Radiation Pneumonitis

[XRT_doc]

Would anyone treat a mild version of radiation pneumoinitis with inhaled steroids as opposed to oral prednisone?

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[Burt Radnolds]

If it's that mild, I would consider close observation for a period. I personally am not familiar with using inhaled steroids for pneumonitis, although the toxicity profile of such drugs is typically favorable.

 

[Gfunk6]

Radiation pneumonitis is a disorder of the lung parenchyma, not the airways (like asthma). Therefore I don't see inhaled steroids having any efficacy.

 

[Haybrant]

agree with the above. I put a guy on 30 of pred recently and he had pretty good improvement although he has multifaceted all issues going on. Will attempt a taper and see how he does. You guys have success starting at lower prednisone doses like this or do you generally have to start higher to see response? Thanks

 

[medgator]

agree with the above. I put a guy on 30 of pred recently and he had pretty good improvement although he has multifaceted all issues going on. Will attempt a taper and see how he does. You guys have success starting at lower prednisone doses like this or do you generally have to start higher to see response? Thanks

I was generally trained at 60 mg daily for several weeks, have also heard 1 mg/kg.

 

[seper]

Yes, rad. pneumonitis is pretty stubborn in my experience; need at least 60 mg for > 3 weeks. If that is not possible, just watch the patient.

 

[RadOncMDPhD]

Would anyone treat a mild version of radiation pneumoinitis with inhaled steroids as opposed to oral prednisone?

Yes, often do. Supported by prospective study from Germany (J Pagel et al Strahlenther Onkol. 1998 Jan;174(1):25-9.)
Inhaled beclomethasone two puffs twice daily is nearly equivalent.

 

[seper]

That's not pertinent. Nobody in their clear mind would prescribed prophylactic steroids with lung XRT.

 

[Chartreuse Wombat]

Yes, often do. Supported by prospective study from Germany (J Pagel et al Strahlenther Onkol. 1998 Jan;174(1):25-9.)
Inhaled beclomethasone two puffs twice daily is nearly equivalent.

Agree that paper referenced is not germane to the question (and the study itself is poorly designed without a control group)

 

[evilbooyaa]

That's not pertinent. Nobody in their clear mind would prescribed prophylactic steroids with lung XRT.

Agree that paper referenced is not germane to the question (and the study itself is poorly designed without a control group)

How bad does a paper from 1998 have to be to end up in a journal like that? Given the crap papers published in IJROBP back in the 90s

I guess that bad.

 

[nkmiami]

Patients need to be on 60 mg prednisone for about 6 weeks. Short courses of steroids can cause a rebound pneumonitis.

 

[Palex80]

Patients need to be on 60 mg prednisone for about 6 weeks. Short courses of steroids can cause a rebound pneumonitis.

That's quite a lot of steroids, in my opinion. I usually give 50-60mg over 3 weeks, then slowly go down.

The whole concept of an "absolute dose" for steroids is also probably not very smart.
It would probably be better to do this weight adjusted, just like the med oncs treat for example colitis resulting from ipilimumab. Perhaps 1mg/kg for pneumonitis?

 

[medgator]

That's quite a lot of steroids, in my opinion. I usually give 50-60mg over 3 weeks, then slowly go down.

The whole concept of an "absolute dose" for steroids is also probably not very smart.
It would probably be better to do this weight adjusted, just like the med oncs treat for example colitis resulting from ipilimumab. Perhaps 1mg/kg for pneumonitis?

Weight based, 1 mg/kg, is correct. But iirc nkmiami is also correct regarding the length of tx.... You might have it flare back up with only a 3 week course

 

[evilbooyaa]

From reading the books it seems that historically it was like 6 weeks (or longer) of prednisone treatment for pneumonitis. I'm not familiar with data (and haven't really looked into it) discussing randomising patients to shorter or longer course of prednisone given the relative rarity of significant radiation pneumonitis.

 

[nkmiami]

From reading the books it seems that historically it was like 6 weeks (or longer) of prednisone treatment for pneumonitis. I'm not familiar with data (and haven't really looked into it) discussing randomising patients to shorter or longer course of prednisone given the relative rarity of significant radiation pneumonitis.

Unfortunately, Its not that rare. I have really struggled with patients who are diabetics and couldnt tolerate high dose prednisone. Other than dosimetric parameters like v20/mean lung dose, it seems to be associated with lower lobe tumors (you end up irradiating more lung due to increased motion) and concurrent taxane (like weekly carbo taxol)