Table 1: Common Immunosuppressive Agents in Cardiac Sarcoidosis, Dosing, Toxicities, Surveillance and Prophylaxis Recommendations.

Drug	Suggested dosing	Important toxicities	Other considerations
Corticosteroid
	Prednisone	0.5–1 mg/kg daily (max dose 60 mg daily) with tapering guided by clinical and imaging response. See treatment algorithm (Figure 4)	Neuropsychiatric: depression, insomnia, psychosis Sodium and fluid retention; worsening heart failure Impaired wound healing Hyperglycaemia Hypertension and increased risk of cardiovascular disease Musculoskeletal: myopathy, osteoporosis, avascular necrosis Adrenal insufficiency Gastrointestinal: gastritis and ulceration	Pre-treatment: Assess cardiovascular risk (lipid, hypertension and glycaemic status) and optimise where possible Exclude latent TB and ensure vaccinations up to date Determine fracture risk using validated tool (e.g. FRAX)[70] and bone densitometry as required Screen for psychiatric comorbidities that may be exacerbated by steroid use Baseline eye exam Monitoring: Hypertension, hyperglycaemia and hyperlipidaemia screening Close monitoring for fluid retention Regular review of fracture risk and bone density screening as required Eye screening for glaucoma and cataract formation Prophylaxis: Gastric: H2 blocker or PPI Pneumocystis prophylaxis for doses ≥20 mg daily Pharmacologic therapy for osteoporosis if indicated by fracture risk
	Antimetabolite
Methotrexate		Initiate at 5–15 mg weekly. Titrate in 5 mg increments every 4 weeks to a target dose of 20 mg weekly[42]	Hepatotoxicity: avoid concurrent alcohol use Myelosuppression: may be preceded by rising MCV Gastrointestinal side-effects: consider increased folic acid or leucovorin rescue therapy; consider splitting daily doses or change to subcutaneous therapy Mucositis: dose dependent Pneumonitis: usually within first year of treatment. Teratogenic: contraindicated in men and women 3 months before planned pregnancy, during pregnancy and breastfeeding	Pre-treatment:[48] Exclude latent TB. Screen for hepatitis B and C and HIV if at risk Baseline chest radiograph, CBC, LFTs, serum creatinine Ensure vaccinations up to date Monitoring: CBC, LFTs and serum creatinine every 2–4 weeks for first 3 months of treatment, every 8–12 weeks for months 3–6 of therapy and every 12 weeks beyond 6 months of therapy[71] Prophylaxis: Folic acid 1 mg daily or 5 mg weekly. Consider leucovorin (folinic acid) rescue therapy in toxicity unresponsive to increased folic acid
TNFi biologic agent
	Infliximab	3–5 mg/kg at weeks 0, 2, 6 and every 4–8 weeks[8]	Worsening of pre-existing heart failure Hypersensitivity reactions Worsening of multiple sclerosis and other demyelinating diseases: avoid[63] Risk of serious infections and malignancy Pre-treatment: Exclude latent TB. Screen for hepatitis B and C and HIV if at risk Baseline chest radiograph, CBC, LFTs, serum creatinine and LVEF Ensure vaccinations up to date Monitoring: Regular specialist review every 1–3 months with CBC and LFTs Active infection: temporarily hold. High index of suspicion for opportunistic infections and PML Close monitoring in patients with LV dysfunction for decompensated heart failure Local recommended population-based malignancy screening Prophylaxis: Low-dose methotrexate ± corticosteroid should be considered to limit development of anti-TNF antibodies
	Adalimumab	80–160 mg at week 0, 40 mg at week 1 and 40 mg weekly thereafter[57]	Similar to infliximab	Similar to infliximab

CBC = complete blood count; CS = cardiac sarcoidosis; FRAX = fracture risk assessment tool; LFT = liver function test; LV = left ventricular; LVEF = left ventricular ejection fraction; MCV = mean corpuscular volume; PML = progressive multifocal leukoencephalopathy; PPI = proton pump inhibitor; TB = tuberculosis; TNFi = tumour necrosis factor inhibitor.