Am Fam Physician. 2002 Sep 1;66(5):872.
Sarcoidosis is a common disorder that may involve the lungs and lead to pulmonary fibrosis. Corticosteroids (oral or inhaled) are often used to decrease symptoms and minimize long-term effects of this disease. However, no guidelines address when to start corticosteroid therapy, how much of these agents to use, or how long to use them. Paramothayan and Jones reviewed the literature for randomized controlled trials addressing these questions.
A literature search yielded eight articles. Some studies compared patients receiving oral corticosteroids with a control group; others compared patients receiving inhaled corticosteroids with a control group. Patients in these trials were given a variety of corticosteroids: methylprednisolone (4 to 32 mg), prednisone (20 to 40 mg), and prednisolone (10 to 20 mg). Combining the results of the studies of oral corticosteroids, a significant improvement was found in the chest radiographs of patients who received corticosteroids compared with those who did not (odds ratio: 2.54,95 percent confidence interval, 1.69 to 3.81). Patients in the control group had more deterioration on chest radiographs than those who received corticosteroids.
In studies that were assigned a global score (based on symptoms, radiographic changes, and lung function), patients who took corticosteroids for three months had improvement in the global score compared with those who did not. When various radiographic stages were analyzed, patients with stage 1 disease did not achieve this improvement, although those with stages 2 and 3 disease did.
Data concerning those who received inhaled corticosteroids after having previously taken oral corticosteroids were difficult to analyze. One study showed no significant improvement in symptoms or lung function but did show improvement in overall perception of health. In another study, chest radiographs improved in patients with stage 2 disease who took inhaled steroids after taking oral steroids. In patients who had not previously received oral corticosteroids, treatment with inhaled budesonide for six months was not associated with any improvement in inspiratory vital capacity or forced expiratory volume in 1 second (FEV1).
At the end of variable follow-up periods, no statistically significant differences were seen in patients who continued to take corticosteroids and those who did not. Patients who had shown improvement in symptoms, radio-graphic findings, or lung function at the end of the treatment phase did not appear to maintain this improvement.
The authors conclude that evidence regarding treatment of sarcoidosis with corticosteroids is limited. Radiographic findings in patients with stage 2 or 3 disease improved after oral corticosteroid use, but it is not clear whether corticosteroids have a disease-modifying effect. The authors recommend that corticosteroids be used only in patients who have a clear need for them as determined by careful clinical assessment with monitoring of chest radiographs and lung function. Once begun, corticosteroids should be tapered and discontinued after six to 24 months of use. The authors acknowledge that the available evidence does not allow for absolute conclusions about the use of inhaled corticosteroids in patients with sarcoidosis.
Paramothayan S, Jones PW. Corticosteroid therapy in pulmonary sarcoidosis. A systematic review. JAMA. March 13, 2002;287:1301–7.
Copyright © 2002 by the American Academy of Family Physicians.
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