# Immune-related pneumonitis from checkpoint inhibitors, by grade

Source: https://onco.cc/protocols/irae-pneumonitis/  
OnCo record `irae-pneumonitis` (Protocol). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Immunotherapy can inflame the lungs. A new cough, breathlessness or chest pain during or after immunotherapy should be reported to your cancer team the same day. A CT scan of the chest confirms it, and steroids are the main treatment; severe cases need hospital and steroids through a drip.

## Summary

Pneumonitis occurs in about 4% of people on PD-(L)1 inhibitors (1% grade 3 or more), 1% on anti-CTLA-4 and 7% on combinations in trials, with higher rates in single-centre practice (19% in one series) and in lung and kidney cancer, smokers, people with asthma or prior chest radiotherapy (SITC 2021). Median onset is about 3 months.

SITC 2021: high-resolution CT of the chest for suspected pneumonitis, with pulmonary function tests (spirometry and DLCO) if the CT is negative. Grade 2: prednisone 1 to 2 mg/kg/day, tapered over 4 to 6 weeks. Grade 3 or more: intravenous methylprednisolone 1 to 2 mg/kg/day, tapered over 4 to 6 weeks. If high-dose steroids do not help within 72 hours, or the illness is life-threatening, the options, in no order, are mycophenolate mofetil, high-dose IVIG, infliximab, cyclophosphamide or tocilizumab, each on low-level evidence. After grade 2, re-challenge may follow complete resolution, with closer follow-up; recurrence was 25% in a small series.

ASCO 2021 gives the general frame: hold for grade 2, high-dose steroids for grade 3, taper over at least 4 to 6 weeks, permanently stop for grade 4. The Chinese 2022 consensus grades by symptoms and the share of lung involved on CT, monitors grade 1, treats grades 2 to 3 with prednisolone-equivalent 1 to 2 mg/kg/day, assesses response at 48 to 72 hours and keeps steroid courses to 6 to 8 weeks, not over 12. ESMO 2022 could not be read.

## Fields

- Kind: Protocol
- Last checked: 2026-11-11
- Also known as: checkpoint inhibitor pneumonitis; CIP; immune checkpoint inhibitor lung inflammation; ICI pneumonitis management; immunotherapy pneumonitis
- Tags: protocol; irae; acute-oncology

## Connected records

- protocols: [Baseline tests and monitoring before and during checkpoint inhibitor treatment](https://onco.cc/protocols/checkpoint-inhibitor-baseline-and-monitoring/), [Checkpoint inhibitor hypophysitis and adrenal insufficiency: emergency treatment, replacement and steroid emergency card](https://onco.cc/protocols/irae-hypophysitis-adrenal/), [Immune-mediated hepatitis from checkpoint inhibitors, by grade](https://onco.cc/protocols/irae-hepatitis/), [Immune-related diarrhoea and colitis from checkpoint inhibitors, by grade](https://onco.cc/protocols/irae-colitis/), [Restarting a checkpoint inhibitor after an immune-related side effect](https://onco.cc/protocols/irae-rechallenge/), [Steroid taper after immunotherapy side effects, with Pneumocystis prophylaxis and adrenal checks](https://onco.cc/protocols/irae-steroid-taper-and-pjp/)
- ideas: [Treat immunotherapy side-effects without wiping out the response](https://onco.cc/ideas/idea-bio2-steroid-sparing-irae/)
- technologies: [Immune checkpoint inhibitors](https://onco.cc/technologies/checkpoint-inhibitor/)
- drugs: [Atezolizumab](https://onco.cc/drugs/atezolizumab/), [Avelumab](https://onco.cc/drugs/avelumab/), [Cemiplimab](https://onco.cc/drugs/cemiplimab/), [Cyclophosphamide](https://onco.cc/drugs/cyclophosphamide/), [Dostarlimab](https://onco.cc/drugs/dostarlimab/), [Durvalumab](https://onco.cc/drugs/durvalumab/), [Ipilimumab](https://onco.cc/drugs/ipilimumab/), [Methylprednisolone](https://onco.cc/drugs/methylprednisolone/), [Nivolumab](https://onco.cc/drugs/nivolumab/), [Pembrolizumab](https://onco.cc/drugs/pembrolizumab/), [Prednisone](https://onco.cc/drugs/prednisone/), [Tocilizumab](https://onco.cc/drugs/tocilizumab/), [Tremelimumab](https://onco.cc/drugs/tremelimumab/)
- institutions: [American Society of Clinical Oncology (ASCO)](https://onco.cc/institutions/asco/), [European Society for Medical Oncology (ESMO)](https://onco.cc/institutions/esmo/), [Society for Immunotherapy of Cancer](https://onco.cc/institutions/sitc/)
- terms: [Immune-related adverse events (irAEs)](https://onco.cc/terms/irae/), [Pneumonitis](https://onco.cc/terms/pneumonitis/)
- key papers: [ASCO 2021 guideline: how to recognise and manage the immune-related side effects of checkpoint inhibitors](https://onco.cc/key-papers/paper-asco-irae-guideline-jco-2021/)

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