Should a patient with sarcoidosis (a systemic granulomatous disease) who experiences desaturation to an oxygen saturation level of 89% during a six-minute walk test (6MWT) receive treatment?

From the Guidelines

Treatment for Sarcoidosis Patient with Desaturation

The patient with sarcoidosis who experiences desaturation to an oxygen saturation level of 89% during a six-minute walk test (6MWT) should receive treatment.

• The desaturation during exercise is a clinical manifestation that suggests pulmonary hypertension (PH) or other cardiac and pulmonary issues associated with sarcoidosis, as indicated in the American Thoracic Society clinical practice guideline 1.
• According to the guideline, patients with suspected PH should undergo initial testing with transthoracic echocardiogram (TTE) 1.
• The European Respiratory Journal also suggests that patients with clinically significant pulmonary sarcoidosis, including those with reduced 6-minute walk distance, should be considered for treatment to achieve disease regression or stabilization 1.
• Treatment goals for sarcoidosis patients include achieving disease regression or short-term disease stabilization with higher dose glucocorticoid treatment and identifying the minimum longer-term glucocorticoid dose required for stabilization of sarcoidosis 1.
• Institution of treatment usually relies on both structural and pulmonary function changes, and lung involvement is not an indication for treatment, but extensive interstitial lung disease (ILD) or pulmonary fibrosis confers an increased long-term risk of respiratory failure 1.
• Given the patient's desaturation during the 6MWT, it is essential to assess for potential PH or other complications and consider treatment to prevent further deterioration and improve quality of life.

From the Research

Sarcoidosis and Six-Minute Walk Test

• The six-minute walk test (6MWT) is a useful tool in assessing the functional status of sarcoidosis patients 2.
• A reduced 6-minute walk distance (6MWD) has been associated with increased mortality in sarcoidosis-associated pulmonary hypertension (SAPH) 3.
• Oxygen desaturation during the 6MWT can be a predictor of maximal exercise-induced gas exchange abnormalities in sarcoidosis 4.

Treatment Considerations

• Sarcoidosis is a systemic disease that requires a multidisciplinary approach for best outcomes, and treatment should be considered on a case-by-case basis 5.
• The decision to start treatment should be based on the assessment of organ involvement and impairment, as well as the patient's overall health status 5.
• Patients with cardiac sarcoidosis may benefit from treatment, as it can improve exercise tolerance and reduce desaturation during the 6MWT 6.

Oxygen Saturation Levels

• A study found that patients with SAPH who had a 6MWD < 300 m had a higher chance of dying or undergoing transplantation compared to those with a 6MWD > 300 m, but no associations with outcome were observed with oxygen saturation < 88% at the end of the 6MWT 3.
• Another study found that normal diffusing capacity of the lung for carbon monoxide (DLco) was a good predictor of the absence of severe desaturation during the 6MWT and at peak exercise during cardiopulmonary exercise test (CPET) 4.
• In the context of the patient's desaturation to an oxygen saturation level of 89% during the 6MWT, treatment may be considered based on the overall assessment of the patient's health status and organ involvement, but the oxygen saturation level alone may not be a definitive indicator of the need for treatment 2, 3, 4.