In patients with sarcoidosis and persistently elevated liver function tests, when do you consider initiating ursodeoxycholic acid (UDCA)?

In patients with systemic sarcoidosis with predominantly elevated alkaline phosphatase, I would be suspicious for liver involvement of their sarcoidosis. If treatment of the systemic sarcoidosis with immunosuppression (typically initiated by Pulmonology or Rheumatology) are ineffective for improving the alk phos predominant elevation in the patient's liver tests, then I would consider ursodiol, which is a medication that is low risk without much adverse effects.

Prior to this, I would have also checked an Anti-Mitochondrial Antibody to look for PBC (would even check sp100, gp210 if I was actually suspicious for PBC), as well as obtained an ultrasound to assess the bile ducts (with MRI/MRCP if I was suspicious for PSC), and made sure a viral...

If the alk phos is high and there is a cholestatic pattern, then I often empirically treat because the risk of ursodiol is low at the general doses we use for hepatic sarcoidosis (13-15 mg/kg PO daily). The adverse effects are minimal at this dose compared to the high dose used in PSC (28-30 mg/kg PO daily).

Most worrisome liver diseases don’t present with a cholestatic pattern of injury, and besides stones, medication side effects are perhaps the most common other etiology. Both stones and med AEs would not typically worsen with empiric UDCA at low dose.

It is important to realize though as above PBC commonly does cause granulomas in liver biopsy, and that PSC is associated with IBD and I’ve seen IBD overlap with sarcoidosis frequently eno...