Steroid Dosing for Interstitial Lung Disease
For steroid-responsive interstitial lung disease in adults, initiate oral prednisone at 20-40 mg daily (not exceeding 60 mg daily), taper rapidly to 10 mg daily within 4-8 weeks, then reduce by 2.5 mg every 2-4 weeks until reaching 5 mg daily, followed by 1 mg reductions every 4 weeks until discontinuation. 1, 2
Initial Dosing Strategy
Start with 20-40 mg oral prednisone daily as a single morning dose. 1 Expert consensus from pulmonary sarcoidosis guidelines establishes this range as optimal for most ILD presentations, balancing efficacy against toxicity risk. 1
- Maximum dose should not exceed 60 mg daily even in symptomatic or moderate-severe disease. 1
- For rapidly progressive ILD or acute respiratory failure, consider pulse-dose IV methylprednisolone (1000 mg for 3 days) or high-dose oral prednisone up to 60 mg daily. 1, 3
- Reduce initial dose in patients with diabetes (consider lower starting dose), psychosis, or osteoporosis to minimize adverse effects. 1
Tapering Schedule
Phase 1: Rapid Taper (Weeks 1-8)
Reduce by 5-10 mg per week until reaching 10 mg daily within 4-8 weeks. 2, 4 This initial phase primarily addresses disease control rather than HPA axis suppression, allowing aggressive dose reduction. 2, 4
Phase 2: Slow Taper (After Week 8)
Once at 10 mg daily, reduce by 2.5 mg every 2-4 weeks until reaching 5 mg daily. 2 This slower pace prevents adrenal insufficiency as you approach physiologic replacement doses.
Below 5 mg daily, taper by 1 mg every 4 weeks until complete discontinuation. 2, 4
Monitoring and Response Assessment
Allow 3-6 months for therapeutic response before declaring treatment failure. 1 Perform pulmonary function tests every 3-6 months, especially in the first 1-2 years. 1
If Disease Improves or Stabilizes:
- Continue tapering to the lowest dose that provides satisfactory symptom relief and disease control. 1
- The goal is complete discontinuation if disease remains quiescent. 1
If Disease Worsens During Taper:
- Immediately return to the pre-relapse dose and maintain for 4-8 weeks before attempting a slower taper. 4
- Add adjunctive steroid-sparing therapy (mycophenolate mofetil or azathioprine as first-line agents) rather than escalating steroid dose. 1
- Re-evaluate the diagnosis to exclude alternative conditions. 1
Steroid-Sparing Agents
Initiate steroid-sparing agents early if:
- Unable to taper below 10 mg daily without disease flare 1
- High risk for steroid toxicity 1
- Long-duration therapy anticipated (>6 months) 1
- Unfavorable adverse effects develop 1
Mycophenolate mofetil or azathioprine are first-line steroid-sparing agents. 1 For refractory disease, consider rituximab or cyclophosphamide. 1
Critical Caveats
Tapering is mandatory for any patient receiving >7.5 mg prednisone daily for >3 weeks due to HPA axis suppression. 2 However, courses <3 weeks at low-moderate doses can be stopped abruptly without taper. 2
All patients require stress-dose steroids during acute illness or physiologic stress, with this requirement persisting up to 12 months after discontinuation in patients who received prolonged therapy. 2
Use single morning dosing to minimize HPA axis suppression throughout the treatment course. 2
Monitor for both disease activity and adrenal insufficiency symptoms (fatigue, weakness, nausea, hypotension) during tapering. 4 Schedule follow-up visits every 4-8 weeks in the first year, then every 8-12 weeks in the second year. 4
Evidence Limitations
The dose and duration of corticosteroids in ILD is not standardized across different connective tissue diseases. 1 The recommendations synthesize expert consensus from sarcoidosis 1 and Sjögren's-ILD guidelines 1, supplemented by general steroid tapering principles. 2, 4 Research studies demonstrate efficacy of low-dose prednisone (<10 mg daily) combined with immunosuppressants in systemic sclerosis-ILD 5, 6 and other CTD-ILD 3, supporting early steroid-sparing strategies over prolonged high-dose monotherapy.