Nonsteroid treatment options in (pulmonary) sarcoidosis. When to consider and why?

Sarcoidosis requires treatment in 30-50% of cases. According to current guidelines, corticosteroids (CS) are the initial drugs of choice, particularly for patients with major organ involvement or when rapid symptom relief is required. However, CS use is associated with substantial toxicity even at low dose. Here, we discuss the evidence that argues against the traditional CS-centred model of sarcoidosis treatment.

A recent prospective trial of patients with pulmonary sarcoidosis showed that high-dose (40 mg) prednisolone was not superior to a lower dose (20 mg) in improving outcomes or health-related quality of life and was associated with similar adverse effects. In addition, in patients with pulmonary sarcoidosis, initial treatment with methotrexate has been shown to be noninferior to prednisone with regard to the change from baseline to week 24 in the percentage of the predicted forced vital capacity (FVC).

The appreciation of CS adverse effects coupled with the observation that methotrexate is as effective as prednisone as initial treatment in pulmonary sarcoidosis supports a paradigm shift in the treatment of pulmonary sarcoidosis that moves away from CS. Differences in the side-effect profile between methotrexate and prednisone may inform shared decision making by providers and patients about the appropriate treatment approach.