Slides on the current management of pulmonary sarcoidosis

1. Management of Pulmonary
Sarcoidosis
Raj B Singh
RRRR 2020
SRMC
15 Feb 2020

2. Treatment of Pulmonary
Sarcoidosis
 Wait and watch
 First line
 Corticosteroids
 Second line
 Methotrexate
 Azathioprine
 Mycophenolate
 Leflunomide
 Third line
 Cyclophosphamide

3. Treatment of Pulmonary
Sarcoidosis – contd….
Anti-iTNFα agents
 Thalidomide and Lenalidomide
 Pentoxifylline
 Roflumilast
 Infliximab, Golimumab, Adalimumab
Nicotine

4. Chest 2003: 124(1);177-185

5. Stats
 90% of Sarcoidosis affects lungs and intrathoracic
lymph nodes
 80% of patients with Stage 1 disease show
regression; 5% develop respiratory impairment over
10 years
 33% show regression in Stages iii and iv
 33% of patients with pulmonary sarcoidosis require
treatment with steroids

6. Indications for treatment
 Symptomatic decline in lung function from baseline
(usually FVC 10-15%)
 Decline of >20% from baseline of DLCO
 FVC <70% of predicted value at presentation and/or
DLCO <60%

7. Algorithm for Rx of Sarcoidosis

8. Sweden
Korea
USA

9. • 230 cases of histologically proven sarcoidosis
• 18 had co-existing TB ie. Features of TB and
Sarcoid found at same time
• 16 had TB following Sarcoid; among these TB
bacilli found in 5

10. Molecular evidence for the role of mycobacteria in
sarcoidosis. A meta-analysis
Gupta D, Agarwal R et al
Prevalence of Mycobacterial DNA in Sarcoidosis 25.6% (Control 9.6%)

11. TB and Sarcoidosis
 Sarcoidosis can precede or follow TB or co-exist
 Infection with M Tuberculosis not uncommon in
patients with Sarcoid; can be activated by treatment
with steroids
 Caseating granuloma alone is not enough to diagnose
TB
 Tuberculous Sarcoidosis?

12. TB and Sarcoidosis
 Sometimes difficult to exclude TB as the sole disease or
co-existing with Sarcoid
 Concomitant ATT with steroids will have to be
considered with caution
 If in doubt, start with ATT
 Vigilant follow up essential for patients on steroids
 TB can be activated even after the discontinuation of
steroids
 Steroid dose need not be reduced in patients with
concomitant TB

13. Sarcoidosis and Asthma
 May co-exist
 Airflow obstruction in PFT may be found in
Sarcoidosis alone; sometimes even showing
reversibility
 Inhaled steroids can be used along with oral
 Smokers less likely to develop Sarcoidosis

16. Sarcoidosis - prognosis
Table taken from MEDSCAPE June 2019

17. Sarcoidosis - survival

18. Lung transplantation
 To be considered before it is too late
 Not only stage of disease but also response to
treatment
 Sarcoidosis may develop also in the transplanted lung

19. Summary
 Sarcoidosis mostly benign; can spontaneously
regress
 Oral corticosteroids the mainstay of treatment
 33% with pulmonary sarcoidosis need treatment
 TB may co-exist or complicate; empirical ATT rarely
needed
 Progressive sarcoidosis not so benign