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Kobak S. Treat to target and tight control: Could be a new approach in the treatment of sarcoidosis? Intractable Rare Dis Res 2023; 12:22-28. [PMID: 36873668 PMCID: PMC9976097 DOI: 10.5582/irdr.2022.01123] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2022] [Revised: 01/30/2023] [Accepted: 02/19/2023] [Indexed: 02/23/2023] Open
Abstract
Sarcoidosis is a chronic granulomatous disease with multisystemic involvement. Although it is accepted as a benign disease, it can sometimes cause life-threatening organ (heart, brain) involvement that determines the prognosis of the disease. There are conflicting opinions about the treatment of the disease. In the generally accepted treatment approach the "step-by-step" model has gained weight. According to this approach, corticosteroids (CS) drugs alone are preferred in the first step in patients who require treatment. In the second step, immunosuppressive drugs (IS) are used in patients who do not respond to CS and/or have contraindications to CS use, and biologics (TNF-alpha inhibitors) are used in the third step. This treatment approach may be valid in cases with mild sarcoidosis. However, although sarcoidosis is considered a benign and self-limiting disease in some major organ involvement, the "step-by-step" approach may be a treatment option that puts the patient's life in danger. In such selected patients, much more rigorous, early and combined treatment approaches that definitely include CS, IS or biologic drugs may be required. In selected sarcoidosis patients with high risk, early diagnosis, "treat-to-target" (T2T) and "tight control" follow-up of patients seems to be a rational approach. This article reviews the "step-down" treatment regimens in light of recent literature data and hypothesizes that the T2T model may be a probable new treatment approach in patients with sarcoidosis.
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Affiliation(s)
- Senol Kobak
- Istinye University Faculty of Medicine, Liv Hospital, Department of Internal Medicine and Rheumatology, WASOG Sarcoidosis Clinic, Istanbul,Turkey
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Obi ON, Saketkoo LA, Russell AM, Baughman RP. Sarcoidosis: Updates on therapeutic drug trials and novel treatment approaches. Front Med (Lausanne) 2022; 9:991783. [PMID: 36314034 PMCID: PMC9596775 DOI: 10.3389/fmed.2022.991783] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/17/2022] [Indexed: 12/04/2022] Open
Abstract
Sarcoidosis is a systemic granulomatous inflammatory disease of unknown etiology. It affects the lungs in over 90% of patients yet extra-pulmonary and multi-organ involvement is common. Spontaneous remission of disease occurs commonly, nonetheless, over 50% of patients will require treatment and up to 30% of patients will develop a chronic progressive non-remitting disease with marked pulmonary fibrosis leading to significant morbidity and death. Guidelines outlining an immunosuppressive treatment approach to sarcoidosis were recently published, however, the strength of evidence behind many of the guideline recommended drugs is weak. None of the drugs currently used for the treatment of sarcoidosis have been rigorously studied and prescription of these drugs is often based on off-label” indications informed by experience with other diseases. Indeed, only two medications [prednisone and repository corticotropin (RCI) injection] currently used in the treatment of sarcoidosis are approved by the United States Food and Drug Administration. This situation results in significant reimbursement challenges especially for the more advanced (and often more effective) drugs that are favored for severe and refractory forms of disease causing an over-reliance on corticosteroids known to be associated with significant dose and duration dependent toxicities. This past decade has seen a renewed interest in developing new drugs and exploring novel therapeutic pathways for the treatment of sarcoidosis. Several of these trials are active randomized controlled trials (RCTs) designed to recruit relatively large numbers of patients with a goal to determine the safety, efficacy, and tolerability of these new molecules and therapeutic approaches. While it is an exciting time, it is also necessary to exercise caution. Resources including research dollars and most importantly, patient populations available for trials are limited and thus necessitate that several of the challenges facing drug trials and drug development in sarcoidosis are addressed. This will ensure that currently available resources are judiciously utilized. Our paper reviews the ongoing and anticipated drug trials in sarcoidosis and addresses the challenges facing these and future trials. We also review several recently completed trials and draw lessons that should be applied in future.
