Prednisone for Pleurisy
Prednisone is NOT recommended for routine treatment of pleurisy, as the evidence shows no clinically meaningful benefit in reducing residual pleural thickening or long-term outcomes, despite some short-term symptomatic improvement. 1, 2
Evidence-Based Recommendation
The decision depends critically on the underlying cause of pleurisy:
For Tuberculous Pleurisy (TB Pleurisy)
Do NOT routinely use prednisone for tuberculous pleurisy, as multiple high-quality randomized controlled trials demonstrate:
No reduction in residual pleural thickening: The most important long-term outcome showed no difference between prednisone and placebo groups (53.1% vs 60% with residual thickening at 6 months, p=NS) 1
No clinically relevant benefit: While one study showed faster symptom resolution (2.4 days vs 9.2 days) and quicker effusion reabsorption (54.5 days vs 123.2 days), 3 other well-designed trials found no meaningful clinical differences in outcomes 1, 2
Standard therapy is adequate: Anti-TB chemotherapy (isoniazid, rifampin, ethambutol for 6-9 months) plus early complete drainage of effusion provides optimal treatment without corticosteroids 1
Exception - Consider prednisone ONLY for:
- TB pericarditis (not pleurisy): Prednisone 60 mg/day for 4 weeks, then 30 mg/day for 4 weeks, then tapered, but only for patients with large effusions, high inflammatory markers, or early constriction 4
- TB meningitis: Dexamethasone 12 mg/day for 3 weeks then tapered - this is standard of care with mortality benefit 4
For Non-Tuberculous (Viral/Idiopathic) Pleurisy
Use NSAIDs as first-line treatment, not prednisone:
Nonsteroidal anti-inflammatory drugs are the recommended treatment for pleuritic pain once life-threatening causes (pulmonary embolism, pneumonia, myocardial infarction, pneumothorax, pericarditis) are excluded 5
No evidence supports corticosteroid use for viral or idiopathic pleurisy 5
Critical Diagnostic Considerations
Before treating pleurisy, you must exclude these life-threatening conditions first:
- Pulmonary embolism (found in 5-20% of patients with pleuritic chest pain presenting to emergency departments) 5
- Pneumonia requiring antibiotics 5
- Myocardial infarction 5
- Pneumothorax 5
- Pericarditis (may benefit from corticosteroids if severe) 5
Required initial workup: History, physical examination, chest radiography, and electrocardiography 5
Common Pitfalls to Avoid
Do not use prednisone hoping to prevent pleural thickening - this has been definitively disproven in TB pleurisy 1, 2
Do not confuse TB pleurisy with TB pericarditis or TB meningitis - only the latter two conditions have evidence supporting corticosteroid use 4
Do not use chronic oral corticosteroids for pulmonary conditions without specific indication - guidelines strongly recommend against this in cystic fibrosis due to adverse effects including glucose abnormalities, cataracts, and growth retardation 6
Prednisone adverse effects are dose and duration-dependent: Fluid retention, insomnia, and metabolic effects increase with treatment beyond 2 weeks 7