From the Guidelines
The recommended duration of a steroid course for the treatment of pneumonitis is 4-6 weeks, with a gradual taper after initial high-dose treatment. This recommendation is based on the most recent and highest quality study, which suggests that steroids should be tapered over 4-6 weeks after recovery and reintroduction of the checkpoint inhibitor should be delayed until the daily dose of steroids equals 10 mg of oral prednisone per day or less 1.
Key Considerations
- The initial dose of prednisone is typically 1 mg/kg daily or equivalent, with a gradual taper over 4-6 weeks 1.
- For moderate to severe cases, methylprednisolone 1-2 mg/kg/day intravenously may be initiated in the hospital setting 1.
- Patients should be monitored for improvement in symptoms such as shortness of breath, cough, and oxygen saturation during treatment.
- Prophylaxis against Pneumocystis pneumonia with trimethoprim-sulfamethoxazole should be considered for courses lasting longer than 3 weeks 1.
Management of Pneumonitis
- Grade 1 and 2 pneumonitis: interrupt ICPi therapy, try to rule out infection, and start with prednisone 1–2 mg/kg orally, tapering over 4–6 weeks 1.
- Grade 3 and 4 pneumonitis: discontinue ICPi permanently, admit the patient to the hospital, and immediately start high-dose (methyl)prednisone 2–4 mg/kg i.v., tapering over a period of 4–6 weeks 1.
Additional Considerations
- Patients with severe or persistent pneumonitis may require longer courses or additional immunosuppressive agents if they don't respond adequately to steroids alone 1.
- Calcium and vitamin D supplementation should be considered with prolonged steroid use 1.
- Proton pump inhibitor therapy should be considered for GI prophylaxis in patients with grade 2–4 pneumonitis receiving steroids 1.