Steroid-resistant sarcoidosis: is antagonism of TNF-alpha the answer?

Design, rationale, and baseline characteristics of a pilot randomized clinical trial of nicotine treatment for pulmonary sarcoidosis

Introduction

Sarcoidosis is a systemic granulomatous disease of unknown cause afflicting young to middle-aged adults. The majority of patients with active pulmonary sarcoidosis complain of overwhelming fatigue, which often persists despite administration of immune-modulating drugs typically used to treat sarcoidosis. Nicotine offers an alternative to conventional treatments, which are associated with a spectrum of serious untoward effects, including diabetes mellitus, osteoporosis, bone marrow suppression, severe infections, cirrhosis. The described pilot randomized trial aims to provide preliminary data required to design subsequent Phase II/III trials to formally evaluate nicotine as a novel low-cost and highly-effective, safe treatment option for patients with active pulmonary sarcoidosis.

Methods

and Design: This is a randomized double-blind controlled trial of adults with confirmed pulmonary sarcoidosis, allocated in equal proportion to sustained release transdermal nicotine or placebo patch. The primary objective outcome is the improvement in forced vital capacity at study week 26 from baseline measurement. Secondary measures include lung texture score, and self-reported outcomes including the Fatigue Assessment Scale, the St George's Respiratory Questionnaire, and the Sarcoidosis Assessment Tool.

Discussion

Current therapies for active pulmonary sarcoidosis, remain either expensive and often with numerous side-effects, as with novel industry developed therapies, or with reduced quality of life, as with corticosteroids. Nicotine therapy provides promise as a safe, available, and cost-effective intervention strategy, which we expect to be acceptable to patients.

ClinicalTrials.gov

NCT02265874.

Long-Term Corticosteroid-Sparing Immunosuppression for Cardiac Sarcoidosis

Background

Long‐term corticosteroid therapy is the standard of care for treatment of cardiac sarcoidosis (CS). The efficacy of long‐term corticosteroid‐sparing immunosuppression in CS is unknown. The goal of this study was to assess the efficacy of methotrexate with or without adalimumab for long‐term disease suppression in CS, and to assess recurrence and adverse event rates after immunosuppression discontinuation.

Methods and Results

Retrospective chart review identified treatment‐naive CS patients at a single academic medical center who received corticosteroid‐sparing maintenance therapy. Demographics, cardiac uptake of 18‐fluorodeoxyglucose, and adverse cardiac events were compared before and during treatment and between those with persistent or interrupted immunosuppression. Twenty‐eight CS patients were followed for a mean 4.1 (SD 1.5) years. Twenty‐five patients received 4 to 8 weeks of high‐dose prednisone (>30 mg/day), followed by taper and maintenance therapy with methotrexate±low‐dose prednisone (low‐dose prednisone, <10 mg/day). Adalimumab was added in 19 patients with persistently active CS or in those with intolerance to methotrexate. Methotrexate±low‐dose prednisone resulted in initial reduction (88%) or elimination (60%) of 18‐fluorodeoxyglucose uptake, and patients receiving adalimumab‐containing regimens experienced improved (84%) or resolved (63%) 18‐fluorodeoxyglucose uptake. Radiologic relapse occurred in 8 of 9 patients after immunosuppression cessation, 4 patients on methotrexate‐containing regimens, and in no patients on adalimumab‐containing regimens.

Conclusions

Corticosteroid‐sparing regimens containing methotrexate with or without adalimumab is an effective maintenance therapy in patients after an initial response is confirmed. Disease recurrence in patients on and off immunosuppression support need for ongoing radiologic surveillance regardless of immunosuppression regimen.

Nutrition and corticosteroids in the treatment of sarcoidosis

PURPOSE OF REVIEW

Sarcoidosis is a chronic disease, which is routinely treated with corticosteroids. Steroid resistance or steroid-induced adverse effects require alternatives. Other immune-modulating pharmacological treatments have been developed, and therefore expanded tremendously. Until now, the role of nutrition in the overall management of sarcoidosis has been neglected although anti-inflammatory properties of nutritional components have been known for many years now. New nutritional possibilities emerge from already existing data and offer new therapeutic avenues in the treatment of sarcoidosis.

