Background: Current guidelines recommend 20–40 mg/day of oral prednisolone for treating pulmonary
sarcoidosis. Whether the higher dose (40 mg/day) can improve outcomes remains unknown.

Methods: We conducted an investigator-initiated, single-centre, open-label, parallel-group, randomised
controlled trial. Consecutive subjects with pulmonary sarcoidosis were randomised (1:1) to receive either high-dose (40 mg/day initial dose) or low-dose (20 mg/day initial dose) oral prednisolone, tapered over 6 months. The primary outcome was the frequency of relapse or treatment failure at 18 months from randomisation. Key secondary outcomes included the time to relapse or treatment failure, overall response, change in forced vital capacity (FVC) at 6 and 18 months, treatment-related adverse effects and health-related quality-of-life (HRQoL) scores using the Sarcoidosis Health Questionnaire and Fatigue Assessment Scale.

Findings: We included 86 subjects (43 in each group). 42 and 43 subjects completed treatment in the highdose and low-dose groups, respectively, while 37 (86.0%) and 41 (95.3%), respectively, completed the 18-month follow-up. 20 (46.5%) subjects had relapse or treatment failure in the high-dose group and 19 (44.2%) in the low-dose group ( p=0.75). The mean time to relapse/treatment failure was similar between the groups (high-dose 307 days versus low-dose 269 days, p=0.27). The overall response, the changes in FVC, and the incidence of adverse effects were also similar. Changes in HRQoL scores did not differ between the study groups.

Interpretation: High-dose prednisolone was not superior to a lower dose in improving efficacy or safety outcomes or the HRQoL in sarcoidosis.