What is the role of corticosteroids (steroids) in the treatment of sarcoidosis?

From the Guidelines

Corticosteroids are the primary treatment for sarcoidosis when therapy is needed, with prednisone being the most commonly prescribed medication, as recommended by the European Respiratory Journal in 2021 1.

Treatment Approach

The treatment approach for sarcoidosis involves the use of corticosteroids to suppress granulomatous inflammation and improve symptoms.

• For symptomatic sarcoidosis requiring treatment, the typical starting dose is 20-40 mg of prednisone daily, which is usually maintained for 1-3 months before gradually tapering down.
• The tapering schedule generally involves reducing the dose by 5-10 mg every 2-4 weeks, with a goal of reaching the lowest effective maintenance dose (often 5-10 mg daily) or complete discontinuation if possible.
• Total treatment duration typically ranges from 6-24 months depending on disease severity and response.

Alternative Options and Steroid-Sparing Agents

Alternative corticosteroid options include methylprednisolone or dexamethasone for patients who cannot tolerate prednisone.

• Steroid-sparing agents like methotrexate, azathioprine, or hydroxychloroquine may be added for patients requiring long-term therapy or experiencing significant steroid side effects.
• The use of infliximab, a biologic agent, may be considered for patients with advanced disease or those who have not responded to other treatments, as suggested by the European Respiratory Review in 2020 1.

Monitoring and Prevention of Complications

Regular monitoring for steroid-related complications such as hyperglycemia, hypertension, osteoporosis, and adrenal suppression is essential, and calcium and vitamin D supplementation should be considered for bone protection during treatment.

• The European Respiratory Journal recommends the use of glucocorticoids for patients with pulmonary sarcoidosis who are at higher risk of future mortality or permanent disability from sarcoidosis, as well as for patients with cutaneous sarcoidosis who have cosmetically important active skin lesions that cannot be controlled by local treatment 1.
• The treatment approach should be individualized based on the patient's specific needs and disease severity, with the goal of improving symptoms, preserving lung function, and maintaining quality of life.

From the Research

Role of Corticosteroids in Sarcoidosis Treatment

• Corticosteroids, such as prednisone, are the mainstay of treatment for sarcoidosis 2, 3, 4, 5, 6
• They are effective in reducing inflammation and preventing organ damage, but long-term use can be associated with toxicity 2
• The initial dose of prednisone is typically 30-60 mg/day or its equivalent, with a gradual tapering of the dose over time 4, 6
• Corticosteroids can be given orally, intravenously, or inhaled, depending on the severity and location of the disease 4, 5

Indications for Corticosteroid Treatment

• Symptomatic patients with stage II-III pulmonary sarcoidosis, and many extrapulmonary manifestations of the disease, must be adequately treated 4
• Symptom-free patients with deteriorating lung function and/or biochemical signs of disease activity also require treatment 4
• Corticosteroids are not indicated for pulmonary stage I disease (hilar lymphadenopathy) with or without erythema nodosum, unless there are troublesome persistent chest symptoms or arthralgia, oedema, and pain of the legs 4

Alternative Treatments and Steroid-Sparing Agents

• Methotrexate, azathioprine, and other immunosuppressive agents can be used as steroid-sparing agents or in patients who do not respond to corticosteroids 2, 3, 5, 6
• Hydroxychloroquine and infliximab may be useful in some patients, particularly those with severe or refractory disease 5, 6
• The choice of alternative treatment depends on the severity and location of the disease, as well as the patient's response to corticosteroids and other medications 6