DEC 20, 2018 09:42 AM PST

Common Medication Regimens for Sarcoidosis

WRITTEN BY: Dena Aruta

Sarcoidosis is a granulomatous disease that most commonly affects the lungs, but any organ system can be involved. It is most often found and diagnosed in individuals before the age of 50 and can affect any race or ethnic group. Its symptomology can range from asymptomatic to severe, life-threatening progressive disease. Due to this wide variation in the presentation of sarcoidosis, there are no standardized treatment regimens; however, corticosteroids are usually the first-line treatment choice. The risks and side effects of corticosteroids are often significant and may cause more harm when using this treatment option. When treatment is required over a long period of time, steroid-sparing agents such as methotrexate, anti-TNF medications, and antimalarials can be initiated.

            Sarcoidosis is a complex disease that often affects multi-organ systems requiring an interdisciplinary approach for treatment to obtain the best patient outcomes. This includes physicians from specialties such as pulmonology, rheumatology, dermatology, neurology, and cardiology. The goal in the treatment of sarcoidosis is to reduce symptoms and damage to the organs involved as well as to improve the quality of life of the patient. While there is a consensus that corticosteroids are the treatment of choice, patients who take these medications have a poorer quality of life than those who do not. Because of this, other medication regimens need to be considered.

            When there is an indication for treatment for sarcoidosis, corticosteroids are considered the drug of choice because of the greatest likelihood of efficacy, and because they work more quickly than other agents. According to Judson (2014), the American Thoracic Society, the European Respiratory Society, and the World Association for Sarcoidosis and Other Granulomatous Disorders (WASOG) recommend 20-40 mg of prednisone daily for the initial treatment of sarcoidosis while utilizing the least dosage that is effective. Acute pulmonary exacerbations have been found to respond effectively to 20 mg of prednisone for an average of three weeks with the return of pulmonary function tests (PFT) and symptoms back to the patient’s baseline. Because sarcoidosis is usually responsive to corticosteroids, it is acceptable to begin these medications when initially treating the sarcoidosis patient.

            Korsten, Mirsaeidi, and Sweiss (2013) state that, because there is well-established knowledge of side effects that are associated with prolonged corticosteroid use, these medications can be less than desirable for disease management. Non-steroidal medications, also known as disease-modifying anti-sarcoid drugs (DMASDs), provide an alternative treatment with complex cases of sarcoidosis. Methotrexate is the most widely researched drug for pulmonary and extra-pulmonary sarcoidosis, and it has been shown to be effective in ocular, cutaneous, neurologic, and musculoskeletal sarcoidosis. Antimalarials such as hydroxychloroquine and TNF-α antagonists including infliximab are also useful as second and third-line treatment options.

            As with any medication regimen, the risks and benefits have to be considered along with close monitoring of efficacy and adverse effects when utilizing any type of drug therapy. Because of frequent multi-system involvement, the collaboration of an interdisciplinary team is necessary to promote the best possible patient outcomes. The interdisciplinary approach involves multiple specialties and creates a group of physicians that come together as a whole to treat the patient. There are both advantages and disadvantages to this approach; however, when utilizing this as a treatment option, the patient outcomes are improved due to the input of experts in differing fields. One disadvantage of this approach is that there can be disagreement among the physicians involved in decisions concerning the course of recommended treatment that will provide improved patient outcomes.

            According to Mana et al. (2017), a multidisciplinary approach with long-term follow-up by specialized teams in sarcoidosis is a valuable treatment option. Since the first recognition of the disease in the 19th century, knowledge has increased across multiple fields including etiology, genetics, epidemiology, and pathology and also clinical issues that include diagnosis, treatment, and prognosis. The daily care of these individuals is performed through close collaboration of a multidisciplinary team involving many specialties. The goal of this approach is to have discussions between the treatment team members according to the type of organ involvement to recommend optimized treatment options. Because of the risks of corticosteroid use in patients with chronic, progressive sarcoidosis, a variety of other medication options needs to be considered while weighing the advantages and disadvantages of each. Other drug choices may not have the same side effect profile that corticosteroids have, however, they are not without risks, which can include severe and life-threatening infections due to immune suppression.

Due to data from numerous research studies, it is recommended that, when initiating treatment for both pulmonary and extra-pulmonary sarcoidosis based on the organ involvement and symptoms, the number of affected organs, as well as the presence of inflammatory markers, must also be assessed to rule out co-occurring autoimmune disorders or other comorbidities that may be present. This is where collaboration and corroboration between multi-disciplinary teams are crucial in determining how to best handle an individual’s treatment of their sarcoidosis with the primary goals of improving outcomes, reducing symptoms, and improving their quality of life.

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