How do you approach a patient with sarcoidosis who cannot tolerate steroids and who is developing ILD?

As with most questions about sarcoidosis, clear understanding of the relevant clinical context should first be established. While interstitial lung disease (ILD) is a common manifestation of sarcoidosis, it often can be safely monitored without treatment, and so radiologically identified sarcoid ILD by itself is not an absolute indication for medications (Thomas-Orogan et al., PMID 38337753). Pharmacologic intervention is indicated (1) if there is potential for permanent organ injury (e.g., lung...

I agree with Dr. @Dr. First Last’s comments and approach. However, I submit that all persons with proven pulmonary sarcoidosis have an interstitial component, regardless of stage or disease severity. Bronchoalveolar lavage in stage I cases with normal-appearing lung parenchyma and lung function demonstrates diffuse alveolitis with lymphocyte-predominant cell differentials and increased cell numbers. Stages III/IV with diffuse pulmonary infiltrates/fibrosis present with a shift towards a more neu...

I will preface by saying that I'm not a specialty expert like Dr. @Dr. First Last and Dr. @Dr. First Last above. However, if you are seeing such a patient for a new diagnosis of pulmonary sarcoidosis AND have decided that they warrant treatment, one could also consider methotrexate (MTX) as a first agent!

Its non-inferiority to corticosteroids was recently highlighted in the PREDMETH trial, which might be of interest to you!

Briefly, it was a multi-center, open-label, RCT evaluating whether MTX is...

Dr. @Dr. First Last and @Dr. First Last have provided excellent information already. There are now several choices in treating sarcoidosis beyond steroids. My first choice would be methotrexate. A recent NJEM open-label non-inferiority study compared methotrexate and prednisone in sarcoidosis lung disease and found methotrexate not inferior to prednisone for maintaining FVC (Kahlmann et al., PMID 40387020).

This study confirmed our clinical impression of the utility of methotrexate, and we use it...

I would start mtx to goal dose 8tabs weekly, steroid sparing, if no disease control, then add to DMARD MTX Humira vs Remicade based on infusion vs SC preference. Try to find a lab to monitor ACE, inflammation markers, and CK. Baseline EKG, HRCT, and PFT are reasonable.