‹letiflim / Correspondence

RAED Dergisi / RAED Journal • Cilt / Volume 5 • Say› / Issue 2 • Aral›k / December 2013

55

Osteosarkoidozun tedavisi ise daha zordur. Kortikoste-

roidler fliflli¤i geriletse de, kemik y›k›m›n› tamamen düzel-

temezler. Baz› olgularda MTX ve antimalaryal ajanlar›n

yararl› olabildi¤i bildirilmifltir.

[1]

Akut sarkoid miyozit KS tedavisine, kronik ve nodüler

miyopatilere göre daha iyi yan›t vermektedir. Akut sarko-

id miyozit tedavisinde MTX’›n etkili oldu¤u gösterilmifl-

tir.

[25]

fiiddetli ve semptomatik kronik ve nodüler myozit

tedavisinde de MTX ve AZA kullan›lmaktad›r, fakat ideal

bir tedavi stratejisi henüz oluflturulamam›flt›r.

[61]

Eritema nodosum tedavisinde indometazin gibi

NSA‹‹’lar, kolflisin ve düflük doz KS’ler yararl› olur. Sar-

koid vaskülitinin tedavisinde KS’ler ilk seçenektir, fakat

doz ve kullan›m süresi hakk›nda kesin bir veri yoktur.

[2]

Relaps s›k görülmektedir. Dirençli olgularda AZA, CYP

gibi ‹S ajanlar ve RTX denenebilir.

[62]

TNF-

α sarkoidozda granülom oluflmas›nda ve granü-

lomun varl›¤›n›n sürdürülmesinde önemli bir stokindir.

Anti TNF-

α tedaviler, dirençli olgularda kullan›lmaktad›r.

‹nfliximab konvansiyonel tedaviye dirençli deri, kalp, göz,

eklem ve nörolojik tutulumlu hastalarda etkili bulunmufl-

tur.

[63,64]

Etanersept ile yap›lan çal›flmalarda sonuçlar çok iyi

olmamas›na ra¤men, olgu bildirimlerinde tedaviye direnç-

li sarkoid artrit

[65]

ve sarkoid vaskülit

[66]

tedavisinde baflar›l›

oldu¤u bildirilmifltir. Adalimumab ile sarkoid vaskülitli bir

olguda

[67]

ve multisitemik tutulumla seyreden sarkoidozlu

üç hastada baflar›l› sonuçlar bildirilmifltir.

[68]

Alveoler mak-

rofajlardan TNF sal›n›m›n› bask›layan talidomid deri sar-

koidozunda;

[69]

TNF üretimini bask›layan pentoksifilin ise

pulmoner sarkoidozda kullan›lm›fl ve etkili bulunmufltur.

[70]

RTX tedavisinin etkinli¤ini gösteren klinik bir çal›flma

yoktur; veriler olgu sunumlar› ile s›n›rl›d›r.

[71,72]

Sarkoidoz

tedavisinde umut verici görünen di¤er biyolojik tedavi

ajanlar› aras›nda ustekinumab, apremilast, certolizumab,

golimumab ve bir fosfodiesteraz 4 inhibitörü olan apremi-

last say›labilir.

[73,74]

Sonuç olarak; sarkoidozun tedavisi bireyseldir; semp-

tomlara ve organ tutufluna göre belirlenir. Asemptomatik

hastalar›n bir süre izlenmesi önerilir. Baz› olgularda spon-

tan remisyon geliflebilece¤i unutulmamal›d›r. Sarkoidozda

standardize edilmifl tedavi protokolleri de yoktur. Tedavi

alan veya almayan tüm hastalar, yeni organ tutulumlar› aç›-

s›ndan izlenmelidir. 

‹laca ba¤l› sarkoidoz

Anti-TNF ajanlar tedaviye dirençli sarkoidoz hastalar›-

n›n tedavisinde baflar›yla kullan›lsa da, sarkoidoz hastal›¤›

olmayan ve baflka nedenlerle anti-TNF ajanlar› kullanan

baz› hastalarda bu tedaviye ba¤l› sarkoidoz geliflebildi¤i de

bildirilmifltir.

[75]

Bunun mekanizmas› tam olarak bilinmese

de, anti-TNF tedavisi sonucunda TNF-

α ile IFN-α sito-

kinleri aras›ndaki dengenin bozulmas› ve sonuçta IFN-·

düzeyinin yükselmesi ile ilgili oldu¤u düflünülmektedir.

Gerçekten, IFN-

α tedavisinde de sarkoidoz ortaya ç›kabil-

mektedir. Anti-TNF tedavisi zemininde geliflen sarkoido-

zun, patogenetik süreç aç›s›ndan anti-TNF tedaviye ba¤l›

psoriyazis veya lupus tablosu ile de benzerlik gösterdi¤i

düflünülmektedir.

[76]

Prognoz

Ço¤u hastada spontan remisyon görülür (%60). Akut

sarkoidozlu hastalar spontan remisyona girme olas›l›klar›

daha fazlad›r. Löfgren sendromlu hastalar genellikle teda-

visiz ve spontan remisyona girerler; prognoz iyidir.

[46]

Sar-

koidoz hastalar›n›n %10-20’sinde KS tedavisi gerekir.

%10-30 olgu kronikleflir. Mortalite oran› %1-5 oran›nda

bildirilmifltir.

[77]

Tüm ölümlerin yar›s› ilerleyici pulmoner

hastal›k, di¤er yar›s› kardiyak/nörolojik hastal›k kaynakl›-

d›r. Tablo 3’te sarkoidozda kötü prognoz ile iliflkili özel-

likler gösterilmifltir.

[50]

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Tablo 3.

Sarkoidozda kötü prognoz göstergeleri.

• 40 yafl üzeri

• Afrika kökenli Amerikal›lar

• Steroid tedavisi ihtiyac› olanlar

• Ekstra pulmoner tutulumu olanlar

- Kardiyak

- Nörolojik

- Lupus Pernio

- Splenomegali

- Hiperkalsemi

- Kemik tutulumu

• Pulmoner tutulum olanlar

- Evre 3-4 gö¤üs radyografi bulgular›

- Pulmoner Hipertansiyon

- Belirgin akci¤er fonksiyon bozuklu¤u

- Dispne (orta-fliddetli)

- Bronkoalveoler lavaj s›v›s›nda nötrofili varl›¤›

---

Tarhan F, Keser G.

Romatolog gözüyle sarkoidoz 

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RAED Dergisi / RAED Journal • Cilt / Volume 5 • Say› / Issue 2 • Aral›k / December 2013

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