Oral and inhaled corticosteroids in the treatment of pulmonary sarcoidosis--a critical reappraisal.

Oral corticosteroids are widely used in patients with pulmonary sarcoidosis, but no consensus has yet been reached on their place in the management of the disease. Over the short term, oral corticosteroids can improve respiratory symptoms, chest X-ray, lung function and biochemical markers of disease activity. However, over the long term, there is no conclusive evidence of an effect on the development of irreversible pulmonary damage. In many patients the lung is the only organ displaying clinically significant impairment of function, and prognosis is closely associated with pulmonary status. The localization of the inflammation in the lungs is predominantly "bronchocentric", and the disease is accompanied by a lymphocytic alveolitis. Due to these features, and a low frequency of side effects, it should be evaluated as to whether inhaled corticosteroids may influence the outcome of the disease. Two double-blind, placebo-controlled studies have examined the effect of inhaled budesonide 1.2 to 2.0 mg/day given for 6 to 12 months to patients with pulmonary sarcoidosis stage I, II or III. In one study there was no effect on any of the recorded parameters (symptoms, chest X-ray, lung function, 67Gallium scan, biochemistry). In the other study there was a favourable effect only on inspiratory vital capacity but not on any of the other parameters. The number of patients who had to be switched to oral corticosteroids was similar in the budesonide and placebo groups. Due to spontaneous recovery from the disease, an improvement was seen in symptoms and biochemical measures in both the budesonide and placebo groups. At present it has not been clarified as whether there is a place for inhaled corticosteroids in the treatment of pulmonary sarcoidosis. Until convincing evidence in favour of inhaled corticosteroids has been presented, these drugs should not be recommended as a routine treatment for pulmonary sarcoidosis.