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Affiliation(s)
- Ogugua Ndili Obi
- Division of Pulmonary Critical Care and Sleep Medicine, Brody School of Medicine, East Carolina University, Greenville, NC, United States,*Correspondence: Ogugua Ndili Obi,
| | - Lesley Ann Saketkoo
- New Orleans Scleroderma and Sarcoidosis Patient Care and Research Center, New Orleans, LA, United States,University Medical Center—Comprehensive Pulmonary Hypertension Center and Interstitial Lung Disease Clinic Programs, New Orleans, LA, United States,Section of Pulmonary Medicine, Louisiana State University School of Medicine, New Orleans, LA, United States,Department of Undergraduate Honors, Tulane University School of Medicine, New Orleans, LA, United States
| | - Anne-Marie Russell
- Exeter Respiratory Institute University of Exeter, Exeter, United Kingdom,Royal Devon and Exeter NHS Foundation Trust, Devon, United Kingdom,Faculty of Medicine, Imperial College and Imperial College Healthcare NHS Trust, London, United Kingdom
| | - Robert P. Baughman
- Department of Medicine, University of Cincinnati, Cincinnati, OH, United States
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Abstract
PURPOSE OF REVIEW In chronic pulmonary sarcoidosis, the transition from the inflammatory to the fibrotic stage of the lungs occurs in about 10-20% of cases, eventually causing end-stage fibrotic disease. To date, pathogenetic mechanisms and clinical management remain challenging; thus, we highlight the recent evidence in pulmonary fibrotic processes, clinical signs for an early detection and the potential role of the current investigated antifibrotic agents and promising targeted therapies. RECENT FINDINGS Recent findings of relevant key cellular pathways can be considered as a glimmer of light in the complexity of sarcoidosis. In some patients, granulomas persist and serve as a nidus for fibrosis growth, sustained by several fibrosis-stimulating cytokines. Preclinical studies have detected profibrotic, antifibrotic and pleiotropic T cells as promoters of fibrosis. Epigenetics, genetics and transcriptomics research can lead to new target therapies. Antifibrotic drug nintedanib has shown a positive effect on non-idiopathic pulmonary fibrosis fibrotic lung diseases including fibrotic sarcoidosis; other antifibrotic drugs are under investigation. SUMMARY Pulmonary fibrosis strongly impacts the outcome of sarcoidosis, and a better understanding of the underlying pathogenic mechanisms can facilitate the development of novel treatments, improving clinical care and life expectancy of these patients. The greatest challenge is to investigate effective antifibrotic therapies once fibrosis develops. The role of these findings in fibrotic sarcoidosis can be translated into other interstitial lung diseases characterized by the coexistence of inflammatory and fibrotic processes.
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Affiliation(s)
- Alessia Comes
- Fondazione Policlinico Universitario A. Gemelli, IRCCS, Università Cattolica del Sacro Cuore, Roma, Italy
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Gonçalves Pimenta DA, Meira L, Rolo R, Ferreira L. Sarcoidosis-like reaction secondary to adalimumab treatment in a patient with axial spondyloarthritis. Monaldi Arch Chest Dis 2022; 93. [PMID: 35791620 DOI: 10.4081/monaldi.2022.2343] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 06/23/2022] [Indexed: 11/23/2022] Open
Abstract
Anti-TNF agents, namely adalimumab, are safe drugs that represent an important arsenal in the treatment of immune-mediated inflammatory diseases. "Paradoxical effects" have been described with their use. A sarcoidosis "like" reaction induced by these agents is rare and is characterized by a systemic granulomatous reaction indistinguishable from sarcoidosis. We present a 55-year-old male patient, with axial spondyloarthritis, treated with with adalimumab. About 17 months under this therapy, he complained of dry cough and wheezing. Chest CT showed a peri-lymphatic and pericisural micronodular pattern and hilo-mediastinal lymph nodes, suggestive of sarcoidosis. Angiotensin converting enzyme was increased. Assuming the hypothesis of a sarcoidosis-like reaction secondary to adalimumab this therapy was discontinued with progressive improvement in the patient's complaints and in the radiological changes.
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Affiliation(s)
| | - Leonor Meira
- Pneumology Unit, Portuguese Institute of Oncology (IPO), Porto.
| | - Rui Rolo
- Pneumology Unit, Hospital of Braga.
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Rabufetti A, Borradori L, Heidemeyer K, Feldmeyer L, Hunger RE, Yawalkar N, Seyed Jafari SM. New onset of sarcoidosis after COVID-19 infection. J Eur Acad Dermatol Venereol 2022; 36:e756-e759. [PMID: 35686935 PMCID: PMC9347996 DOI: 10.1111/jdv.18313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Andrea Rabufetti
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland
| | - Luca Borradori
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland
| | - Kristine Heidemeyer
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland
| | - Laurence Feldmeyer
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland
| | - Robert E Hunger
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland
| | - Nikhil Yawalkar
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland
| | - S Morteza Seyed Jafari
- Department of Dermatology, Inselspital - Bern University Hospital, University of Bern, Bern, Switzerland
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Wu JH, Imadojemu S, Caplan AS. The Evolving Landscape of Cutaneous Sarcoidosis: Pathogenic Insight, Clinical Challenges, and New Frontiers in Therapy. Am J Clin Dermatol 2022; 23:499-514. [PMID: 35583850 DOI: 10.1007/s40257-022-00693-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2022] [Indexed: 12/13/2022]
Abstract
Sarcoidosis is a multisystem disorder of unknown etiology characterized by accumulation of granulomas in affected tissue. Cutaneous manifestations are among the most common extrapulmonary manifestations in sarcoidosis and can lead to disfiguring disease requiring chronic therapy. In many patients, skin disease may be the first recognized manifestation of sarcoidosis, necessitating a thorough evaluation for systemic involvement. Although the precise etiology of sarcoidosis and the pathogenic mechanisms leading to granuloma formation, persistence, or resolution remain unclear, recent research has led to significant advances in our understanding of this disease. This article reviews recent advances in epidemiology, sarcoidosis clinical assessment with a focus on the dermatologist's role, disease pathogenesis, and new therapies in use and under investigation for cutaneous and systemic sarcoidosis.
