International survey on Current Standards for Immunosuppression in Fibrosing Interstitial Lung Diseases

<bold>Rationale:</bold> Immunosuppression plays an important role in inflammatory ILD, but a significant knowledge gap exists for the efficacy of steroids in fILD. In the absence of evidence, our study aimed to establish consensus among ILD experts on the role of immunosuppression in fILD. <bold>Methods:</bold> A modified Delphi survey was conducted among global ILD experts. Following a qualitative review about criteria for inflammation in fILD statements were formulated and circulated. Participants were selected from the REMAP-ILD network and the Swiss Special Interest Group for ILD. In two rounds consensus was sought using a 5-point Likert scale, with a threshold of 75% for agreement or disagreement. <bold>Results:</bold> 56 and 67 physicians participated in the first and second rounds, respectively. Statements were adapted after comments from the first round. Consensus was reached for: 1) steroid treatment should be considered in fILD when inflammation is suspected, 2 and 3) initial assessment prior to steroids should include lung function and HRCT, 4) lung biopsies should not always be performed prior to steroids, 5) BAL lymphocytosis >30% provides support for the use of steroids, 6) HRCT with ground glass and consolidations indicate inflammation and provides support for steroid use, 7) there are no systemic markers indicating pulmonary inflammation to inform about steroid response, 8 and 9) if steroids are considered, most ILD physicians choose oral application doses between 10-50mg/d and 10) treatment should be reviewed within 3 months. <bold>Conclusions:</bold> Our survey reflects challenges in fILD with inflammation. New studies are needed to evaluate safety and effectiveness of steroids in fILD.