In this study, the efficacy and safety of treating pulmonary sarcoidosis with 12 months vs. 6 months of prednisolone will be compared. The hypothesis is that longer treatment DURAtion would be more effective in preventing treatment failure or early relapse in SARCoidosis (DURASARC trial). The premise of this hypothesis is that even small doses of prednisolone given over longer periods can effectively suppress disease activity in sarcoidosis without a significant increase in adverse effects.
Sarcoidosis is an idiopathic disorder that manifests with granulomatous inflammation affecting several organs, but most commonly the lungs and mediastinal lymph nodes. When asymptomatic or minimally symptomatic, it does not require regular pharmacologic treatment. Organ dysfunction or impaired quality of life trigger the introduction of immunosuppressive therapy. Glucocorticoids are the first-line drugs for this purpose. Different glucocorticoids have been studied in the past, but prednisone/prednisolone is the most used agent. Evidence is sparse on the ideal glucocorticoid regimen to treat patients with sarcoidosis. A recent randomized controlled trial (RCT) named the SARCORT study found that a 6-month prednisolone regimen using an initial dose of 40 mg/day was not superior to one that initiated with a daily dose of 20 mg. The appropriate duration of glucocorticoid treatment for treating newly diagnosed patients with sarcoidosis is unknown. The treatment duration of 6 months in the SARCORT study was at the shorter end of the suggested range (6-24 months). There was a high (45%) overall relapse incidence which was proposed to be due to the shorter duration of treatment. In contrast, a study with a glucocorticoid treatment duration of one year described a 13% relapse rate. In another study, significantly better results were observed in patients who had received prolonged treatment for 4 years or more. In this study, the aim is to compare the efficacy and safety of treating pulmonary sarcoidosis with 12 months vs. 6 months of prednisolone. The hypothesis is that longer treatment DURAtion would be more effective in preventing treatment failure or early relapse in SARCoidosis (DURASARC trial). The premise of this hypothesis is that even small doses of prednisolone given over longer periods can effectively suppress disease activity in sarcoidosis without a significant increase in adverse effects.
Study Type
INTERVENTIONAL
Allocation
RANDOMIZED
An initial dose of 40 mg/day will be administered for 1 week, followed by 30 mg/day for 1 week, 20 mg/day for 6 weeks, 15 mg/day for 4 weeks, 10 mg/day for 8 weeks, 5 mg/day for 4 weeks, 2.5 mg/day for 2 weeks after which the drug will be discontinued (cumulative prednisolone dose, 2485 mg).
An initial dose of 40 mg/day will be administered for 1 week, followed by 30 mg/day for 1 week, 20 mg/day for 6 weeks, 15 mg/day for 4 weeks, 10 mg/day for 14 weeks, 5 mg/day for 24 weeks, 2.5 mg/day for 2 weeks after which the drug will be discontinued (cumulative prednisolone dose, 3605 mg).
Post Graduate Institute of Medical Education and Research
Chandigarh, Chandigarh, India
Relapse or treatment failure
Proportion of subjects with a relapse (worsening after 4 weeks of stopping treatment) or treatment failure (worsening during treatment or within 4 weeks of stopping treatment requiring an increase in the treatment intensity) in the study groups. Worsening is defined as persistent (≥2 weeks) worsening of cough and/or dyspnea, and one or more of the following: a) worsening of lung function (≥5-point reduction in percentage-predicted FVC or FEV1), or b) increase in the chest radiograph abnormalities due to sarcoidosis.
Time frame: 12 months
Treatment response
Proportion of subjects with good or fair treatment response between the study groups defined as: Good response: Resolution (no symptoms attributable to sarcoidosis, a normal chest radiograph, and normal lung function with normal laboratory parameters related to the initial treatment-requiring indication) or improvement (improvement in respiratory symptoms with either (a) decrease in radiological abnormalities, or (b) a ≥5-point increase in the percentage-predicted FVC or FEV1 from the baseline, or (c) both, with no worsening on imaging or spirometry along with normal/stable laboratory parameters related to the initial treatment-requiring indication) with treatment. Fair response: Stabilization (any reduction in symptoms along with stable radiological abnormalities, and less than a 5-point change in the percentage-predicted FVC and FEV1 along with normal/stable lab parameters) of disease during treatment.
Time frame: 12 months
Sarcoidosis health related quality of life
Sarcoidosis health related quality of life will be assessed using the King's Sarcoidosis Questionnaire (KSQ). KSQ is a validated multidomain instrument used to assess QoL of patients with sarcoidosis. The domains include: general health (GH), lung, medication, skin and eyes. The questionnaire consists of 29 items (general health: 10, lung: 6, medication: 3, skin: 3, eyes: 7) that assess the disability that the symptoms in various domains have posed on the patient's day-to-day activities in the past week. Each item is rated on a 7-point Likert scale from 1 (all of the time) to 7 (none of the time). The KSQ module and overall (total) scores are finally transformed to a range of 0-100 \[(actual score - lowest possible score/range) ×100\], where higher scores represent better health status. A minimal clinically important difference (MCID) of 8 for the KSQ GH and of 4 for the KSQ lung have been proposed in a study of 271 subjects.
This platform is for informational purposes only and does not constitute medical advice. Always consult a qualified healthcare professional.
Purpose
TREATMENT
Masking
NONE
Enrollment
100
Time frame: 12 months
Forced vital capacity
Mean change in forced vital capacity assessed using spirometry between the study groups. Spirometry will be performed according to the ATS/ERS guidelines using an ultrasonic flow sensor spirometer (NDD Medizintechnik AG, Zurich, Switzerland) and will be expressed in liters.
Time frame: 12 months
Adverse effects
Proportion of subjects having glucocorticoid-related adverse effects will be recorded including weight gain, Cushingoid features, infections, skin thinning, ecchymosis, cataracts, increased intraocular pressure, hypertension, gastritis, osteoporosis, myopathy, mood disorder, psychosis, memory impairment, hyperglycemia, and others.
Time frame: 12 months
Time to relapse or treatment failure
Mean time to relapse (worsening after 4 weeks of stopping treatment) or treatment failure (worsening during treatment or within 4 weeks of stopping treatment requiring an increase in the treatment intensity) in the study groups. Worsening is defined as persistent (≥2 weeks) worsening of cough and/or dyspnea, and one or more of the following: a) worsening of lung function (≥5-point reduction in percentage-predicted FVC or FEV1), or b) increase in the chest radiograph abnormalities due to sarcoidosis
Time frame: 12 months
Sarcoidosis-associated fatigue
Sarcoidosis-associated fatigue will be assessed using the Fatigue assessment scale (FAS). FAS is a questionnaire with ten items, with five ques¬tions for physical fatigue and five questions reflecting mental fatigue.25 The questionnaire is self-completed by patients and all question¬naire items are rated on a five-point Likert scale (1, never to 5, always). The response scores are sum¬mated to get a total score, which ranges from 10- 50. FAS scores ≥22 and ≥35 imply fatigue and severe fatigue respectively.26 A four-point change in FAS scores after treatment is considered clinically significant.
Time frame: 12 months