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Prednisone vs methotrexate in treatment naïve cardiac sarcoidosis

  • ORIGINAL ARTICLE
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Journal of Nuclear Cardiology Aims and scope

Abstract

Background

Side effects limit the long-term use of glucocorticoids in cardiac sarcoidosis (CS), and methotrexate has gained attention as steroid sparing agent although the supporting evidence is poor. This study compared prednisone monotherapy, methotrexate monotherapy or a combination of both, in the reduction of myocardial Fluorine-18 fluorodeoxyglucose (FDG) uptake and clinical stabilization of CS patients.

Methods and results

In this retrospective cohort study, 61 newly diagnosed and treatment naïve CS patients commenced treatment with prednisone (N = 21), methotrexate (N = 30) or prednisone and methotrexate (N = 10) between January 2010 and December 2017. Primary outcome was metabolic response on FDG PET/CT and secondary outcomes were treatment patterns, major adverse cardiovascular events, left ventricular ejection fraction, biomarkers and side effects. At a median treatment duration of 6.2 [5.7-7.2] months, 71.4% of patients were FDG PET/CT responders, and the overall myocardial maximum standardized uptake value decreased from 6.9 [5.0-10.1] to 3.4 [2.1-4.7] (P < 0.001), with no significant differences between treatment groups. During 24 months of follow-up, 7 patients (33.3%; prednisone), 6 patients (20.0%; methotrexate) and 1 patient (10.0%; combination group) experienced at least one major adverse cardiovascular event (P = 0.292). Left ventricular ejection fraction was preserved in all treatment groups.

Conclusions

Significant suppression of cardiac FDG uptake occurred in CS patients after 6 months of prednisone, methotrexate or combination therapy. There were no significant differences in clinical outcomes during follow-up. These results warrant further investigation of methotrexate treatment in CS patients.

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Abbreviations

EANM:

European Association of Nuclear Medicine

AVB:

Atrioventricular block

BMI:

Body mass index

CMR:

Cardiac magnetic resonance imaging

CS:

Cardiac sarcoidosis

CT:

Computed tomography

FDG:

Fluorine-18 fluorodeoxyglucose

ICD:

Implantable cardioverter defibrillator

LGE:

Late gadolinium enhancement

MACE:

Major adverse cardiovascular events

MTX:

Methotrexate

NT-pro-BNP:

N-terminal pro-brain natriuretic peptide

OSA:

Obstructive sleep apnea

PET:

Positron emission tomography

PRED:

Prednisone

RV:

Right ventricular

sIL-2R:

Serum soluble interleukin-2 receptor

SUVmax:

Maximum standardized uptake value

VA:

Ventricular arrhythmias

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Disclosures

Roeland Vis, Harold Mathijssen, Ruth G.M. Keijsers, Ewoudt M.W. van de Garde, Marcel Veltkamp, Fatima Akdim, Marco C. Post and Jan C. Grutters have no conflicts of interest or funding sources to disclose.

Author information

Author notes

  1. Roeland Vis and Harold Mathijssen have contributed equally to this work and are co-first authors.

Authors and Affiliations

  1. Interstitial Lung Diseases Center of Excellence, Department of Pulmonology, St Antonius Hospital, Nieuwegein, The Netherlands

    Roeland Vis PharmD, Harold Mathijssen MD, Ruth G. M. Keijsers MD, PhD, Ewoudt M. W. van de Garde PharmD, PhD, Marcel Veltkamp MD, PhD, Fatima Akdim MD, PhD, Marco C. Post MD, PhD & Jan C. Grutters MD, PhD

  2. Department of Clinical Pharmacy, St Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands

    Roeland Vis PharmD & Ewoudt M. W. van de Garde PharmD, PhD

  3. Department of Cardiology, St Antonius Hospital, Nieuwegein, The Netherlands

    Harold Mathijssen MD, Fatima Akdim MD, PhD & Marco C. Post MD, PhD

  4. Department of Nuclear Medicine, St Antonius Hospital, Nieuwegein, The Netherlands

    Ruth G. M. Keijsers MD, PhD

  5. Division of Pharmacoepidemiology and Clinical Pharmacology, Department of Pharmaceutical Sciences, Utrecht University, Utrecht, The Netherlands

    Ewoudt M. W. van de Garde PharmD, PhD

  6. Division of Heart & Lungs, University Medical Center Utrecht, Utrecht, The Netherlands

    Marcel Veltkamp MD, PhD & Jan C. Grutters MD, PhD

  7. Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands

    Marco C. Post MD, PhD

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Correspondence to Roeland Vis PharmD.

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Vis, R., Mathijssen, H., Keijsers, R.G.M. et al. Prednisone vs methotrexate in treatment naïve cardiac sarcoidosis. J. Nucl. Cardiol. 30, 1543–1553 (2023). https://doi.org/10.1007/s12350-022-03171-6

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  • DOI: https://doi.org/10.1007/s12350-022-03171-6

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