From the Guidelines
Prednisone does not have a direct role in Pneumocystis jirovecii pneumonia (PCP) prophylaxis, but rather, it is a factor in determining the risk of PCP.
Key Points
- The risk of PCP is related to the daily dose and duration of corticosteroid therapy, such as prednisone 1.
- Prophylaxis against PCP can be considered in patients receiving the prednisone equivalent of 20 mg or more daily for 4 or more weeks 1 or 20 mg/d for 4 weeks 1.
- The recommended prophylaxis for PCP is trimethoprim/sulfamethoxazole (TMP/SMX), with alternatives such as atovaquone, dapsone, or pentamidine for patients who are TMP/SMX-intolerant 1.
- The duration of prophylaxis depends on the underlying condition and treatment, such as allogeneic HCT, acute lymphoblastic leukemia, or autologous HCT 1.
- Prednisone itself is not used for PCP prophylaxis, but rather, the dose and duration of prednisone are used to assess the risk of PCP and determine the need for prophylaxis 1.
From the Research
Role of Prednisone in Pneumocystis jirovecii Pneumonia (PCP) Prophylaxis
- The use of prednisone is a significant factor in the development of PCP, with patients on high-dose prednisone (≥20 mg/day) for an extended period (≥4 weeks) being at increased risk 2, 3, 4.
- A study found that 86% of patients with rheumatic diseases who developed PCP were receiving ≥20 mg prednisone daily at the time of diagnosis 2.
- Another study suggested that patients using ≥30 mg prednisone for >1 month may benefit from PCP prophylaxis, especially those with high-risk disease or other risk factors 3.
- The decision to administer PCP prophylaxis depends on the balance between the Number Needed to Treat (NNT) and the Number Needed to Harm (NNH) of trimethoprim/sulfamethoxazole (TMP/SMX) or other forms of prophylaxis 3.
Risk Factors for PCP
- Concomitant use of immunosuppressive medications, such as cyclophosphamide, increases the risk of PCP 2, 4.
- Baseline lymphopenia is also a significant risk factor for PCP 5.
- Patients with underlying rheumatologic conditions, such as inflammatory myopathy, lupus, and granulomatosis with polyangiitis, are at increased risk of developing PCP 2.
Prophylaxis Guidelines
- There is no current consensus on the indications for PCP prophylaxis in patients with rheumatological diseases who are receiving higher-dose glucocorticoid treatment over a prolonged period 3.
- A study suggested that prophylactic TMP-SMX may have greater benefit than potential risk in patients with rheumatic diseases receiving prolonged, medium-dose steroids (≥15 to <30 mg/day) who have risk factors for PCP 5.
- The number needed to treat with TMP-SMX to prevent one PCP in the high-risk subgroup was lower than the number needed to harm by serious adverse drug reactions 5.