Rheumatologic Manifestations of Sarcoidosis

Nadera J. Sweiss, M.D.; Karen Patterson, M.D.; Ray Sawaqed, M.D.; Umair Jabbar; Peter Korsten, M.D.; Kyle Hogarth, M.D.; Robert Wollman, M.D.; Joe G.N. Garcia, M.D.; Timothy B. Niewold, M.D.; Robert P. Baughman, M.D.

Disclosures

Semin Respir Crit Care Med. 2010;31(4):463-473. 

In This Article

Approach for Management of Sarcoid Arthritis

There are no U.S. Food and Drug Administration (FDA)-approved therapies for sarcoidosis in general, or for any of its manifestations in particular. Our proposed approach for the management of patients with sarcoid arthritis is shown in Figure 3. After establishing a diagnosis, first-line therapies include nonsteroidal antiinflammatory drugs (NSAIDs), local or low-dose systemic steroids, or methotrexate. Other agents may be considered depending on the severity of the signs and symptoms as well as the radiographic progression. Periodic disease assessments are required to determine whether the response is adequate. If the response is adequate, we continue treating with the first-line agents that are working well. Nonresponders may be tried on a higher dose of systemic steroids, or advanced directly to second-line treatments. Second-line therapies include methotrexate if patients are methotrexate-naïve or, in patients previously tried unsuccessfully on methotrexate or intolerant to the drug, biologic therapies, an alternate disease-modifying antirheumatic drug (DMARD) monotherapy, or a combination of these treatments. Methotrexate has been used as an alternative to corticosteroids in the treatment of chronic and refractory sarcoidosis for years. It has proven to effectively manage the disease in many patients.[63] However, no studies have looked at its role in sarcoid arthritis in particular. Its benefits to patients with rheumatoid arthritis have been well documented over the past 40 years, and it is therefore considered a first-line therapy in that disease setting.[64] Despite the clinical utility of DMARDs, randomized studies for some (e.g., sulfasalazine, hydroxychloroquine, leflunamide, azathioprine, and minocycline) are lacking in the sarcoidosis setting. Even in the context of rheumatoid arthritis, the evidence for sulfasalazine and minocycline benefit comes from case reports, observational studies, and small nonrandomized studies.[65] Keeping in mind that there is a lack of large, randomized trials evaluating the utility of DMARDs in sarcoidosis, our suggested treatment algorithm proposes these agents in the first-line setting for some patients, based on our own clinical experience. Of note, clinicians should monitor patients' progress and periodically check for toxicities (Table 1). An approach for toxicity monitoring prior to initiating therapy or increasing dosages of DMARDs was recently proposed by the American College of Rheumatology based on the rheumatoid arthritis literature. As shown in Table 1, baseline evaluations of patients receiving DMARDs should include complete blood count (CBC), liver transaminase, creatinine, hepatitis B and C testing, and ophthalmologic evaluations.[65] For patients failing second-line treatment, a different biologic agent, a trial of high-dose systemic steroids, or enrollment in a clinical trial should be considered.

Figure 3.

Diagnosis and management of patients with sarcoid arthritis. MTX, methotrexate; SZA, sulfasalazine; DMARD, disease modifying antirheumatic drugs (hydroxychloroquine, MTX, SZA, minocycline, azathioprine, leflunomide); NSAIDs, nonsteroidal antiinflammatory drugs; PT/OT, physical therapy/occupational therapy; biologics, anti-TNF agents (Infliximab, adalimumab), co-stimulatory agents (abatacept); B-cell depleting agents (rituximab); combination therapy, multiple DMARDs and/or a DMARD plus a biologic. *Low-dose steroids, <10 to 20 mg prednisone daily **Suboptimal response to MTX, intolerance to drug, lack of satisfactory efficacy on dosage up to 25 mg/week, or a contraindication to medication use. ***DMARD failure, progressive disease or drug intolerance. ****Methylprednisone preferred over prednisone if prednisone has been used prior.

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