A clinical approach to the use of methotrexate for sarcoidosis

The management of patients with sarcoidosis has been the subject of many papers in this1 and other journals.2-5 The large number of papers are, in part, because of the difficulty in defining who should be treated for this disease and with what. The most commonly used pharmaceutical class for sarcoidosis has been corticosteroids, both topically and systemically.6 The use of systemic steroids for sarcoidosis was the subject of a trial by the British Thoracic Society1 which concluded that there were some patients who required no treatment and some who would need immediate treatment because of the severity of the disease. In between was a group of patients with persistent disease who appeared to benefit from treatment with corticosteroids. One of the points made was that some patients needed treatment for long periods of time.

The term “chronic sarcoidosis” has been used by Dr Geraint James to describe patients with disease for more than two years.7He noted that some features of sarcoidosis such as lupus pernio and neurological disease were associated with a low rate of remission, while other features such as erythema nodosum were associated with a high resolution rate by two years. Several other manifestations of the disease have been associated with chronic disease: bone cysts, cor pulmonale, pulmonary fibrosis,8 and nephrolithiasis.9 Based on the type and duration of symptoms one can classify patients as acute or chronic.10A third group is also evident—namely, those who are refractory to corticosteroid therapy. This includes some neurosarcoidosis patients, patients who develop organ failure, and those who die despite corticosteroid treatment.11 12 Treatment for sarcoidosis is often dependent on the patient’s own manifestation. A patient with anterior uveitis may be a candidate for topical steroids alone, but a patient with neurological disease …