Treatment

The mainstay of sarcoidosis treatment is corticosteroid therapy. Mild disease, such as cutaneous lesions, anterior uveitis, sinonasal disease, and cough, can be treated topically by direct application of a corticosteroid to the affected site (e.g., application of cream or drops, or inhaled form of corticosteroid). Additionally, local injections of corticosteroids can be used for the treatment of recalcitrant skin lesions. In addition to posterior segment ocular inflammation, systemic corticosteroid therapy may be warranted for severe sinus disease, progressive pulmonary disease, involvement of the heart or nervous system, and clinically significant hypercalcemia (30,33). The optimal dose, course, and duration of corticosteroid therapy have not been studied in randomized controlled trials. Dose and duration are individualized according to the clinical situation. For example, the initial treatment of pulmonary disease is 20 to 40 mg/day of prednisone; whereas, higher doses (e.g., 1 mg/kg/ day of prednisone or its equivalent) may be used for the treatment of neurologic, cardiac, and progressive ocular disease. With initial improvement, the corticosteroid dose is tapered to 5 to 10 mg daily or every other day. Treatment is usually given for 9 to 12 months. If a patient fails to respond to corticosteroid therapy in three months, it is unlikely that a longer course will be effective.

Patients with sarcoidosis who fail to improve adequately with corticosteroid therapy or who have significant corticosteroid side effects are candidates for treatment with other immunosuppressive drugs (Table 2). The effectiveness of immunosuppressive drugs has not been established in controlled trials, so the evidence for their efficacy is limited to case reports and small case series. Methotrexate is among the most widely used of these immunosuppressive agents. Some studies also suggest that TNF antagonists, etanercept, infliximab, and adalimumab provide clinical benefits for selected patients with treatment-refractory disease.

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