Approach to the initial treatment of pulmonary sarcoidosis in adults

* In our experience, patients with bronchitic symptoms (cough or wheezing) are most likely to benefit from a trial of inhaled glucocorticoid therapy.

¶ In patients with mild disease who remain clinically stable after a trial of therapy, a risk-benefit discussion regarding escalation or discontinuation of therapy is appropriate based on severity of symptoms and tolerance of treatment.

Δ A favorable response to therapy is defined by 1) a decrease in symptoms, especially dyspnea, cough, hemoptysis, chest pain, or fatigue; 2) a reduction in or clearing of radiographic abnormalities; or 3) physiologic improvements in spirometry, diffusing capacity, or exercise oximetry. Stabilization of radiographic and lung function abnormalities for prolonged periods of time can also be considered a favorable response in those with previously progressive disease.

◊ Any of the following indicate pulmonary sarcoidosis progression: 1) progressive pulmonary symptoms leading to worsening impairment in quality of life, 2) a significant decline in lung function (spirometry, lung volumes, or diffusing capacity), 3) a decrease in oxygen saturation on pulse oximetry at rest or with exercise (indicating worsening gas exchange), or 4) worsening of interstitial opacities.

§ A minority of patients with severe or progressive pulmonary sarcoidosis are unable to tolerate glucocorticoids. For these patients, a nonbiologic immunosuppressant, typically methotrexate, is preferred to achieve disease control.