Pulmonary Sarcoidosis: Long-term Follow-up of the Effects of Steroid Therapy

doi:10.1378/chest.82.1.84

Chest

Volume 82, Issue 1, July 1982, Pages 84-87

https://doi.org/10.1378/chest.82.1.84 Get rights and content

Fifteen years ago we began a prospective study using alternate case treatment with prednisone in patients with pulmonary function abnormalities due to sarcoidosis. Twenty-five patients were divided into treatment and control groups that were similar in sex, age, race, degree of pulmonary dysfunction, and duration of disease. Evaluation included complete spirometric studies, single-breath carbon monoxide diffusion capacity, and arterial blood gases. Follow-up studies at six months, one to two years, and ten to 15 years show no difference between the treated and untreated groups. Improvement or deterioration in pulmonary function of individual patients in the treated group was reflected in the control group, even in those patients with a diffusing capacity and forced vital capacity less than 65 percent of predicted. Data from this long-term study fail to show any benefit of short-term use of steroids in therapy for pulmonary sarcoidosis.

Section snippets

MATERIALS AND METHODS

Initially there were 12 treated and 13 untreated pattients. The criteria used for inclusion of a patient in the treatment protocol were a diffusing capacity less than 80 percent of predicted or an arterial Po₂ less than 80 mm Hg at rest or after exercise. Alternate patients meeting these criteria were treated with prednisone. They were equally matched for age, sex, pulmonary symptoms, and pulmonary function abnormalities.⁸ After ten to 15 years, two patients cannot be located, and two patients

RESULTS

The clinical features of the 22 patients in whom long-term follow-up was obtained are shown in Table 1, including the one patient who died after 12 years but not the patient who died at two years. The treated and untreated patients had similar results in every measurement. The length of follow-up was 11.5 years and 10.8 years in the treated and untreated patients, respectively. Both groups were similar in age, predominantly men, and 60 to 70 percent were black.

The incidence of pulmonary

DISCUSSION

The effectiveness of corticosteroid therapy in pulmonary sarcoidosis has not been established despite its use for more than 20 years. Several studies have not supported the use of corticosteroids.1, 2, 8 Many others, however, continue to advocate their use, even though a prospective controlled study showing their therapeutic benefit has not been done.3, 4, 5, 6, 7 In addition, those who support the use of corticosteroids vary widely in their indications for therapy and in their recommendation

ACKNOWLEDGMENT

The authors express their appreciation to Mr. Donald C. Hudson and Ms. Stephanie Klein for technical assistance and to Mrs. JoAnn Honn for preparing the manuscript.

