What is the treatment for sarcoidosis?

From the Guidelines

Sarcoidosis treatment should be individualized based on the severity and organs affected, with corticosteroids like prednisone being the first-line therapy for symptomatic cases, starting at 20-40mg daily for 1-3 months, then gradually tapering to the lowest effective dose, as recommended by the European Respiratory Journal in 2021 1.

Treatment Approach

The treatment approach for sarcoidosis depends on the severity and organs affected, with mild cases often requiring no treatment. For symptomatic cases, the goal is to reduce inflammation, prevent organ damage, and improve quality of life.

• Corticosteroids like prednisone are the first-line therapy, typically starting at 20-40mg daily for 1-3 months, then gradually tapering to the lowest effective dose.
• For those who cannot tolerate steroids or need steroid-sparing options, immunosuppressants such as methotrexate (10-25mg weekly), azathioprine (50-200mg daily), or hydroxychloroquine (200-400mg daily) may be used, as suggested by the Delphi consensus recommendations in 2020 1.
• TNF inhibitors like infliximab (3-5mg/kg IV every 4-8 weeks) are reserved for refractory cases, as recommended by the European Respiratory Journal in 2021 1.

Organ-Specific Treatment

• Pulmonary sarcoidosis may benefit from inhaled corticosteroids like fluticasone or budesonide.
• Cutaneous sarcoidosis may require systemic glucocorticoids, with treatment associated with improvement or remission in up to two-thirds of patients, as reported by the European Respiratory Journal in 2021 1.
• Cardiac sarcoidosis requires prompt treatment with glucocorticoids, with or without other immunosuppressives, to prevent cardiac damage, as recommended by the European Respiratory Journal in 2021 1.

Lifestyle Modifications

• Regular monitoring of organ function, particularly lung function tests and eye examinations, is essential.
• Lifestyle modifications including adequate rest, balanced nutrition, and avoiding respiratory irritants can help manage symptoms.
• Treatment duration varies from months to years depending on disease activity and response, with the goal of achieving disease regression or short-term disease stabilisation, as noted by the European Respiratory Journal in 2021 1.

From the FDA Drug Label

Symptomatic sarcoidosis

• Treatment: Prednisone (PO) is indicated for symptomatic sarcoidosis 2.
• Key point: The drug label does not provide specific treatment guidelines or dosing recommendations for sarcoidosis, only that prednisone is indicated for symptomatic cases.

From the Research

Treatment Options for Sarcoidosis

• Not all patients with sarcoidosis require treatment, but for those who do, the outcome can be considered in three broad groupings: acute, chronic, and refractory 3.
• Corticosteroids remain the initial drug of choice for most patients who require therapy, but several steroid-sparing alternatives have been found effective in treating many aspects of sarcoidosis 3, 4.

First-Line Treatment

• Prednisone is currently recommended as the first-line treatment for pulmonary sarcoidosis, but it is associated with many side effects 5, 6.
• Methotrexate, which is recommended as a second-line treatment, appears to have fewer side effects than prednisone but a slower onset of action 5, 6.
• A recent study found that methotrexate was noninferior to prednisone as first-line treatment for pulmonary sarcoidosis, with regard to the change from baseline to week 24 in the percentage of the predicted forced vital capacity (FVC) 5.

Second-Line and Alternative Treatments

• Cytotoxic agents, such as methotrexate, azathioprine, and leflunomide, have been shown to be effective in treating chronic sarcoidosis 3, 4, 7.
• Biologics, such as infliximab, have been found to be effective in treating refractory sarcoidosis 3, 4.
• Other agents, such as repository corticotropin injection and rituximab, have also been reported to be effective in some cases 4.

Side Effects and Patient Reported Outcomes

• Patient reported side-effects of prednisone and methotrexate in a real-world sarcoidosis population found that methotrexate seems to have fewer and less bothersome side-effects than prednisone 6.
• A study found that significantly more side-effects were reported for prednisone than for methotrexate, 78% versus 49% (p = 0.006) 6.