Prednisolone is not for all patients. It is relatively contraindicated for very common conditions—obesity, diabetes, prediabetes and low bone density, Dr. Dhooria points out. Some prediabetics on prednisolone will develop permanent diabetes, and osteopenia patients could develop osteoporosis. “Both SARCORT and the PREDMETH trial offer a lot of good evidence, so the physicians who are treating sarcoidosis can really reduce the steroid dose or take it away completely to avoid all these adverse effects,” he says.
The choice between the two drugs “may come down to faster relief with higher risk of long-term side effects [with steroids], or slower relief with fewer long-term side effects [with methotrexate],” adds Dr. Wijsenbeek-
Lourens. She notes, however, that her trial’s patients reported meaningful improvement in lung symptoms after four weeks. “Taken together in the context of SARCORT, [findings from both trials suggest] if prednisone is chosen, it should always be at the lowest effective dose. For most patients, 20 mg/day is sufficient as a starting point.”
“An alternative option could be to use combination therapy and taper prednisone quickly to minimize the risk of side effects, though we have not studied this approach,” she adds.
Rheumatologists’ Role
Both pulmonologists note that rheumatologists play an important role in pulmonary sarcoidosis treatment as part of interdisciplinary teams. Because sarcoidosis can affect any organ, close collaboration between specialists is essential, Dr. Wijsenbeek-Lourens says. At her hospital, a multidisciplinary sarcoidosis team meets weekly and includes a rheumatologist, immunologist, cardiologist and neurologist.
“We believe it is important for each patient to have one coordinator, depending on the major organ involvement,” says Dr. Wijsenbeek-Lourens. Because “the lungs are often involved, this role is frequently performed by the pulmonologist.”
Dr. Dhooria also calls for multidisciplinary patient management. Two decades ago in India, sarcoidosis was mainly treated by rheumatologists; today, pulmonologists are more likely to lead treatment teams due to frequent lung involvement and the increasing role of bronchoscopic diagnosis.
In contrast, pulmonologists have long dominated sarcoidosis treatment in the U.S., notes rheumatologist Arthur Yee, MD, PhD, director of the Hospital for Special Surgery Sarcoidosis Collaborative, New York. That’s because, in part, U.S. medical training usually covers sarcoidosis in units on lung disease, so most U.S. physicians—including rheumatologists—tend to think of it as a lung disease. In contrast to pulmonologists, rheumatologists “deal with diseases that affect many different organ systems, sometimes simultaneously, sometimes asynchronously,” he says. “We are familiar with that kind of illness, but we have never had a foothold in the sarcoid world [in the U.S.], even though we probably know the medicines better than most other specialists.”
