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 types of fibrotic hypersensitivity pneumonitis or immune-mediated ILDs, rather than idiopathic pulmonary fibrosis (IPF) where their use is not recommended to modify disease progression.

In idiopathic pulmonary fibrosis, corticosteroids like prednisolone should not be used to modify disease progression due to lack of efficacy and potential harm; if patients are already on corticosteroids, the risks and benefits of continuing or discontinuing should be carefully discussed with specialist input NICE CG163.

However, corticosteroids may be used in other ILDs with an inflammatory or immune basis, such as fibrotic hypersensitivity pneumonitis, where immunosuppression including corticosteroids can be part of management to reduce inflammation and slow progression Mullin et al. 2022.

In immune checkpoint inhibitor-related ILD, corticosteroids are a mainstay of treatment to control immune-mediated lung inflammation Kim & Lim 2022.

When to consider corticosteroids: They should be considered when there is evidence of active inflammation or immune-mediated lung injury, for example in non-IPF ILDs like fibrotic hypersensitivity pneumonitis or drug-induced ILD, and in acute exacerbations of ILD where inflammation predominates Mullin et al. 2022Kim & Lim 2022.

Before initiating corticosteroids, individual risk factors for adverse effects must be assessed, including age, comorbidities (e.g., diabetes, hypertension), and infection risk, with appropriate monitoring and vaccination status reviewed NICE CKS.

In IPF, corticosteroids are not recommended for disease modification but may be used for symptom relief or in palliative care settings as part of best supportive care NICE CG163.

Overall, corticosteroids have a limited role in IPF but remain important in other ILDs with inflammatory or immune components, and their use should be guided by specialist multidisciplinary team assessment and tailored to the specific ILD subtype and clinical scenario NICE CG163; Mullin et al. 2022; Kim & Lim 2022.