eMedicine Specialties > Pulmonology > Occupational Lung Diseases

Berylliosis: Treatment & Medication

Author: Raed A Dweik, MD, FACP, FCCP, FRCPC, Associate Professor of Medicine; The Cleveland Clinic, Lerner College of Medicine; Director, Pulmonary Vascular Program, Respiratory Institute, The Cleveland Clinic Foundation
Contributor Information and Disclosures

Updated: Nov 19, 2008

Treatment

Medical Care

  • Prevention is a key component in the management of chronic beryllium disease (CBD).
    • The current Occupational Safety and Health Administration (OSHA) standards for workplace air require an 8-hour, time-weighted average maximum permissible level of 2 mcg/m3 along with a peak level of 25 mcg/m3.
    • The beryllium concentration in the air around factories is not to exceed 0.01 mcg/m3.
    • Some studies suggest that the current standard of 2 mcg/m3 is not protective.8
    • Although no proof exists that cessation of exposure to beryllium improves the disease course or slows the progression, advising all patients with CBD to avoid any further exposure to beryllium is prudent.
  • Due to the use of BeLPT testing to screen workers exposed to beryllium, many cases now are diagnosed very early in the course of the disease, before radiographic or physiologic changes are observed and before symptoms or physical signs develop.
  • The natural history of the disease is not clear in patients who have granulomas on TBBX but who are asymptomatic and have no physiologic or radiographic abnormalities.
  • The current indications for therapy include the presence of symptoms, abnormal pulmonary function test results, or a decline in pulmonary function over time. In the absence of any of these criteria, no therapy is recommended. Close monitoring of symptoms and follow-up pulmonary function testing is recommended.
  • No controlled studies for CBD therapy are available.
    • Based on the pathogenesis of the disease (immune-mediated) and due to the similarities with sarcoidosis, CBD is treated with corticosteroids.
    • When corticosteroid therapy fails or in patients who develop significant adverse effects, methotrexate (MTX) may be considered.

Surgical Care

In end-stage cases, lung transplantation may be considered.

Consultations

A team approach involving industrial hygiene, occupational health, and pulmonary specialists is necessary for prevention, screening, early diagnosis, and appropriate treatment of CBD.

Medication

Corticosteroids are the treatment of choice for chronic beryllium disease (CBD). No consensus on the dose or duration of corticosteroid therapy exists. A starting dose of 20-40 mg of oral prednisone daily or every other day usually is used. After an initial 4-6 weeks of therapy, prednisone is tapered, depending on the clinical response.

MTX may be considered in patients who do not respond to corticosteroids or in patients who develop significant adverse effects on corticosteroid therapy.

Corticosteroids

Have anti-inflammatory properties and cause profound and varied metabolic effects. Corticosteroids modify the body's immune response to diverse stimuli.


Prednisone (Deltasone, Orasone, Sterapred)

Immunosuppressant for treatment of autoimmune disorders. May decrease inflammation by reversing increased capillary permeability and suppressing PMN activity. Stabilizes lysosomal membranes and also suppresses lymphocytes and antibody production. A 3-phase approach is suggested.

Adult

Initiation phase: 20-40 mg PO qd or qod for 4-6 wk
Tapering phase: Reduce dose gradually over 2-6 mo to lowest dose that keeps disease under control as determined by patient symptoms and pulmonary function testing (eg, spirometry, lung volumes, DLCO, ABGs, exercise capacity)
Maintenance phase: Lowest effective dose used for maintenance; further tapering or complete discontinuation of corticosteroids generally is not recommended

Pediatric

Not established

Coadministration with estrogens may decrease prednisone clearance; concurrent use with digoxin may cause digitalis toxicity secondary to hypokalemia; phenobarbital, phenytoin, and rifampin may increase metabolism of glucocorticoids (consider increasing maintenance dose); monitor for hypokalemia with coadministration of diuretics

Documented hypersensitivity; viral infection; peptic ulcer disease; hepatic dysfunction; connective tissue infections; fungal or tubercular skin infections; GI disease

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals

Precautions

Abrupt discontinuation of glucocorticoids may cause adrenal crisis; hyperglycemia, edema, osteonecrosis, myopathy, peptic ulcer disease, hypokalemia, osteoporosis, euphoria, psychosis, myasthenia gravis, growth suppression, and infections may occur with glucocorticoid use

Cytotoxic agents

Inhibit cell growth and proliferation, which decreases immune system activity.


