Phase II Investigation of the Efficacy of Antimycobacterial Therapy in Chronic Pulmonary Sarcoidosis

Chest. 2021 May;159(5):1902-1912. doi: 10.1016/j.chest.2020.12.027. Epub 2020 Dec 30.

Abstract

Background: A Phase I, single-center investigation found that 8 weeks of antimycobacterial therapy improved sarcoidosis FVC. Safety and efficacy assessments have not been performed in a multicenter cohort.

Research question: The objective of this study was to determine the safety and efficacy of antimycobacterial therapy on the physiological and immunologic end points of sarcoidosis.

Study design and methods: In a double-blind, placebo-controlled, multicenter investigation, patients with pulmonary sarcoidosis were randomly assigned to receive 16 weeks of concomitant levofloxacin, ethambutol, azithromycin, and rifabutin (CLEAR) or matching placebo to investigate the effect on FVC. The primary outcome was a comparison of change in percentage of predicted FVC among patients randomized to receive CLEAR or placebo in addition to their baseline immunosuppressive regimen. Secondary outcomes included 6-min walk distance (6MWD), St. George's Respiratory Questionnaire (SGRQ) score, adverse events, and decrease in mycobacterial early secreted antigenic target of 6 kDa (ESAT-6) immune responses.

Results: The intention-to-treat analysis revealed no significant differences in change in FVC among the 49 patients randomized to receive CLEAR (1.1% decrease) compared with the 48 randomized to receive placebo (0.02% increase) (P = .64). Physiological parameters such as the change in 6MWD were likewise similar (P = .91); change in SGRQ favored placebo (-8.0 for placebo vs -1.5 for CLEAR; P = .028). The per-protocol analysis revealed no significant change in FVC at 16 weeks between CLEAR and placebo. There was no significant change in 6MWD (36.4 m vs 6.3 m; P = .24) or SGRQ (-2.3 vs -7.0; P = .14). A decline in ESAT-6 immune responses at 16 weeks was noted among CLEAR-treated patients (P = .0003) but not patients receiving placebo (P = .24).

Interpretation: Despite a significant decline in ESAT-6 immune responses, a 16-week CLEAR regimen provided no physiological benefit in FVC or 6MWD among patients with sarcoidosis.

Keywords: ESAT-6; FVC; antimycobacterial therapy; sarcoidosis.

Publication types

  • Clinical Trial, Phase II
  • Comparative Study
  • Randomized Controlled Trial
  • Research Support, N.I.H., Extramural
  • Research Support, Non-U.S. Gov't

MeSH terms

  • Anti-Bacterial Agents / therapeutic use*
  • Antitubercular Agents / therapeutic use*
  • Azithromycin / therapeutic use
  • Chronic Disease
  • Double-Blind Method
  • Drug Therapy, Combination
  • Ethambutol / therapeutic use
  • Female
  • Humans
  • Levofloxacin / therapeutic use
  • Male
  • Middle Aged
  • Respiratory Function Tests
  • Rifabutin / therapeutic use
  • Sarcoidosis, Pulmonary / drug therapy*
  • Sarcoidosis, Pulmonary / immunology
  • Sarcoidosis, Pulmonary / microbiology*

Substances

  • Anti-Bacterial Agents
  • Antitubercular Agents
  • Rifabutin
  • Levofloxacin
  • Azithromycin
  • Ethambutol