Cortisol, the main glucocorticoid hormone, has strong antiinflammatory activity. The antiinflammatory activity of cortisol, and its more powerful synthetic derivatives, is often utilized in medicine.

Systemic corticosteroid drugs have common and serious side effects. These adverse effects are not only due to direct toxicity but may also be related to withdrawal. In fact, exogenous use of corticosteroid interferes with the function of the HPA axis, and may suppress the endogenous production of cortisol, predisposing patients experiencing abrupt interruption of the drug to adrenal insufficiency.

Systemic corticosteroid drugs are effective, cheap, easily available, and accessible. Their use remains common in several respiratory diseases, such as COVID-19 pneumonia, severe community-acquired pneumonia, ARDS, septic shock, some interstitial lung diseases, COPD, and asthma and their exacerbations.

Guideline recommendations on systemic corticosteroid use in respiratory medicine show some discrepancies, with unclear chapters, and are often updated. New knowledge and alternative therapeutic options also make their extensive implementation difficult in real life. Effective and safe treatment with corticosteroids is a challenge and forces clinicians to continuously review and balance the risks and benefits of treatment.

This review aims to update current indications to systemic corticosteroid use in respiratory medicine, including choice of drug, dosage, timing, and duration of treatment and tapering strategy.

There is increasing evidence suggesting limiting as much as possible the use of systemic corticosteroids. When complete discontinuation of corticosteroids is not possible, all efforts should be made to achieve clinically meaningful reductions. Meanwhile, monitoring the patient carefully to detect early side effects and to treat accordingly is always required.