From the Guidelines
The initial treatment for sarcoidosis often involves oral corticosteroids as the first-line therapy, typically prednisone starting at 20-40 mg daily for 3-6 months, as recommended by the Delphi consensus recommendations 1. For symptomatic patients or those with significant organ involvement, this approach is supported by the European Respiratory Society (ERS) clinical practice guidelines, which suggest the use of glucocorticoids to improve and/or preserve forced vital capacity (FVC) and quality of life (QoL) 1. The treatment algorithm proposed by the Delphi consensus recommendations highlights the importance of considering disease phenotype and progression when making treatment decisions, with options for adding antimetabolites, such as methotrexate, or biologics, such as infliximab, in cases of disease progression or toxicity 1. Key considerations in treatment decisions include disease severity, organ involvement, and individual patient factors, with the goal of controlling inflammation, preventing organ damage, and managing symptoms while minimizing medication side effects 1. Regular monitoring of lung function, eye examinations, and other affected organ systems is essential during treatment to assess response and adjust therapy as needed, as emphasized by the ERS guidelines 1. In cases where patients cannot tolerate or respond inadequately to corticosteroids, second-line options, such as methotrexate or hydroxychloroquine, may be considered, as outlined in the ERS guidelines 1. Ultimately, treatment decisions should prioritize minimizing morbidity, mortality, and improving quality of life, as highlighted by the ERS guidelines 1.
From the FDA Drug Label
Symptomatic sarcoidosis The initial treatment for sarcoidosis is prednisone (PO), as it is indicated for symptomatic sarcoidosis 2.
- The drug label does not provide further information on the specific dosage or treatment duration.
- Prednisone is used as an initial treatment to manage symptoms of sarcoidosis.
From the Research
Initial Treatment for Sarcoidosis
The initial treatment for sarcoidosis typically involves the use of glucocorticosteroids, which are considered the "drugs of choice" for this condition 3.
- The recommended initial dose of prednisolone is 30-60 mg/day or its equivalent 3.
- Daily therapy with oral steroids is the most widely applied method of administration 3.
- Alternate day therapy can be used during the maintenance phase 3.
- Inhaled steroids can also be tried during the maintenance phase for treatment of pulmonary sarcoidosis 3.
Alternative Treatment Options
Other drugs that may be effective in sarcoidosis and have a steroid-sparing capacity include:
- Methotrexate 3, 4
- Azathioprine 3, 4
- Chlorambucil 3
- Cyclophosphamide 3
- Chloroquine can be used for chronic skin lesions 3
- Potassium para-aminobenzoate may soften fibrotic lesions and keloids 3
Treatment Duration and Monitoring
The duration of treatment varies with the clinical situation, ranging from 6 to 18 months to lifetime 3.
- Continuing signs of disease activity and functional impairment require continuing treatment 3.
- Symptomatic patients with stage II-III pulmonary sarcoidosis, and many extrapulmonary manifestations of the disease, must be adequately treated 3.
- Symptom-free patients with deteriorating lung function and/or biochemical signs of disease activity also require treatment 3.
Cardiac Sarcoidosis Treatment
For cardiac sarcoidosis, first-line therapy is usually with prednisone, based on clinician experience, expert opinion, and small observational cohorts 5.
- A low-dose prednisone/methotrexate combination may have non-inferior efficacy to standard-dose prednisone and result in significantly better quality of life 5.
Corticosteroid Therapy Phases
Corticosteroid therapy for pulmonary sarcoidosis involves six phases:
- Initial high doses to control inflammation
- Tapering to a maintenance dose
- Continuing to receive the maintenance dose
- Tapering off corticosteroid therapy
- Observation for relapse
- Treatment if relapse occurs 6
Comparison of Treatment Options
A randomized trial (SARCORT trial) compared high-dose (40 mg) versus low-dose (20 mg) prednisolone for treating sarcoidosis and found that high-dose prednisolone was not superior to a lower dose in improving outcomes or health-related quality of life 7.