From the Guidelines
If ACE levels increase while tapering steroids in sarcoidosis, don't immediately change your treatment plan based on this finding alone, instead focus on clinical symptoms, pulmonary function tests, and imaging findings to guide management decisions. According to the most recent and highest quality study, the Delphi consensus recommendations for a treatment algorithm in pulmonary sarcoidosis 1, the management of sarcoidosis should be based on the patient's phenotype and disease severity. The study suggests that corticosteroids, such as prednisone, should be tapered to the lowest effective dose, and steroid-sparing agents like methotrexate, azathioprine, or hydroxychloroquine should be considered for patients requiring long-term steroid therapy.
When tapering steroids, it's essential to monitor the patient's clinical symptoms, pulmonary function tests, and imaging findings to guide management decisions. If there are signs of disease recurrence, such as worsening symptoms, declining lung function, or new radiographic changes, consider slowing the taper or temporarily increasing the steroid dose. The European Respiratory Journal study 1 also supports the use of steroid-sparing agents, such as methotrexate, azathioprine, and hydroxychloroquine, in the treatment of sarcoidosis.
Some key points to consider when managing sarcoidosis include:
- Focusing on clinical symptoms, pulmonary function tests, and imaging findings to guide management decisions
- Tapering corticosteroids to the lowest effective dose
- Considering steroid-sparing agents, such as methotrexate, azathioprine, or hydroxychloroquine, for patients requiring long-term steroid therapy
- Monitoring for signs of disease recurrence and adjusting the treatment plan accordingly
It's also important to note that ACE levels can fluctuate for various reasons unrelated to sarcoidosis activity, including the direct suppressive effect of steroids on ACE production. Therefore, ACE levels should not be relied upon as the sole indicator of disease activity. The study by Rahaghi et al. 1 provides a comprehensive treatment algorithm for sarcoidosis, which can be used to guide management decisions.
From the Research
Managing Increased ACE Levels While Tapering Steroids in Sarcoidosis
- Increased ACE levels can indicate disease activity in sarcoidosis 2
- Tapering steroids can lead to increased ACE levels, suggesting a potential flare-up of the disease
- To manage this, consider the following:
- Monitor ACE levels regularly to assess disease activity and response to treatment 2
- Adjust the tapering schedule of steroids to minimize the risk of flare-ups 3
- Consider adding or switching to alternative immunosuppressive agents, such as methotrexate or azathioprine, to help control disease activity and reduce steroid use 4, 5
- Biologic therapy may be considered for patients who are refractory to other treatments 3
Alternative Therapies
- Methotrexate and azathioprine have been shown to have significant steroid-sparing potency and can help control disease activity 4
- These agents can be used as second-line therapy for patients who are intolerant of or failing to improve with steroids 4, 5
- Biologic therapy may be considered for patients who are refractory to other treatments 3