What role do corticosteroids play in the management of interstitial lung disease, and when should they be considered?

Role of corticosteroids in interstitial lung disease (ILD) management: Corticosteroids are primarily considered in ILD cases where inflammation is a significant component, such as in certain immune-mediated or hypersensitivity pneumonitis forms, rather than idiopathic pulmonary fibrosis (IPF), where corticosteroids are not recommended to modify disease progression due to lack of efficacy and potential harm NICE CG163.

In IPF, prednisolone and other corticosteroids should not be used to alter disease progression, and if patients are already on corticosteroids, the risks and benefits of continuing or discontinuing therapy should be carefully discussed NICE CG163.

However, corticosteroids may be used in ILD subtypes with an inflammatory or immune-mediated basis, such as fibrotic hypersensitivity pneumonitis or immune checkpoint inhibitor-related ILD, where immunosuppression can reduce inflammation and improve symptoms Mullin et al. 2022Kim & Lim 2022Sweis et al. 2023.

In these contexts, corticosteroids are often the first-line treatment to induce remission or control acute exacerbations, with dosing and duration tailored to disease severity and patient response Mullin et al. 2022Kim & Lim 2022.

Inhaled corticosteroids have no established role in ILD management and are primarily used in airway diseases such as asthma or COPD NICE CKS.

When to consider corticosteroids in ILD: Corticosteroids should be considered in ILD patients with evidence of active inflammation, such as those with hypersensitivity pneumonitis, connective tissue disease-associated ILD, or drug-induced ILD, especially when there is clinical, radiological, or histological evidence supporting an inflammatory process Mullin et al. 2022Sweis et al. 2023.

They are also used in immune checkpoint inhibitor-related ILD to manage immune-mediated lung inflammation Kim & Lim 2022.

In IPF, corticosteroids are generally avoided for disease modification but may be used cautiously for symptom relief or in acute exacerbations under specialist guidance NICE CG163.

Decisions on corticosteroid use should be made by a multidisciplinary team with ILD expertise, considering individual patient factors, potential benefits, and risks of adverse effects NICE CG163.