Table 1. Summary of medical therapies for cardiac sarcoidosis based upon recommendations of the American College of Cardiology, American Heart Association, and the Heart Rhythm Society.
| Therapy | Medication | Mechanism | Potential benefit | Potential harm |
|---|---|---|---|---|
| Medical immunosupressive therapy | Prednisone (level of evidence C) | Anti-inflammatory, start 40–60 mg per day | No RCT data. An observational study of 23 cardiac sarcoid subjects suggests that 18F-FDG PET may guide steroid therapy (LVEF of 3.8% per reduction in SUV volume of 100 cm3 above a threshold value, P=0.022) (18) | Diabetes, weight gain, hypertension, insomnia, depression and irritability, fractures, infection |
| Methotrexate (level of evidence C) | Anti-metabolite and immune-modulator | Steroid-sparing. No RCT data. In a three year open-label study comparing 7 vs. 10 CS subjects treated with steroid or steroid + MTX, respectively, steroid + MTX had improved LVEF (44.5%±13.8% vs. 60.7%±14.3%, P=0.04) (19) | Thrombocytopenia, anemia, immunosuppression, pulmonary and liver toxicity, neurologic toxicity, infection | |
| Other immune-modulators (level of evidence C) | Varied | Steroid-sparing. Case reports only have included Infliximab, Azathioprine, Cyclosporine, Anti-malarials, Pentoxifylline, Azathioprine, Thalidomide | Anemia, immunosuppression, other specific toxicities | |
| Medical therapy for heart failure | ACE/ARB (level of evidence A) | Improves adverse cardiac remodeling | Class I to reduce mortality and morbidity of HFrEF. Class IIa for structural heart disease without impaired LVEF or symptoms (20) | Renal impairment, electrolyte abnormality, allergy, angioedema, cough |
| Beta-blockers (level of evidence C) | Negative inotrope, delays AV conduction | Class I to reduce mortality and morbidity for HFrEF (20) | Fatigue, cardiac conduction block, mood effects, erectile dysfunction | |
| Diuretics and restricted dietary sodium (level of evidence C) | Fluid and sodium excretion | Class I for HFrEF and symptoms (20) | Renal impairment, electrolyte abnormality, orthostasis |
18F-FDG PET, 18F-fluorodeoxyglucose positron emission tomography; LVEF, left ventricular ejection fraction; SUV, standardized uptake values; CS, cardiac sarcoidosis.