Combination Therapy With Mycophenolate Mofetil And Prednisone In The Treatment Of Cardiac Sarcoidosis

Abstract

Introduction Long-term immunosuppression is the mainstay of treatment for cardiac sarcoidosis (CS). While steroids are the cornerstone of therapy, steroid-sparing alternatives are considered second-line or adjunctive in the management of CS. We aimed to evaluate the efficacy of mycophenolate mofetil and steroids on the clinical and radiographic outcomes of patients with CS. Methods A retrospective chart review at a single academic medical center of patients with CS that were treated with prednisone or combination therapy with prednisone and MMF was conducted between 2019-2021. Baseline demographics, clinical data, echocardiography and PET data was collected pre and post-treatment. Improvement in disease was based on improvement in left ventricular ejection fraction (LVEF), reduction of arrhythmia burden, and regional maximum Standardized Uptake Value and percentage of inflammation on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). The parameters were then compared between the MMF and non- MMF group. Results There were 19 total patients (63% male and 52% black that were found to have CS- of which 7 had a positive cardiac or extracardiac biopsy. 17 patients were treated with combination therapy consisting of prednisone and MMF. Median follow-up between scans was 154 days in MMF group and 156.5 days in the non-MMF group. In the MMF group, there was an improvement in EF with a median of 6.5 (p 0.22), regional max SUV decreased by 1.35 (p <0.05) and percent inflammation decreased by a median of 22 percentage points (p 0.11). Of the 14 patients in the MMF group that had an underlying arrhythmia, 11 (78%) had a mitigated or absent arrhythmia burden. In the non-MMF group, the LVEF decreased by a median of 9 (p 0.22), regional max SUV was increased to 1.9 (p <0.05) and percent inflammation decreased by a median of 2 percentage points. 1 of the 2 patients in the non-MMF group showed an improvement in arrhythmia burden. Conclusion CS patients treated with combination therapy consisting of prednisone and MMF appeared to have radiographic and clinical evidence of improvement. MMF may be considered an effective adjunctive therapy to prednisone alone. Long-term immunosuppression is the mainstay of treatment for cardiac sarcoidosis (CS). While steroids are the cornerstone of therapy, steroid-sparing alternatives are considered second-line or adjunctive in the management of CS. We aimed to evaluate the efficacy of mycophenolate mofetil and steroids on the clinical and radiographic outcomes of patients with CS. A retrospective chart review at a single academic medical center of patients with CS that were treated with prednisone or combination therapy with prednisone and MMF was conducted between 2019-2021. Baseline demographics, clinical data, echocardiography and PET data was collected pre and post-treatment. Improvement in disease was based on improvement in left ventricular ejection fraction (LVEF), reduction of arrhythmia burden, and regional maximum Standardized Uptake Value and percentage of inflammation on 18F-fluorodeoxyglucose positron emission tomography (FDG-PET). The parameters were then compared between the MMF and non- MMF group. There were 19 total patients (63% male and 52% black that were found to have CS- of which 7 had a positive cardiac or extracardiac biopsy. 17 patients were treated with combination therapy consisting of prednisone and MMF. Median follow-up between scans was 154 days in MMF group and 156.5 days in the non-MMF group. In the MMF group, there was an improvement in EF with a median of 6.5 (p 0.22), regional max SUV decreased by 1.35 (p <0.05) and percent inflammation decreased by a median of 22 percentage points (p 0.11). Of the 14 patients in the MMF group that had an underlying arrhythmia, 11 (78%) had a mitigated or absent arrhythmia burden. In the non-MMF group, the LVEF decreased by a median of 9 (p 0.22), regional max SUV was increased to 1.9 (p <0.05) and percent inflammation decreased by a median of 2 percentage points. 1 of the 2 patients in the non-MMF group showed an improvement in arrhythmia burden. CS patients treated with combination therapy consisting of prednisone and MMF appeared to have radiographic and clinical evidence of improvement. MMF may be considered an effective adjunctive therapy to prednisone alone.