Prednisone for Pleurisy: Dosing and Duration
For tuberculous pleurisy specifically, prednisone 60 mg/day (or 0.75-1 mg/kg/day) for 4 weeks followed by tapering over 2 weeks is the established regimen, though evidence shows minimal clinical benefit beyond symptom relief. For non-tuberculous inflammatory pleurisy, treatment should be reserved for moderate-to-severe cases with prednisone 0.5-1 mg/kg/day for 1-2 weeks with tapering.
Tuberculous Pleurisy
Evidence-Based Dosing
- Prednisone 60 mg/day (or 0.75-1 mg/kg/day) for 4 weeks, followed by gradual tapering over 2 additional weeks 1
- Alternative regimen: Prednisone 1 mg/kg/day for 15 days, then taper 2
- Always combine with standard antituberculous therapy (isoniazid, rifampicin, and other agents as indicated) 1, 2
Clinical Outcomes and Limitations
The evidence for corticosteroids in tuberculous pleurisy reveals important nuances:
- Symptom relief occurs faster (8 weeks vs 12 weeks), but this difference is not clinically significant at later follow-up evaluations 3
- No reduction in residual pleural thickening: Studies consistently show no benefit in preventing long-term pleural sequelae, with 53-60% of patients developing residual thickening regardless of steroid use 3, 2, 4
- Modest reduction in pleural changes: A Cochrane review found corticosteroids may reduce pleural thickening/adhesions by approximately one-third (RR 0.72), translating to 16% absolute risk reduction 4
- Complete drainage of effusion at presentation is more important than subsequent steroid therapy for symptom improvement 3
Safety Considerations
- Increased adverse events: Risk of discontinuation due to adverse effects is higher with corticosteroids (RR 2.78) 4
- HIV-positive patients: Exercise extreme caution—Kaposi's sarcoma cases occurred only in the steroid group (6/99 vs 0/98) in one trial 4
- Antifungal prophylaxis: Consider itraconazole when using corticosteroids to reduce dissemination risk 1
Non-Tuberculous Inflammatory Pleurisy
Moderate-to-Severe Cases
- Prednisone 0.5-1 mg/kg/day for 1-2 weeks with gradual tapering 1
- For severe cases with respiratory compromise: Methylprednisolone 0.5-1 mg/kg/day IV 1
Mild Cases
- NSAIDs are first-line for mild pleuritic pain 1
- Reserve corticosteroids for cases not responding to NSAIDs or when symptoms persist beyond 4 weeks 1
Critical Monitoring and Supportive Care
Essential Prophylaxis (for treatment ≥3 months or ≥20 mg/day for ≥4 weeks)
- Pneumocystis jirovecii prophylaxis for patients on prolonged high-dose steroids 1
- Proton pump inhibitor for GI prophylaxis 1
- Calcium and vitamin D supplementation at initiation 1
- Osteoporosis screening and bisphosphonates if treatment expected >3 months, especially in postmenopausal women and men >50 years 1
Tuberculosis Screening
- T-spot testing should be performed before initiating corticosteroids to exclude latent TB 1
Common Pitfalls to Avoid
Overestimating benefit: Do not use corticosteroids expecting prevention of pleural thickening—the evidence does not support this 3, 2, 4
Prolonged therapy without indication: Limit duration to 4-6 weeks for tuberculous pleurisy; longer courses increase toxicity without additional benefit 1, 3
Neglecting complete drainage: Early thoracentesis with complete drainage is more important than steroid therapy for symptom relief 3
HIV patients: Be particularly cautious with corticosteroids in HIV-positive patients due to increased infection risk and potential for Kaposi's sarcoma 4
Monotherapy: Never use corticosteroids alone for tuberculous pleurisy—always combine with appropriate antituberculous drugs 1, 2