The novel coronavirus disease 2019 (COVID-19) has created several challenges at the clinician and hospital levels, and these challenges are complicated when patients present with infection and comorbid disease. In patients with sarcoidosis, COVID-19 can increase the risk for poor outcomes and death, which has resulted in the need for additional guidance on caring for these patients during the pandemic.
An international team of pulmonary care specialists and researchers published a set of guidance statements on the management of sarcoidosis during the COVID-19 era in the journal, CHEST. The authors emphasized the need to reduce immunosuppression dose in patients with sarcoidosis, as patients who receive immunosuppression often have an increased risk for poor outcomes if they become infected with SARS-CoV-2. Systemic glucocorticoid, tumor necrosis factor inhibitors, and methotrexate may also increase the risk for serious infections, according to the guidance statement.
However, patients with sarcoidosis who have their immunosuppression dose reduced because of a COVID-19 infection are at risk of worsening sarcoidosis. Clinicians may attempt to reduce the corticosteroid dose slowly in stable patients who are taking glucocorticoid therapy alone. De-escalation therapy may be considered in stable patients who are taking disease-modifying antisarcoid drugs (DMASDs), which can be achieved by either reducing the dose or lengthening the dosing interval. Antimalarial agents should be continued in patients who are already receiving this type of therapy.
Immunosuppressive biologic agents, such as infliximab, can be reduced by administrating the drugs less frequently or at a lower weight-based dose. Pretreatment with glucocorticoids could also be minimized or eliminated from the infusion protocol. The guidance statement recommends that clinicians should instruct their patients to report any changes in their condition if immunosuppression is reduced. Furthermore, a telemedicine strategy should be implemented when possible, to communicate about changes that are suggestive of active disease.
In patients with sarcoidosis and organ- or life-threatening disease who are taking glucocorticoid therapy alone, patients should be treated with the lowest possible dose that ensures control of their disease. The addition of DMASDs may be helpful to reduce glucocorticoid requirements if a patient is taking very high doses of glucocorticoids, such as prednisone >40 to 60 mg/d. Biologic agents, if previously prescribed, should be continued in patients with life-threatening disease. The use of pulmonary function tests and chest imaging to assess symptoms in these patients should be performed only under necessary circumstances to avoid visits to the clinic and hospital.
The guidance committee wrote that treating clinicians “should remain vigilant to the changing landscape of the available COVID-19 testing, the high variability in local and regional prevalence of the virus and the evolving COVID-19 treatments in their decision making.”
Sweiss NJ, Korsten P, Syed H, et al. When the game changes: guidance to adjust sarcoidosis management during the COVID-19 pandemic [published online April 29, 2020]. CHEST. doi: 10.1016/j.chest.2020.04.033