From the Guidelines
The treatment of pneumonitis with corticosteroids is recommended as an initial treatment, based on several studies that report clinical improvement in > 80% of cases 1.
Key Considerations
- The incidence of pneumonitis in patients treated with immune checkpoint inhibitors (ICPi) can range from 0% to 10%, with an overall incidence of 2.7% reported in a recent meta-analysis of 20 studies with PD-1 inhibition 1.
- The risk of ICPi-related pneumonitis and pneumonitis-related deaths based on tumor type remains equivocal, but patients with non-small cell lung cancer (NSCLC) or renal cell carcinoma (RCC) may be at higher risk 1.
- Ground-glass opacities or patchy nodular infiltrates, predominantly in the lower lobes, are common findings on chest imaging, and radiologic abnormalities can vary 1.
Treatment Approach
- For symptomatic ICPi pneumonitis, corticosteroids are the mainstay of treatment, typically starting with prednisone 1-2 mg/kg/day or equivalent, with gradual tapering over 4-6 weeks based on clinical response 1.
- In cases of steroid-refractory pneumonitis, options include infliximab, mycophenolate mofetil, intravenous immune globulin (IVIG), or cyclophosphamide, based on two large retrospective experiences 1.
- Antibiotics are not routinely indicated unless there is evidence of bacterial infection.
- Regular follow-up with pulmonary function tests and imaging is essential to monitor treatment response and adjust therapy accordingly.
Important Considerations
- The decision to proceed with biopsy should be taken after careful risk-benefit analysis, with the optimal technique, number, size, and location of biopsies depending upon the suspected diagnosis, the anatomic distribution of the disease process, and the availability of interventional pulmonologists 1.
- Sarcoid-like granulomatous reactions, including subpleural micro-nodular opacities and hilar lymphadenopathy, as well as pleural effusions, have been associated with both CTLA-4 and PD-1/PD-L1–targeted therapies 1.
From the FDA Drug Label
Azithromycin should not be used in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following: patients with cystic fibrosis, patients with nosocomially acquired infections, patients with known or suspected bacteremia, patients requiring hospitalization, elderly or debilitated patients, or patients with significant underlying health problems that may compromise their ability to respond to their illness (including immunodeficiency or functional asplenia). Community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy
The treatment of pneumonitis is not directly addressed in the provided drug labels. However, the labels do discuss the treatment of community-acquired pneumonia due to certain microorganisms in patients appropriate for oral therapy.
- Key points:
- Azithromycin is indicated for the treatment of community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae, or Streptococcus pneumoniae in patients appropriate for oral therapy 2.
- Azithromycin should not be used in patients with pneumonia who are judged to be inappropriate for oral therapy due to moderate to severe illness or certain risk factors 2. However, pneumonitis is not the same as pneumonia, and the provided drug labels do not directly address the treatment of pneumonitis.
From the Research
Treatment of Pneumonitis
- The treatment of pneumonitis typically involves the use of antibiotics, with the specific choice of antibiotic depending on the underlying cause of the infection 3.
- For atypical pneumonia, azithromycin has been shown to be effective in treating the condition, with a 3-day or 5-day course of treatment being equally effective 4.
- In critically ill patients, the management of pneumonia requires early initiation of adequate antimicrobial treatment, as well as identification of the underlying causative pathogen 5.
- The use of prophylactic antibiotics in patients with chronic obstructive pulmonary disease (COPD) has been shown to reduce the frequency of exacerbations, but the evidence is of very low certainty and further research is needed 6.
- The combination of oseltamivir and azithromycin has been shown to be effective in preventing complications and relieving symptoms in patients with Influenza-A (H1N1)pdm09 infection 7.
Antibiotic Treatment
- Azithromycin is a commonly used antibiotic for the treatment of pneumonitis, particularly for atypical pneumonia 4.
- The choice of antibiotic should be based on the local epidemiology and antibiotic susceptibility patterns 3.
- The use of broad-spectrum antibiotics should be avoided whenever possible to minimize the risk of antibiotic resistance 5.
Patient Outcomes
- The treatment of pneumonitis can improve patient outcomes, including reducing the length of hospitalization and the need for respiratory support 7.
- The use of prophylactic antibiotics in patients with COPD can reduce the frequency of exacerbations, but the evidence is of very low certainty 6.
- The combination of oseltamivir and azithromycin has been shown to be effective in reducing the severity of influenza symptoms and preventing complications 7.