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Affiliation(s)
- Julie H Wu
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, 240 East 38th Street, 11th Floor, New York, NY, 10016, USA
| | - Sotonye Imadojemu
- Department of Dermatology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Avrom S Caplan
- Ronald O. Perelman Department of Dermatology, New York University Grossman School of Medicine, 240 East 38th Street, 11th Floor, New York, NY, 10016, USA.
- New York University Sarcoidosis Program, New York University Grossman School of Medicine, New York, NY, USA.
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Nienhuis WA, Grutters JC. Potential therapeutic targets to prevent organ damage in chronic pulmonary sarcoidosis. Expert Opin Ther Targets 2021; 26:41-55. [PMID: 34949145 DOI: 10.1080/14728222.2022.2022123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Sarcoidosis is a granulomatous inflammatory disease with high chances of reduced quality of life, irreversible organ damage, and reduced life expectancy when vital organs are involved. Any organ system can be affected, and the lungs are most often affected. There is no preventive strategy as the exact etiology is unknown, and complex immunogenetic and environmental factors determine disease susceptibility and phenotype. Present-day treatment options originated from clinical practice and are effective in many patients. However, a substantial percentage of patients suffer from unacceptable side effects or still develop refractory, threatening pulmonary or extrapulmonary disease. AREAS COVERED As non-caseating granulomas, the pathological hallmark of disease, are assigned to divergent activation and regulation of the immune system, targets in relation to the possible triggers of granuloma formation and their sequelae were searched and reviewed. EXPERT OPINION :The immunopathogenesis underlying sarcoidosis has been a dynamic field of study. Several recent new insights give way to promising new therapeutic targets, such as certain antigenic triggers (e.g. from Aspergillus nidulans), mTOR, JAK-STAT and PPARγ pathways, the NRP2 receptor and MMP-12, which await further exploration. Clinical and trigger related phenotyping, and molecular endotyping in sarcoidosis will likely hold the key for precision medicine in the future.
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Affiliation(s)
- W A Nienhuis
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - J C Grutters
- ILD Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands.,Division of Hearth and Lungs, University Medical Center Utrecht, Utrecht, The Netherlands
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Affiliation(s)
- Marjolein Drent
- From the Interstitial Lung Diseases (ILD) Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Department of Pharmacology and Toxicology, Faculty of Health and Life Sciences, Maastricht University, Maastricht, and the ILD Care Foundation Research Team, Ede - all in the Netherlands (M.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Ohio State University, Columbus (E.D.C.); and the Respiratory Medicine Division, Department of Medicine Solna, and the Center for Molecular Medicine, Karolinska Institutet, and Respiratory Medicine, Theme Inflammation and Aging, Karolinska University Hospital - both in Stockholm (J.G.)
| | - Elliott D Crouser
- From the Interstitial Lung Diseases (ILD) Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Department of Pharmacology and Toxicology, Faculty of Health and Life Sciences, Maastricht University, Maastricht, and the ILD Care Foundation Research Team, Ede - all in the Netherlands (M.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Ohio State University, Columbus (E.D.C.); and the Respiratory Medicine Division, Department of Medicine Solna, and the Center for Molecular Medicine, Karolinska Institutet, and Respiratory Medicine, Theme Inflammation and Aging, Karolinska University Hospital - both in Stockholm (J.G.)
| | - Johan Grunewald
- From the Interstitial Lung Diseases (ILD) Center of Excellence, Department of Pulmonology, St. Antonius Hospital, Nieuwegein, the Department of Pharmacology and Toxicology, Faculty of Health and Life Sciences, Maastricht University, Maastricht, and the ILD Care Foundation Research Team, Ede - all in the Netherlands (M.D.); the Division of Pulmonary, Critical Care, and Sleep Medicine, Ohio State University, Columbus (E.D.C.); and the Respiratory Medicine Division, Department of Medicine Solna, and the Center for Molecular Medicine, Karolinska Institutet, and Respiratory Medicine, Theme Inflammation and Aging, Karolinska University Hospital - both in Stockholm (J.G.)
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