Experts call for urgent shift away from long-term corticosteroids, citing preventable harm and promoting steroid-sparing alternatives.
A new international position paper has called for a rethink on how corticosteroids are used to treat sarcoidosis, arguing that decades of routine reliance on long-term steroid therapy has caused widespread and preventable harm.
For more than 70 years, oral corticosteroids such as prednisone have been the default first-line treatment for nearly all forms of the inflammatory disease, valued for their speed in reducing granulomatous inflammation and their low cost.
However, experts from the World Association of Sarcoidosis and Other Granulomatous Disorders, together with endorsement from the Americas Association of Sarcoidosis and Other Granulomatous Disorders, now say this long-standing approach has inadvertently entrenched chronic steroid usage despite mounting evidence of significant toxicity.
Their position paper has been published this month in The Lancet Respiratory Medicine.
“We believe that oral corticosteroids should no longer be considered as first-line therapy in all patients with sarcoidosis requiring treatment,” the authors wrote.
“Furthermore, we view long-term use of oral corticosteroids in sarcoidosis as an undesirable outcome.
“When initial oral corticosteroids are required, we propose that oral corticosteroids be used as bridging therapy, ideally for no longer than three-four months.
“There is an urgent need to address the widespread use of long-term maintenance therapy with oral corticosteroids in patients with sarcoidosis, and we advocate the systematic withdrawal of steroid therapy with replacement, if necessary, by other immunosuppressive agents.”
The authors highlighted that although corticosteroids can provide rapid relief, many patients remain on them for years with minimal dose reductions attempted.
Even low doses, traditionally considered safer, have been shown to cause “insidious” long-term complications, including diabetes, hypertension, glaucoma, sleep disturbances, mood changes, increased infection risk, worsening cardiac disease, and reduced quality of life.
“Mortality can be twice as high in patients with sarcoidosis treated with oral corticosteroids than in untreated patients with sarcoidosis,” the authors wrote.
The authors contended that the belief in “safe” low-dose long-term therapy had been definitively disproven.
Current steroid-sparing agents, including methotrexate, azathioprine, leflunomide, mycophenolate, hydroxychloroquine, and biologics such as TNF inhibitors, were already widely used, but the paper urged a far more proactive approach.
Evidence suggested that methotrexate may be an effective alternative initial therapy for certain patients with pulmonary sarcoidosis, though dosing strategies remain inconsistent.
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The authors also stress the importance of distinguishing between symptoms caused by active granulomatous inflammation and those arising from para-sarcoidosis syndromes, such as fatigue or small-fibre neuropathy, which often did not respond to steroids at all.
The authors noted their position paper was not a guideline, covering all aspects of sarcoidosis management, but that they hoped that it would serve as a “bridge to guideline updates, following prospective evaluation of both existing steroid-sparing agents and novel therapies in the context of systematic oral corticosteroid minimisation”.
“The goal of our multispecialty steroid stewardship team is to curb excesses in both the dose and duration of oral corticosteroid treatment for sarcoidosis,” they concluded.
“Achieving these goals will require aggressive tapering of oral corticosteroids with the goal of complete withdrawal, treatment of some patients with steroid-free regimens from the outset, and identifying para-sarcoidosis symptoms, such as fatigue and small-fibre neuropathy, that usually do not respond to oral corticosteroids.
“These aims apply equally to the possible use of oral corticosteroid-free initial therapy and to minimising oral corticosteroids usage, both initially and in the longer term.”