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The sequence of physiologic changes in pulmonary sarcoidosis: correlation with radiographic stages and response to therapy
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Citation Excerpt :
In many of these trials, the corticosteroid-treated groups generally had more severe disease,1,2,6,7 and therefore, the groups may not have been directly comparable. Others have showed short-term improvement but no long-term difference in radiographic stage, clinical symptoms, or pulmonary function and therefore have not supported the use of long-term corticosteroids.8–11 A recent Cochrane meta-analysis suggested that oral corticosteroids improved chest radiographic findings in sarcoidosis following 6 to 24 months of oral corticosteroid treatment.12
Although corticosteroids are the drug of choice for acute exacerbations of pulmonary sarcoidosis, the dose and duration of therapy is not standardized. We reviewed the short-term treatment outcome (median duration = 21 days) of 36 patients with acute exacerbations of pulmonary sarcoidosis using low-dose corticosteroid therapy (20 mg or less of daily prednisone equivalent). To the best of our knowledge, this is the shortest period of time over which the treatment of pulmonary sarcoidosis with corticosteroids has been assessed.
Patients were identified retrospectively from an institution-approved database. Patient symptoms and spirometry were obtained from chart review. Additional clinical data were obtained from chart and database review.
Follow-up visits occurred a median of 21 days after the date of the exacerbation (mean 25 ± 3 standard error of mean). The average prednisone dose was 19 mg ± 0.4 standard error of mean. Patients had significant improvement in spirometry on this low-dose treatment regimen by the time of their short-term follow-up (forced vital capacity percent predicted improved from 68 to 82 [P < 0.0001] and was not significantly different from baseline; forced expiratory volume in 1 second percent predicted improved from 57 to 72 [P < 0.0001] and was not significantly different from baseline). Pulmonary symptoms also improved.
Treatment of acute exacerbations of pulmonary sarcoidosis with 20 mg prednisone for a median of 21 days improved spirometry back to baseline and improved clinical symptoms. These data suggest that this corticosteroid dose can be safely used initially, and an attempt at tapering can be considered within the first month.
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It is also noteworthy that results ofoptimally designed dose-response studies are lacking, and little isknown about the necessary duration of treatment. Although initial improvements are seen, many controlled clinicalstudies have failed to demonstrate a persisting difference in lungfunction tests and radiographic appearance betweencorticosteroid-treated and untreated patients.1415 Theopinion has therefore often been expressed that corticosteroids do notalter the course of the disease and that treatment should be used onlyfor relief of symptoms.2
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Randomized, double-blind,placebo-controlled, parallel-group study for 18 months. Thereafter,open follow-up without treatment.
Twentypulmonary medicine departments in Finland.
One hundred eighty-nine adult patients, most of them with normal lungfunction, were randomized to treatment. One hundred forty-nine patientswere followed up for 5 years: 79 patients with initial stage I diseaseand 70 patients with stage II disease.
Oralprednisolone for 3 months followed by inhaled budesonide for 15 months(800 μg bid), or placebo tablets followed by placebo inhaler therapy.Thereafter, treatment only on an individual basis in the case ofclinical deterioration.
Yearly follow-upvisits with chest radiographs, lung function tests (FEV₁,FVC), diffusion capacity of the lung for carbon monoxide(Dlco), serum angiotensin-converting enzyme (SACE), andserum and urinary calcium measurements.
Noinitial differences were observed in chest radiographic findingsbetween the active-treatment and placebo-treatment groups, either inpatients with initial stage I or stage II(-III) disease. However, afterthe 5-year follow-up, 18 steroid-treated patients (26%) and 30placebo-treated patients (38%) still had remaining chest radiographicchanges. Placebo-treated patients more frequently required treatmentwith corticosteroids during the 5-year follow-up (p < 0.05).Steroid-treated patients with initial stage II(-III) disease improvedmore in FVC and Dlco (p < 0.05). No differences inreported adverse events or in SACE, serum calcium, or urinary calciumvalues were seen.
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Citation Excerpt :
Several randomized trials3,4 have shown that corticosteroids are superior to placebo in the short term (3 to 7 months) for acute pulmonary sarcoidosis, as measured by improved radiographic findings and spirometry. However, most randomized trials3,4,5,6 do not demonstrate a long-term benefit (≥ 5 years after therapy). Indeed a retrospective study7 suggested that treatment with corticosteroids may promote relapse of sarcoidosis.

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Research performed at Wilford Hall USAF Medical Center, Lackland AFB, Tex.

The opinions expressed are those of the authors and do not necessarily represent official USAF policy.

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Chest

Preliminary ReportPulmonary Sarcoidosis: Long-term Follow-up of the Effects of Steroid Therapy

Section snippets

MATERIALS AND METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENT

Chest

A controlled trial of prednisone treatment of sarcoidosis

Am Rev Respir Dis

Clinical and functional results of a controlled clinical trial of the value of prednisone therapy in sarcoidosis Stage I and II

Long-term corticosteroid treatment of pulmonary sarcoidosis

Pulmonary function followup of 120 patients with sarcoidosis

Ann NY Acad Sci

Extended experience in the long-term corticosteroid treatment of pulmonary sarcoidosis

Ann NY Acad Sci

The sequence of physiologic changes in pulmonary sarcoidosis: correlation with radiographic stages and response to therapy

Mt. Sinai J Med NY

Preliminary Report
Pulmonary Sarcoidosis: Long-term Follow-up of the Effects of Steroid Therapy