RECENT FINDINGS

Various dietary components have been shown to reduce pulmonary inflammatory processes. It is increasingly recognized, however, that the specificity and magnitude of the effect of nutrition differs from pharmacological interventions. Conventional randomized clinical trials are less suitable to test the effect of nutrition in comparison with testing drugs. Mechanistic knowledge on the action of dietary components in conjunction with an increasing understanding of the molecular processes underlying steroid resistance (as investigated in asthma and COPD and unfortunately hardly in sarcoidosis) lead to exciting suggestions on combinations of nutrition/nutritional bioactive compounds and corticosteroids that may benefit sarcoidosis patients.

SUMMARY

In order to understand the effects of nutrition in chronic disease, it is important to elucidate mechanisms and pathways of effects. Several complementing lines of evidence should be integrated in order to be able to advise sarcoidosis patients on a healthy diet as such or in combination with prescribed anti-inflammatory therapy.

Hepatic involvement in sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Liver is frequently involved in the pathological process. Wide range of clinical manifestations can be seen: from asymptomatic lesion with normal liver function tests to cirrhosis with portal hypertension. Biopsy plays the key role in diagnosis of the hepatic sarcoidosis. It is essential for morphological diagnosis to exclude other causes of granulomatous liver disease, most often - primary biliary cholangitis. Nowadays there are no standard treatment protocols for patients with hepatic sarcoidosis.

Sarcoidosis and the Liver

Hepatic granulomas are a common finding in systemic sarcoidosis, but most patients remain asymptomatic. Elevated alkaline phosphatase is the most common sign of hepatic sarcoidosis (HS). Lacking a specific diagnostic test, the diagnosis of HS is one of exclusion. Therapy may be indicated in a minority of patients to control symptoms, but the effects of therapy in the natural history of HS are unknown.

Hepatic sarcoidosis: pathogenesis, clinical context, and treatment options

Sarcoidosis is typically characterized as a non-caseating granulomatous disease that has the ability to affect multiple different organ systems. Although extra-thoracic sarcoidosis can occur in the presence and also without lung involvement, isolated extra-pulmonary disease is rare. The liver is the third most commonly affected organ system after the lungs and lymph nodes. When discussing hepatic sarcoidosis it is important to keep in mind that many patients in this population may not present as one would typically expect since most of the patients are asymptomatic or have mild presentations. Therefore, the diagnosis can be difficult at times since no single laboratory or imaging study can definitively diagnose this systemic disease. In the rare case of some patients where there is difficulty in discerning between different pathologies, the use of image-guided tissue biopsy may be necessary to establish a diagnosis. At the current time, there are no clear guidelines for the management of hepatic sarcoidosis and are mostly dependent on a patient's clinical status at time of presentation. The current body of research in regard to treatment suggests steroids to be the mainstay of therapy. However, there is a role for additional immunosuppressive therapy in cases where the initial treatment is refractory to steroids. In this manuscript, we discussed the pathogenesis of liver sarcoidosis and context of its presentation. In addition, the differential diagnosis and imaging evaluation in this population is discussed. Finally, treatment options are reviewed in setting of previous studies for liver sarcoidosis.

Amyloïdosis, sarcoidosis and systemic lupus erythematosus

The occurrence of renal and multiple organ Amyloïdosis is currently considered exceptional in the course of systemic lupus erythematosus. We report a case of a concomitant SLE and Amyloïdosis in a 57 year old female patient with hypothyroidism history, who presented with erythema nodosum, fever, arthralgia and sicca syndrome. Biological findings showed an inflammatory syndrome, renal failure, proteinuria (1g / 24h), positive auto antibodies and anti DNA. Lung radiology revealed medistinal lymphadenopathy, pleural nodules, ground glass infiltrates and pleuritis. Bronchial biopsy showed non specific inflammation. The salivary gland biopsy showed amyloïd deposits. This case report reminds us that lupus and Amyloïdosis association, although exceptional remains possible. The occurrence of Lofgren syndrome in this situation make the originality of this report.

Sarcoidosis in celiac disease: A page written by genetic variants in IL-18 miRNAs target site?

