Table 3.
Glucocorticoids are associated with a high level of adverse effects, long-term complications, and disability in sarcoidosis. Thus, inappropriately used and monitored, glucocorticoids can result in greater diminishment of HRQoL, the sarcoidosis disease process itself. This table provides a checklist of preventive measures when using glucocorticoids.
| Bone Health [148,149,150] |
| Counsel patients about the risk of osteoporosis and screen for risk factors. |
| Baseline DEXA scan (for patients anticipated to need glucocorticoids for >3 months). Initiation of bisphosphonate for prevention according to American College of Rheumatology guidelines. |
| Calcium supplementation is controversial in sarcoidosis and vitamin D supplementation, only if 1,25 dihydroxy is low. |
| Counseling on lifestyle modifications—smoking cessation, weight-bearing activities. |
| Baseline height as surrogate for vertebral height/compression fracture. |
| Gastrointestinal [148] |
| Counsel on gastric protection, take with food, H2 Blocker, or PPI depending on risk level. Assess for risk factors for PUD–history of PUD, heavy smokers, heavy alcohol use, age >65 years old, other medications that increase risk of PUD. |
| For patients on glucocorticoids and nonsteroidal anti-inflammatory drugs, start PPI. |
| For patients with multiple risk factors for PUD, consider addition of PPI. |
| Endocrinology [148] |
| In patients with diabetes, glucose monitoring with sliding scale insulin instructions. Consider screening for diabetes–hemoglobin A1C, basic metabolic panel, or fingerstick glucose. |
| Monitoring fingerstick glucose or basic metabolic panel in patients. |
| Consider prescribing home glucometer for patients on long-term high dose glucocorticoids. |
| Monitoring of electrolytes. |
| Cardiovascular [148] |
| Baseline lipid panel. |
| Blood pressure monitoring and treatment of hypertension if indicated. |
| Immunizations [148] |
| Inquire about vaccination history. |
| Live vaccines should be given 2–4 weeks prior to initiation of glucocorticoids if possible. |
| Administer vaccines according to standard schedule as indicated; withholding live vaccines. |
| Psychiatric [148] |
| Inquire about history of neuropsychiatric disease, suicidal ideation, and self-harm. |
| Referral to psychiatrist if indicated. |
| Counsel family members on risk of mood and behavior changes and advise physician if any changes are noted. |
| Dose glucocorticoids in the morning to reduce insomnia. Monitor for insomnia, manage insomnia as needed. |
| Ocular [148] |
| Assess for personal and/or family history of glaucoma or cataracts. |
| Obtain baseline ophthalmologic exam for patients who may need long-term glucocorticoid treatment. |
| Infectious [148] |
| Consider PCP prophylaxis for patients taking the equivalent of ≥20 mg prednisone for ≥4 weeks, especially if a second risk factor is present—hematologic malignancy, interstitial lung disease, or use of other immunosuppressant medication. |
| Inquire about infection history and risk factors for bacterial, fungal, and viral infections, and screen if indicated. |
DEXA: dual energy x-ray absorptiometry; PCP: pneumocystis pneumonia; PPI: proton pump inhibitor; PUD: peptic ulcer disease.