Management of Sarcoidosis

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Terms and Conditions* This field is required.This clinical tool should NOT be used as a substitute of provider judgement and consideration of unique factors regarding the management of each patient. Bear in mind that individual and unique circumstances may lead the user to reach decisions not presented in this tool. By proceeding you agree with the terms above and choose to take full responsibility for any decision regarding your patient's management plan.

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What type of Sarcoidosis?* This field is required.

Pulmonary Sarcoidosis

Extrapulmonary Sarcoidosis

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What organs are affected?

Eyes, brain, heart, GI, bones or genitourinary tract.

Skin or systemic lymphadenopathy.

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So, for skin or systemic lymphadenopathy:

1 - Start low dose prednisolone/prednisone (10-20 mg/day)

Patient already on low dose steroids?

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Sarcoidosis Stage?* This field is required.Select the stage below corresponding to your patient:

Stage I - hilar adenopathy

Stage II - hilar adenopathy + infiltrates

Stage III - infiltrates only (shrunken nodes)

Stage IV - advanced fibrosis

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Does the patient have respiratory symptoms?* This field is required.(eg. cough, shortness of breath, sputum production, chest pain)

YESNO

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Asymptomatic Stage I ?

1- Annual visit

2 - Annual eye examination

3 - Annual PFTs, ECG, Chest X-rays

4 - Annual biomarkers (CRP, ACE, sIL-2R, Lysozyme, CD4+ T cell count)

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Symptomatic Stage I ?

1 - Evaluate and treat other possible conditions (eg. viral or bacterial bronchitis)

2 - Start Inhaled steroids + LABA or/and LAMA

Patient has already been on therapy above and is unresponsive

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Stages II - IV? Does any of these apply to your patient?* This field is required.

Respiratory symptoms (eg. cough, shortness of breath, sputum production, chest pain.)

Changes in PFTs

Active extrapulmonary sarcoidosis

Activity per biomarkers (eg. hypercalcemia, elevated sIL-2R)

None of the above

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Great! This is all you will need to do:

Follow up in the next 3-6 months

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Therapy with steroids is indicated.

1 - Start Prednisone/Prednisolone 20-30 mg/day

2 - Monthly visits

Patient has already been on steroids for at least 3 months

Patient has a contraindication to steroids or BMI higher than 35

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Did your patient respond well to the steroids without severe side effects?

YESNO

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Very good! Then do the following:

Continue steroid therapy for the next 3-9 months

Tappering steroid to less than 10 mg/day

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Ok. Then do the following:

1 - Request pharmacogenetic tests

2 - Start second-line drugs (eg. Methotrexate, Azathioprine or Leflunomide)

3 - Consider biological agent (anti-TNFα, melanocortin receptor agonist) if the disease is present in more than three organs.

Patient has already been on second-line therapy for at least 2 months

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Steroid Contraindication? Then do the following:

1 - Start second-line drugs (eg. Methotrexate, Azathioprine or Leflunomide)

2 - Request pharmacogenetic tests

Patient has already been on second-line therapy for at least 3 months

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Did your patient respond well to second-line therapy without severe side effects?

YESNO

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Very Good! Then do the following:

Tapering of second-line agent

Stop second-line agent when steroid dose is tapered to less than 10 mg/day

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Ok. Then do the following:

Request PET CT Scan

Start biological agent (eg. anti-TNFα, melanocortin receptor agonist)

Consider consult with a sarcoidosis expert

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Consider the following based on pharmacogenetics studies:

Decrease Methotrexate dose by 25% if moderate interaction with SLCO1B1.

Decrease Azathioprine dose by 25% if moderate interaction with TPMT or NUDT15.

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≥ 3 organs are involved?

YESNO

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Then do the following:

1 - Start low dose prednisolone/prednisone (10-20 mg/day)

2 - Start a second line medication (eg. Methotrexate, Azathioprine or Leflunomide)

3 - Start a biological agent (eg. anti-TNFα, melanocortin receptor agonist)

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Less than 3? Then do the following:

1 - Start low dose prednisolone/prednisone (10-20 mg/day)

2 - Start a second line medication (eg. Methotrexate, Azathioprine or Leflunomide)

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