Sarcoidosis is a chronic idiopathic granulomatous disease. Interleukin-18 (IL-18) has been strongly implicated in the pathogenesis of sarcoidosis. Sarcoidosis shows characteristic microRNAs (miRNAs) profiles. MiRNAs have recently emerged as a new class of modulators of gene expression. MiRNAs are involved in susceptibility to a number of autoimmune diseases promoting and inhibiting the gene expression of different Th1 pro-inflammatory cytokines including IL18. Sarcoidosis has been connected with a variety of autoimmune disorders including celiac disease (CD). CD is a chronic, immune-mediated condition of the small intestine caused by permanent intolerance to dietary gluten. IL-18 has been reported to play an important role in inducing and maintaining inflammation after gluten exposure. MiRNAs expression is significantly altered in CD patients. We hypothesize that sarcoidosis and CD may be the result of common genetic variants in IL-18 miRNA target site.

Management of Arrhythmias in Cardiac Sarcoidosis

The prevalence of cardiac involvement in sarcoidosis is under-recognized and is associated with multiple complications, including conduction block, arrhythmias, and sudden death. The comparative roles of common therapies have been inadequately studied. The purpose of this review is to examine the literature regarding treatments utilized to manage arrhythmias associated with cardiac sarcoidosis.

A case of neurosarcoidosis secondary to treatment of etanercept and review of the literature

There are only three cases in the literature that describe development of neurosarcoidosis in a patient who is on tumour necrosis factor α inhibitors. We describe a case of a 33-year-old woman with a history of juvenile rheumatoid arthritis and refractory uveitis (with previous treatment trials of adalimumab, infliximab, mycophenolate, methotrexate) who had been stable for 2 years on etanercept. She was diagnosed with biopsy-proven systemic sarcoidosis with meningeal and parenchymal neurosarcoidosis. She was switched to infliximab and methotrexate, with clinical and imaging improvements. This is a case that demonstrates the difficulty of choosing tumour necrosis factor α (TNF-α) inhibitors when treating patients with multiple clinical autoimmune entities. It is also a case where a change in the mechanism of TNF-α inhibition pathway can still be used to treat refractory sarcoidoisis and rheumatoid arthritis. It is still unclear what the exact difference between the TNF-α blockers and their neurological complications is, and who the patients at risk of developing neurological complications are.

Clinical presentation and protocol for management of hepatic sarcoidosis

The liver is one of the most commonly involved extrapulmonary sites in sarcoidosis. Hepatic sarcoidosis has a broad range of presentations from scattered, asymptomatic noncaseating granulomas with normal liver enzymes, which are very common in patients with known pulmonary sarcoidosis, to portal hypertension and cirrhosis, which are relatively uncommon. Diagnosis is based on a combination of clinical, laboratory and histological manifestations. The authors' protocol for management of patients with suspected sarcoidosis of the liver without focal lesions includes a transjugular liver biopsy with portal pressure measurements to confirm the diagnosis, rule out coexisting liver diseases and to identify select patients with fibrosis or portal hypertension for consideration of immunosuppression. Steroids and azathioprine are the preferred agents and methotrexate is not recommended.

Off-label uses of anti-TNF therapy in three frequent disorders: Behçet's disease, sarcoidosis, and noninfectious uveitis

Tumoral necrosis factor α plays a central role in both the inflammatory response and that of the immune system. Thus, its blockade with the so-called anti-TNF agents (infliximab, etanercept, adalimumab, certolizumab pegol, and golimumab) has turned into the most important tool in the management of a variety of disorders, such as rheumatoid arthritis, spondyloarthropatties, inflammatory bowel disease, and psoriasis. Nonetheless, theoretically, some other autoimmune disorders may benefit from these agents. Our aim is to review these off-label uses of anti-TNF blockers in three common conditions: Behçet's disease, sarcoidosis, and noninfectious uveitis. Due to the insufficient number of adequate clinical trials and consequently to their lower prevalence compared to other immune disorders, this review is mainly based on case reports and case series.

