Inhaler Therapy for Pulmonary Sarcoidosis

First-Line Treatment for Pulmonary Sarcoidosis

The American Thoracic Society and European Respiratory Society recommend oral glucocorticoids as the first-line therapy for symptomatic pulmonary sarcoidosis, typically starting with prednisone 20-40 mg daily for 2-6 weeks 4

The American College of Chest Physicians (CHEST) guidelines specifically recommend against routine use of inhaled corticosteroids for chronic cough in pulmonary sarcoidosis (Grade 2C recommendation) 1, 2, 3
Inhaled corticosteroids may be considered in specific situations, such as for symptomatic relief of cough or for asthma-like symptoms in patients with sarcoidosis, as suggested by the European Respiratory Review 4

For patients requiring prolonged prednisone ≥10 mg/day or experiencing adverse effects from glucocorticoids, the European Respiratory Journal suggests considering second-line immunosuppressive agents such as methotrexate and azathioprine 5, 6
Methotrexate has been shown to be steroid-sparing, though it may not significantly improve forced vital capacity (FVC), according to the European Respiratory Journal 5, 6
Infliximab has demonstrated improvement in FVC in phase III randomized trials for chronic respiratory symptoms, as reported in the European Respiratory Journal 5, 6, 7

Before attributing cough solely to sarcoidosis, the Chest guidelines recommend excluding other common causes such as upper airway cough syndrome and gastroesophageal reflux disease 8
For intractable cough that persists despite standard treatment, the Chest guidelines suggest that proton pump inhibitors are not recommended for cough in sarcoidosis patients with negative workup for acid reflux 1, 2

Consider prophylactic antibiotics for pneumocystis pneumonia for patients receiving prolonged corticosteroid therapy, as recommended by the Journal for ImmunoTherapy of Cancer 10