Knowing when to use steroids, immunosuppressants or biologics for the treatment of sarcoidosis

ABSTRACT

Introduction: Care of patients with sarcoidosis requires familiarity with its natural history as well as of various immunosuppressants employed in its treatment. We would like to share our approach to management based on our experience and understanding of the relevant literature.

Areas covered: Asymptomatic patients with pulmonary sarcoidosis ought to be managed conservatively. Systemic sarcoidosis with burdensome symptoms usually responds to corticosteroids, but one needs to consider the risk of long-term steroid toxicity as well as relapse. Rapidly tapering steroids can decrease cumulative exposure without compromising efficacy. Steroid-sparing anti-sarcoidosis (SSAS) agents take longer to act and are associated with unique but mostly reversible toxicities. Used judiciously and with careful monitoring, they effectively suppress granulomatous inflammation. Patients intolerant of or failing to improve with a particular drug can be switched to another, and occasionally combination therapy with two SSAS agents might prove effective. A small proportion of patients are refractory, but often achieve control and sometimes remission with stepping up to biologic therapy.

Expert opinion: Adopting a strategy of early SSAS therapy ought to effectively control sarcoidosis and avoid harm from prolonged corticosteroid dosing.

KEYWORDS:

• Steroid sparing
• immunosuppressant
• sarcoidosis

Article highlights

• The decision to treat a newly diagnosed case of sarcoidosis involves considering the natural history of the disease and determining that the risk of side effects and toxicity from treatment does not outweigh potential benefit.

• We recommend the use of steroid-sparing anti-sarcoidosis agents in combination with systemic corticosteroids as a first-line treatment strategy.

• Potential toxicities of these agents should be considered and drug choice tailored to the comorbidities of the patient as suggested in Table 3.  They can be prescribed in combination to optimize efficacy.

• Biologic agents are available to use upfront for fulminant presentations, critical organ involvement or in case other drugs prove ineffective.

Declaration of interest

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they are a member of the ERS Task Force which develops new treatment recommendations for Sarcoidosis. Peer reviewers on this manuscript have no other relevant affiliations to disclose.

Additional information

Funding

This paper was not funded.