Refractory multisystem sarcoidosis responding to infliximab therapy

Chronic progressive multisystem granulomatous disease is seen in 10-30% of patients with sarcoidosis and can result in end organ damage. Corticosteroids are the mainstay of treatment with the addition of cytotoxic agents in severe cases. Some patients are refractory to such treatment and, therefore, management is a challenge. There is currently limited evidence for biological agents such as infliximab, a monoclonal anti-tumor necrosis factor-α antibody in the treatment of multisystem sarcoidosis. We report outcomes of three patients with extensive multisystem sarcoidosis refractory to conventional treatment and treated at our center. Clinical assessment and radiographic imaging were used to assess the response to infliximab treatment. Infliximab therapy induced clinical remission in all three patients, and this clinical response correlated with radiographic evidence of the resolution of granulomatous disease. Serum ACE level was reduced in all cases, and daily steroid dosage was reduced. We propose that infliximab can be an effective treatment in patients with multisystem complex sarcoidosis refractory to conventional drug therapy and can result in sustained clinical remission. Our experience supports the urgent need for randomized controlled clinical trials of anti-TNF therapy in refractory systemic sarcoidosis.

Isolated intramedullary neurosarcoidosis of the thoracic spine: case report and review of the literature

Sarcoidosis can involve the central nervous system in approximately 5-15% of cases. Any part of the nervous system can be involved, so presentation can be quite varied. Isolated disease of the spinal cord is even less common and reports are limited to single cases and small series. Although in the setting of systemic disease the diagnosis can be made with skin or lymph node biopsy, isolated disease of the spinal cord presents a diagnostic challenge. We present a case of isolated intramedullary neurosarcoidosis of the distal thoracic spinal cord presenting with posterior column dysfunction. Imaging demonstrated T2 changes in the patient's lower thoracic cord adjacent to disc herniation. Over time, however, his symptoms progressed despite decompression, and the abnormal region began to exhibit focal contrast enhancement. The persistence of symptoms as well as the new enhancement led us to perform a spinal cord biopsy, which demonstrated histopathological findings consistent with sarcoidosis. Further workup failed to reveal any evidence of systemic disease. Intramedullary sarcoidosis without systemic sarcoidosis is extremely rare. With its variable imaging appearance and inconsistent clinical manifestations, it can be difficult to diagnose. It should be considered in the differential diagnosis of a mass-like intramedullary lesion with progressive symptoms. Biopsy with histopathological correlation may be the only definite management option.

Tumor necrosis factor-alpha antagonist-induced sarcoidosis

Sarcoidosis is a multisystem granulomatous disease of unknown etiology. Tumor necrosis factor (TNF)-alpha is an important player in granuloma formation, and recent clinical trials have investigated the efficacy of TNF-alpha inhibitors in sarcoidosis. Paradoxically, there are several case reports in the medical literature describing the development of sarcoidosis in patients treated with TNF-alpha inhibitors. We describe 3 cases of TNF-alpha antagonist-induced sarcoidosis: 1 case of pulmonary, ocular and cutaneous sarcoidosis developing in a patient receiving infliximab for erosive rheumatoid arthritis, 1 case of etanercept-induced sarcoidosis in a patient with seronegative rheumatoid arthritis, and 1 case of sarcoidosis developing in a patient receiving etanercept for erosive rheumatoid arthritis. We also provide a brief discussion on the role of TNF alpha in granuloma formation and implications in the use of TNF-alpha antagonists in autoimmune disease.

Overlap, common features, and essential differences in pediatric granulomatous inflammatory bowel disease

Overlap in the clinical presentation of pediatric granulomatous inflammatory bowel disease may be substantial, depending on the mode of presentation. Chronic granulomatous disease (CGD) may present with granulomatous colitis, perianal abscesses, hepatic abscesses or granulomas, failure to thrive, and obstruction of the gastrointestinal tract (including esophageal strictures and dysmotility, delayed gastric emptying, and small bowel obstruction). Anemia, thrombocytosis, elevated C-reactive protein and erythrocyte sedimentation rate, and hypoalbuminemia are nonspecific and may occur in any of the granulomatous inflammatory bowel diseases. In histology, macrophages with cytoplasmic inclusions will be rather specific for CGD. Sarcoidosis may present with abdominal pain or discomfort, diarrhea, weight loss, growth failure, delayed puberty, erythema nodosum, arthritis, uveitis, and hepatic granulomata. Only in 55% of the patients will angiotensin-converting enzyme be elevated. The noncaseating epithelioid granulomata will be unspecific. Bronchoalveolar lymphocytosis and abnormalities in pulmonary function are reported in sarcoidosis and in Crohn disease (CD) and CGD. Importantly, patients with CD may present with granulomatous lung disease, fibrosing alveolitis, and drug-induced pneumonitis. Sarcoidosis and concomitant gastrointestinal CD have been reported in patients, as well as coexistence of CD and sarcoidosis in siblings. Common susceptibility loci have been identified in CD and sarcoidosis. CD and CGD share defects in the defense mechanisms against different microbes. In the present review, common features and essential differences are discussed in clinical presentation and diagnostics--including histology--in CGD, sarcoidosis, and CD, together with 2 other granulomatous inflammatory bowel diseases, namely abdominal tuberculosis and Hermansky-Pudlak syndrome. Instructions for specific diagnosis and respective treatments are provided.

