What type of inhaler is prescribed for sarcoidosis affecting the lungs?

Inhaler Therapy for Pulmonary Sarcoidosis

Inhaled corticosteroids should not be routinely prescribed for the treatment of chronic cough in pulmonary sarcoidosis. 1

First-Line Treatment for Pulmonary Sarcoidosis

• Oral glucocorticoids are the first-line therapy for symptomatic pulmonary sarcoidosis (with symptoms like cough and dyspnea), typically starting with prednisone 20-40 mg daily for 2-6 weeks 1, 2
• Oral steroids can be tapered over 6-18 months if symptoms, pulmonary function tests, and radiographic findings improve 2, 3
• Prolonged prednisone may be required to stabilize disease in some patients 2

Role of Inhaled Corticosteroids in Sarcoidosis

• The CHEST guidelines specifically recommend against routine use of inhaled corticosteroids for chronic cough in pulmonary sarcoidosis (Grade 2C recommendation) 1
• Limited evidence exists for the efficacy of inhaled corticosteroids in pulmonary sarcoidosis 4
• Inhaled corticosteroids may be considered in specific situations:
  • For symptomatic relief of cough (though not routinely recommended) 1
  • For asthma-like symptoms in patients with sarcoidosis 1
  • Should be discontinued if ineffective or if toxicities develop 1

Second and Third-Line Treatments

• For patients requiring prolonged prednisone ≥10 mg/day or experiencing adverse effects from glucocorticoids, consider: 2, 3
  • Second-line: Immunosuppressive agents such as methotrexate and azathioprine 1, 2
  • Third-line: Anti-TNF medications such as infliximab 1
• Methotrexate has been shown to be steroid-sparing, though it may not significantly improve FVC 1
• Infliximab has demonstrated improvement in FVC in phase III randomized trials for chronic respiratory symptoms 1

Management of Cough in Sarcoidosis

• Before attributing cough solely to sarcoidosis, exclude other common causes such as upper airway cough syndrome and gastroesophageal reflux disease 1
• For intractable cough that persists despite standard treatment:
  • Consider thalidomide in selected cases with careful monitoring for adverse effects 5
  • Proton pump inhibitors are not recommended for cough in sarcoidosis patients with negative workup for acid reflux 1

Monitoring and Follow-up

• Regular monitoring of symptoms, pulmonary function tests, and radiographic findings is essential 2, 3
• Assess for development of complications such as pulmonary fibrosis or pulmonary hypertension, which can significantly impact mortality 2, 3
• Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving prolonged corticosteroid therapy 1

Special Considerations

• Relapse rates in sarcoidosis range from 13% to 75% depending on disease stage, organ involvement, and other factors 2
• Up to 40% of pulmonary sarcoidosis patients may progress to stage IV disease with lung parenchymal fibrosis 2
• Patients with stage IV fibrocystic sarcoidosis with significant pulmonary impairment have the highest mortality risk (>40% at 5 years) 2

While inhaled corticosteroids may provide symptomatic relief for some patients with cough or asthma-like symptoms, the evidence does not support their routine use in pulmonary sarcoidosis. Oral corticosteroids remain the cornerstone of therapy, with immunosuppressants and biologics reserved for refractory cases.