Ab0790 Infliximab-Treated Extrapulmonary Sarcoidosis: A Single Centre Experience

Background: Sarcoidosis is an inflammatory condition characterised by accumulation of non-necrotizing epithelioid cell granulomas. Despite the lung being the most common site, granulomas can accumulate in any organ, with heterogenous clinical presentations. While steroids and DMARDs represent the mainstay of the initial treatment, anti-Tumor necrosis factor (TNF), and in particular Infliximab (IFX), is used as third-line. Despite this, there is a paucity of large randomised clinical trials (RCT) for the use of IFX in refractory sarcoidosis, with the majority of the studies focusing on pulmonary involvement, and neglecting extra-pulmonary manifestations1. Objectives: To examine the efficacy, tolerability, and subsequent reduction in steroid usage among refractory sarcoidosis patients with extra-pulmonary manifestations treated with IFX. Methods: We identified 36 patients with refractory sarcoidosis who received IFX treatment (5mg/kg) at the tertiary Sarcoidosis Centre at Royal Free Hospital in London, UK, from 2002 to 2023 (3 patients started before 2012, the remaining after 2012), through pharmacy records. In a retrospective audit, we examined the primary organ involved as the indication for Infliximab, the steroid dosage at 12 months, and the occurrence of side effects within the first year. Results: In our group of refractory sarcoid patients, cutaneous sarcoid accounted for the most common extra-pulmonary indication for IFX (30.5%), followed by neuro-sarcoid (27.7%). Less frequent indications included inflammatory arthritis, bone sarcoid, systemic sarcoid, myositis, hepatic, and cardiac involvement (Table 1). Notably, only 5.5% of patients were prescribed IFX for pulmonary indication. Treatment was well tolerated within the initial 12 months: 77% of patients remained on treatment, 13.8% experienced non-severe adverse reactions, and only the 2.7% developed infective complications (TB). Significantly, half of the patients successfully reduced their steroid dose by more than 50% after 12 months of IFX treatment, while another 16.6% achieved a reduction of less than 50%. Conclusion: IFX is used as third line treatment for refractory sarcoidosis, but limited RCT data, mostly focusing on pulmonary indications, are available. In our centre at Royal Free Hospital, we audited how well patients tolerated IFX, finding that almost 80% tolerated it in the first year, with minimal adverse reactions and, and limited infective complications. This is in line with data published in RCT where IFX was used for lung sarcoid (adverse effects described in 21.42% at week 262, and in 21.7% after 52 weeks3). In contrast with other published cohorts1, our main indications for IFX were for extra-pulmonary manifestations, in particular skin and neuro-sarcoid. Across all manifestations, IFX use was associated with clinically relevant reduction of steroid dosage, kerbing steroid burden, and improving health-related quality of life (HRQoL)4. Further measurements of HRQoL will need to be routinely included in the assessment of treatment response in sarcoidosis, and the development of validated tools to measure response is warranted to harmonize future patient care. REFERENCES: 1 Obi et al 10.3389/fmed.2022.991783 2 Vorselaars et al 10.1183/09031936.00227014 3 Baughman et al 10.1164/rccm.200603-402OC 4 Khan et al 1016/j.rmed.2017.09.003 Acknowledgements: NIL. Disclosure of Interests: None declared.