The edition · Pulmonology
Immune-related pneumonitis: a three-week steroid taper fell short of six
The first randomised trial of steroid duration for checkpoint-inhibitor pneumonitis backs the guideline course; an emulated trial questions immunosuppression in some fibrotic ILDs.
The edition in brief
In a randomised trial of 106 patients with grade 1–2 immune checkpoint inhibitor pneumonitis, a 3-week corticosteroid taper failed to show non-inferiority to the guideline 6-week taper: treatment success at 8 weeks was 66.7% against 85.2%, and an exploratory analysis favoured 6 weeks. Grade 3 or worse adverse events were commoner with the longer course (24% vs 12%) but manageable, and survival was similar. An international working group has revised the definition of acute exacerbation to cover all fibrotic interstitial lung disease, distinguishing exacerbation with diffuse alveolar damage from other causes of acute respiratory worsening such as oedema or pneumonia. A target trial emulation in 2270 patients with non-IPF fibrotic ILD found no survival or lung function benefit from starting mycophenolate or azathioprine, and an association with worse survival in non-IPF idiopathic interstitial pneumonia and fibrotic hypersensitivity pneumonitis; this is observational and does not override current practice. A crossover trial of 40 patients with COPD or ILD and exertional desaturation found walk distance identical on portable oxygen and air, though breathlessness was lower with oxygen. The pearl covers antigen avoidance in hypersensitivity pneumonitis.
Acute exacerbation of fibrotic ILD redefined across all fibrotic diseases
In acute deterioration of fibrotic ILD, separate true exacerbation with diffuse alveolar damage from other treatable causes of worsening.
Mycophenolate or azathioprine in non-IPF fibrotic ILD: no benefit, possible harm in an emulated trial
Weigh immunosuppression carefully in non-IPF fibrotic ILD; this study found no benefit and possible harm in some subtypes.
Portable oxygen during walking: same distance as air, but less breathlessness
Consider a trial walk on and off oxygen before prescribing a portable concentrator for exertional desaturation.
In hypersensitivity pneumonitis, find the antigen first
Take a structured exposure history and remove the antigen before escalating treatment in hypersensitivity pneumonitis.
Checkpoint-inhibitor pneumonitis: keep the six-week steroid taper
Use the six-week corticosteroid taper for mild immune checkpoint inhibitor pneumonitis; three weeks was not enough.
Read the rest in the app
You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this one is waiting in it.
Scan to keep reading on your phone. No account needed to start.
Tomorrow morning, before your first patient
One edition a day for pulmonology, written by the desk, every claim tied to its paper. Six minutes.
Get the app — free