From the Guidelines
Treatment for sarcoidosis should be discontinued when the disease is in remission, symptoms have significantly improved, and lung function tests have stabilized for at least 3-6 months, as recommended by the Delphi consensus algorithm 1. Here are specific guidelines:
- For patients on corticosteroids (e.g., prednisone):
- Gradually taper the dose over 3-6 months
- Start tapering when symptoms improve and lung function tests stabilize
- Aim to discontinue completely if possible, or reach the lowest effective dose, considering the potential toxicity of prolonged corticosteroid use 1
- For patients on immunosuppressants (e.g., methotrexate, azathioprine):
- Continue for at least 1-2 years after achieving remission
- Slowly taper and discontinue if disease remains stable, taking into account the risk of relapse and the need for ongoing therapy 1
- For antimalarial drugs (e.g., hydroxychloroquine):
- Can be stopped when skin lesions resolve
- May need to continue longer for maintenance in some cases, depending on the individual patient's response to therapy 1
- Monitor patients closely for relapse after stopping treatment:
- Perform regular clinical assessments, chest X-rays, and pulmonary function tests
- Resume treatment if symptoms recur or worsen, considering the potential for disease progression and the need for prompt intervention 1 The decision to stop treatment should be individualized based on disease severity, organ involvement, and response to therapy, with a focus on minimizing medication side effects and risks associated with prolonged immunosuppression, as emphasized by the Delphi consensus algorithm 1.
From the Research
Discontinuation of Treatment in Sarcoidosis
The decision to discontinue treatment in sarcoidosis is complex and depends on various factors, including the severity of symptoms, organ involvement, and response to treatment.
- Treatment duration should be of at least 12 months 2.
- A 36-month duration monitoring is warranted to confirm recovery after treatment completion 2.
- Periodic attempts at tapering are justified, and repeated relapses may indicate the need for life-long treatment 3.
- Continued low-dose prednisone at daily doses of 10-15 mg is helpful in preventing relapses and further progression of disease 3.
- When irreversible changes are present, especially in the presence of chronic fibrotic disease, changing goals of treatment to provide optimal supportive care may represent better management than having unrealistic expectations from increased corticosteroid dosage or the addition of other potentially toxic immunosuppressive agents 3.
Factors to Consider for Discontinuation
Several factors should be considered when deciding to discontinue treatment, including:
- Severity of symptoms and organ involvement 4
- Response to treatment and presence of relapses 3
- Potential for organ failure or death 4
- Toxicity associated with long-term treatment 4
Alternative Treatments
Alternative treatments, such as cytotoxic agents, biologic agents, and other anti-inflammatory drugs, may be considered when discontinuing glucocorticoids due to toxicity or lack of response 4.