Methotrexate (Folex PFS, Rheumatrex)

Unknown mechanism of action in treatment of inflammatory reactions. May affect immune function. Ameliorates symptoms of inflammation (eg, pain, swelling, stiffness). Adjust dose gradually to attain satisfactory response.

Adult

5-10 mg PO qwk

Pediatric

Not established

Oral aminoglycosides may decrease absorption and blood levels of concurrent oral MTX; charcoal lowers MTX levels; coadministration with etretinate may increase hepatotoxicity of MTX; folic acid or its derivatives contained in some vitamins may decrease response to MTX; coadministration with NSAIDs may be fatal; indomethacin and phenylbutazone can increase MTX plasma levels; may decrease phenytoin serum levels; probenecid, salicylates, procarbazine, and sulfonamides, including TMP-SMZ, may increase effects and toxicity of MTX; may increase plasma levels of thiopurines

Documented hypersensitivity; alcoholism; hepatic insufficiency; documented immunodeficiency syndromes; preexisting blood dyscrasias (eg, bone marrow hypoplasia, leukopenia, thrombocytopenia, significant anemia); renal insufficiency

Pregnancy

X - Contraindicated; benefit does not outweigh risk

Precautions

Monitor CBC counts monthly and liver and renal function q1-3mo during therapy (monitor more frequently during initial dosing, dose adjustments, or during risk of elevated MTX levels, eg, dehydration); MTX has toxic effects on hematologic, renal, GI, pulmonary, and neurologic systems; discontinue if significant drop in blood counts occurs; aspirin, NSAIDs, or low-dose steroids may be administered concomitantly with MTX (possibility of increased toxicity with NSAIDs, including salicylates, has not been tested)

More on Berylliosis

Overview: Berylliosis
Differential Diagnoses & Workup: Berylliosis
Treatment & Medication: Berylliosis
Follow-up: Berylliosis
Multimedia: Berylliosis
References
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References

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Further Reading

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Keywords

berylliosis, beryllium, Be, chronic beryllium disease, CBD, acute beryllium disease, acute chemical pneumonitis

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Contributor Information and Disclosures

Author

Raed A Dweik, MD, FACP, FCCP, FRCPC, Associate Professor of Medicine; The Cleveland Clinic, Lerner College of Medicine; Director, Pulmonary Vascular Program, Respiratory Institute, The Cleveland Clinic Foundation
Raed A Dweik, MD, FACP, FCCP, FRCPC is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American College of Physicians-American Society of Internal Medicine, American Federation for Medical Research, American Medical Association, American Thoracic Society, Royal College of Physicians and Surgeons of Canada, and Society of Critical Care Medicine
Disclosure: Nothing to disclose.

Medical Editor

Oleh Wasyl Hnatiuk, MD, Program Director, National Capital Consortium, Pulmonary and Critical Care, Walter Reed Army Medical Center; Associate Professor, Department of Medicine, Uniformed Services University of Health Sciences
Oleh Wasyl Hnatiuk, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Gregg T Anders, DO, Medical Director, Great Plains Regional Medical Command , Brook Army Medical Center; Clinical Associate Professor, Department of Internal Medicine, Division of Pulmonary Disease, University of Texas Health Science Center at San Antonio
Gregg T Anders, DO is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, and American Thoracic Society
Disclosure: Nothing to disclose.

CME Editor

Timothy D Rice, MD, Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, Saint Louis University School of Medicine
Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians
Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD, Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center; Professor of Medicine, David Geffen School of Medicine at UCLA
Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society
Disclosure: Nothing to disclose.

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