisone) 1
• For rapidly progressive ILD or acute respiratory failure: Pulse dose IV methylprednisolone (1000 mg daily for 3 days) followed by high-dose oral prednisone (up to 60 mg daily) 1
• For SSc-ILD: Strong recommendation AGAINST daily glucocorticoids as first-line treatment due to risk of scleroderma renal crisis 1
• For idiopathic pulmonary fibrosis (IPF): Not recommended to use corticosteroid therapy except in the context of acute exacerbation 1

Steroid Dosing Protocol

• Initial IV phase (for severe/rapidly progressive cases):

  • Methylprednisolone 1000 mg IV daily for 3 days 2
  • Alternative: Two courses of pulse dose methylprednisolone (1000 mg IV for 3 days a week for 2 weeks) 2

• Oral phase:

  • Prednisone starting at 0.5-1 mg/kg/day (not to exceed 60 mg daily) 1
  • Slow taper over weeks to months based on clinical response 1
  • Target maintenance: Lowest effective dose or complete discontinuation 1

Steroid-Sparing Agents (to be initiated concurrently)

• First-line options (in order of preference):

  • Mycophenolate mofetil (preferred for all SARD-ILD types) 1
  • Azathioprine 1
  • Rituximab (especially with inflammatory arthritis or myositis) 1
  • Cyclophosphamide (for severe, rapidly progressive cases) 1

• Disease-specific additional options:

  • For SSc-ILD: Tocilizumab, nintedanib 1
  • For myositis-ILD: Calcineurin inhibitors (tacrolimus), JAK inhibitors 1, 2

Monitoring During Inpatient Treatment

• Daily assessment of respiratory status and oxygen requirements 1
• Pulse oximetry at rest and with activity 1
• Serial pulmonary function tests as clinically indicated 1
• Monitor for steroid-related complications (hyperglycemia, hypertension, etc.) 1
• Consider echocardiogram if pulmonary hypertension is suspected 1

Important Caveats and Pitfalls

• Steroid resistance: Up to 30% of patients with connective tissue disease-ILD may be steroid-resistant and require early initiation of steroid-sparing agents 3
• Scleroderma renal crisis: Avoid high-dose steroids in systemic sclerosis due to increased risk of renal crisis 1
• Infection risk: Balance immunosuppression with risk of opportunistic infections, particularly with combination therapy 1
• Steroid dependence: Inability to taper steroids should prompt early addition of steroid-sparing agents 1
• IPF exception: Corticosteroids have not shown survival benefit in IPF and are associated with substantial long-term morbidity 1

Discharge Planning

• Taper steroids to off or lowest most effective dose 1
• Continue steroid-sparing agents as maintenance therapy 1
• Close monitoring of PFTs every 3-6 months, especially in the first 1-2 years 1
• Consider antifibrotic therapy (nintedanib) for progressive fibrotic ILD phenotype 1