Systemic
corticosteroids (CSs), a keystone in pulmonology, are drugs with strong antiinflammatory activity. They are cheap, easily available, and accessible, but with common and serious side effects. Moreover, the use of exogenous CSs may suppress the hypothalamic-pituitary-adrenal (HPA) axis, predisposing to
adrenal insufficiency. Safe CS treatment is a challenge of pharmacological research. This narrative review examined the indications of CSs in some
respiratory diseases, analyzing what types, dosages, and length of treatment are required as the dosage and duration of CS treatments need to be minimized. Chronic maintenance treatments with CSs are associated with poor prognosis, but they are still prescribed in patients with severe
asthma,
Chronic obstructive pulmonary disease (
COPD), and
interstitial lung diseases. When CS discontinuation is not possible, all efforts should be made to achieve clinically meaningful reductions. Guidelines suggest the use of
methylprednisolone at a dose of 20-40 mg/day or equivalent for up to 10 days in subjects with
COVID-19 pneumonia (but not other respiratory
viral diseases) and
respiratory failure, exacerbations of
asthma, and
COPD. Some guidelines suggest that CS treatment shorter than 10-14 days can be abruptly stopped, strictly monitoring subjects with unexplained symptoms after CS withdrawal, who should promptly be tested for
adrenal insufficiency (AI) and eventually treated. CSs are often used in severe community-acquired
pneumonia associated with markedly increased serum
inflammation markers, in
acute respiratory distress syndrome (ARDS), in
septic shock unresponsive to hydro-saline replenishment and vasopressors, and acute exacerbations of
interstitial lung diseases. As these cases often require higher doses and longer duration of CS treatment, CS tapering should be gradual and, when useful, supported by an evaluation of HPA axis function.