Five principles and protocols for the clinician based on the 2021 ERS and BTS statements for treating sarcoidosis

The European Respiratory Society (ERS) and the British Thoracic Society (BTS) have recently published their statements on the treatment of sarcoidosis. There are five key questions in sarcoidosis treatment that need to be addressed: when to treat, how to initiate treatment, how long to treat, when and how to change treatment, and how to treat relapses. Herein, we describe the principles and protocols to answer these questions based on the ERS and BTS statements and other expert reviews. Pulmonary or extrapulmonary sarcoidosis should be treated with anti-inflammatory therapy if it significantly impairs the quality of life (QoL), causes significant organ dysfunction, or threatens to cause organ damage, disability, or death. If treatment is initiated for improving the QoL alone, low-dose (10 mg/day) prednisone is a good initial treatment that can be tapered and stopped over 3 months. Disease that causes significant organ dysfunction needs to be treated with medium-dose glucocorticoids (initial daily dose, 20 mg of prednisone equivalent) tapered over a minimum duration of 6 months. Worsening of disease while tapering treatment indicates that longer (9-24 months) treatment may be necessary. If a daily prednisone dose of >10 mg is required for >6 months to maintain remission, it is best to use a second-line drug such as methotrexate or azathioprine. Anti-tumor necrosis factor agents, such as infliximab or adalimumab, may be used to treat inflammatory disease that persists on combination treatment with glucocorticoids and a second-line agent.