[TNFα blocking agents and sarcoidosis: an update]

Increased production of TNFα by alveolar macrophages and involvement of TNFα in granuloma formation suggest that this cytokine is involved in the pathophysiology of sarcoidosis. The three available TNFα blocking agents have been tested in sarcoidosis refractory to corticosteroids or immunosuppressive drugs. Data are available from isolated case reports or limited series of patients treated in open label trials with favourable issue with anti-TNFα monoclonal antibodies. Two randomized placebo controlled studies evaluated the efficacy of infliximab in pulmonary and extra-pulmonary sarcoidosis, showing that infliximab improves significantly extra-pulmonary disease. There is no significant difference between infliximab and placebo in the treatment of pulmonary manifestations. Etanercept showed no efficacy for treating ocular sarcoidosis in a controlled trial and for pulmonary disease in an open label trial. Paradoxical cases of proven sarcoidosis have been reported in patients receiving anti-TNFα agents for chronic inflammatory rheumatic diseases. A literature review identified 28 cases, including 16 with etanercept, eight with infliximab and four with adalimumab. Although these cases were mainly reported with etanercept, paradoxical sarcoidosis has been reported with the three available anti-TNFα agents, suggesting a class effect. Changes in the cytokine balance may be involved in these cases of induced sarcoidosis, which must be known by the clinician.

Neurologic presentations of sarcoidosis

Neurosarcoidosis is a diagnostic consideration in diverse clinical settings. Efforts should be made to secure pathologic confirmation of systemic sarcoidosis; only rarely is central nervous system (CNS) pathologic confirmation available. CNS infection and malignancy should be reasonably excluded before making a diagnosis of CNS sarcoidosis. Corticosteroid therapy alone may not be sufficient to treat neurosarcoidosis; adjunct immunosuppressive agents are increasingly used to achieve an optimal clinical outcome.

The use of infliximab in a patient with idiopathic granulomatous hepatitis

We report a therapeutic response to infliximab in a patient with idiopathic granulomatous hepatitis resistant to treatment with methotrexate and corticosteroids. A 41-year-old woman presented with a 12-month history of fever, night sweat, gross hepatomegaly and 13 kg weight loss. Infection and malignancy were carefully excluded and a liver biopsy showed changes consistent with idiopathic granulomatous hepatitis. The patient was treated with high dose steroids and methotrexate, but her clinical symptoms and biochemical and radiological signs did not settle. Introduction of infliximab led to rapid and sustained resolution of symptoms, hepatomegaly and liver function tests (LFTs) after 1 year of follow-up. To our knowledge this is the first successful use of infliximab in idiopathic granulomatous hepatitis.

Dramatic MRI improvement with refractory neurosarcoidosis treated with infliximab

BACKGROUND

Neurosarcoidosis is often a devastating, refractory condition without definite pharmacotherapies beyond corticosteroids.

AIM

To describe a case of steroid-refractory neurosarcoidosis with a marked clinical and radiological response to infliximab.

METHODS

We describe the case of a young female patient with biopsy-proven neurosarcoidosis leading to gait failure. She described significant corticosteroid-related side effects without clinical response to the therapy. Infliximab therapy was considered as a possible rescue medication.

RESULTS

Within months of starting intravenous infliximab therapy, she regained her ability to walk and magnetic resonance imaging identified significant improvements over a sustained course of infliximab therapy, including loss of enhancing nodules and loss of meningeal enhancement.

CONCLUSION

Mounting evidence suggests that infliximab is a valuable pharmacological agent in the management of patients with refractory and disabling neurosarcoidosis. Controlled studies of infliximab in this condition are needed.