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. Author manuscript; available in PMC: 2021 Oct 20.
Published in final edited form as: J Am Coll Cardiol. 2020 Oct 20;76(16):1878–1901. doi: 10.1016/j.jacc.2020.08.042

Table 4.

Common Corticosteroid Sparing/Replacing Agents for Treatment of Sarcoidosis

Drugs Usual dosage Mechanism of action Common Toxicities Corticosteroid sparing potential Corticosteroid replacing potential Comments
Adalimumab 40 units every week SC. Consider initial higher loading dosages. TNF-α antagonism Allergic reaction, increased risk of infection especially TB, CHF, possible increased risk of malignancy, injection site reaction +++ ++ Less immunogenic than infliximab, screening for latent TB is required.
Azathioprine 50–200 mg daily As a purine analogue, inhibits purine synthesis necessary for T-, B- cell proliferation Leukopenia, hepatotoxicity, risk of infection, skin cancer +++ + Monitor CBC & LFT; check TPMT level at initiation (controversial)*.
Infliximab 3–5 mg/kg initially & at 2 weeks and 6 weeks, then every 4–6 weeks IV TNF-α antagonism Allergic reaction, increased risk of infection especially TB, CHF, possible increased risk of malignancy +++ ++ Autoantibodies may develop with chronic use that may reduce efficacy, screening for latent TB is required.
Leflunomide 10–20 mg daily Inhibits COX- 2 enzyme; DHODH inhibition affecting pyrimidine synthesis Leukopenia, hepatotoxicity, risk of infection, skin rash, fatigue, pneumonitis, peripheral neuropathy +++ + Monitor CBC & LFT; because of a long circulating half-life, leflunomide toxicity may require cholestyramine to quickly remove the drug and its metabolites.
Methotrexate 10–15 mg weekly Inhibits the metabolism of folic acid in purine and pyrimidine synthesis GI intolerance, oral ulcers, hepatotoxicity, leukopenia, fatigue, risk of infection, pneumonitis +++ + Teratogenic; folate supplementation is recommended; monitor CBC & LFT.
Mycophenolate 3000–1500 daily Inhibits de novo guanosine nucleotide synthesis and has a cytostatic effect on T and B cell proliferation Leukopenia, risk of infection, lymphoproliferative disorders, skin cancer +/− +/− Very limited data supporting both effectiveness and safety
Repository Corticotropin (RCI) 40–80 unit SC twice weekly Stimulates ACTH secretion Mood change, elevated HBA1c, bruising +++ +++
Rituximab 375 mg/m2 IV every 2 weeks Monoclonal antibody against CD20 surface antigen of B-lymphocytes Transfusion reaction, pancytopenia, opportunistic infection, fatigue, headache, neuropathy + +

CBC: complete blood count; LFT: liver function test; DHODH: dihydroorotate dehydrogenase; COX 2: cyclooxygenase-2; TPMT: Thiopurine; IV: intravenous: SC: subcutaneous; TB: Tuberculosis; CHF: congestive heart failure; GI: gastrointestinal; +++: very good; ++: good; +: fair