A discouraging conclusion to many years of study of the natural history of sarcoidosis is the realization that the proper word for the course of sarcoidosis is ‘unpredictable’. An impressive lesson of a controlled study was the frequency with which unexpected and dramatic improvement occurred in the placebo group. Although patients with pulmonary infiltration, uveitis and cutaneous sarcoid have a worse prognosis than the asymptomatic patient with hilar adenopathy, many patients in the former category will recover and some in the latter will go on to death.
A trial of prednisone therapy in a small number of patients with disease restricted to the mediastinal and hilar nodes (Stage I) suggests that prednisone treatment in this form of sarcoidosis may minimize dissemination and progression. An extended trial in Stage I sarcoidosis appears warranted. In more disseminated forms of the disease, the effects of corticosteroids seem to be merely palliative: there is no persuasive evidence that their use in pulmonary sarcoidosis averts fibrosis.
Occasionally corticosteroid therapy is contraindicated, poorly tolerated, or ineffective. In such circumstances chlorambucil or methotrexate may be given a trial. It is clear that both drugs exert an antiinflammatory action similar to that of the corticosteroids; in a few instances these agents appear to surpass corticosteroids in effectiveness.
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