From the Guidelines
The pretreatment workup for sarcoidosis should include a comprehensive evaluation to assess disease extent, severity, and potential contraindications to therapy, as recommended by the most recent guidelines from the European Respiratory Journal in 2021 1.
Key Components of Pretreatment Workup
The workup should begin with a thorough history and physical examination, focusing on symptoms and organ involvement. Essential laboratory tests include:
- Complete blood count
- Comprehensive metabolic panel (with liver and kidney function)
- Serum calcium
- 25-hydroxyvitamin D
- Angiotensin-converting enzyme (ACE) levels Pulmonary function tests with diffusion capacity and a 6-minute walk test are crucial for respiratory assessment.
Imaging and Organ-Specific Testing
Imaging studies should include:
- Chest X-ray
- High-resolution CT scan of the chest Cardiac evaluation with ECG and echocardiogram is important to rule out cardiac sarcoidosis. Ophthalmologic examination is necessary to detect ocular involvement. Additional organ-specific testing may be required based on symptoms, such as:
- Brain MRI for neurologic symptoms
- 24-hour urine calcium for hypercalcemia
Diagnosis and Screening
Tissue biopsy from affected organs showing non-caseating granulomas remains the gold standard for diagnosis. Before initiating corticosteroids or immunosuppressants, screen for latent tuberculosis with either tuberculin skin test or interferon-gamma release assay, and check for hepatitis B and C, as suggested by the American Journal of Respiratory and Critical Care Medicine in 2020 1. This comprehensive workup helps determine disease activity, organ involvement, and guides treatment decisions while establishing baseline parameters to monitor treatment response and potential medication side effects, in line with the treatment algorithm proposed by the European Respiratory Review in 2020 1.
From the Research
Pretreatment Workup for Sarcoidosis
The recommended pretreatment workup for Sarcoidosis involves a comprehensive assessment of the disease, including:
- Confirmation of diagnosis through the presence of noncaseating granuloma and compatible clinical presentations, after exclusion of other identifiable causes 2
- Evaluation of organ involvement and impairment, as sarcoidosis can affect virtually any organ 3, 4, 5
- Assessment of pulmonary function, including diffusing capacity of the lung for carbon monoxide (Dlco), FEV1, FVC, and total lung capacity 6
- Identification of sites of organ involvement, including cardiac, neurologic, and skin involvement 6
- Determination of disease severity, using a comprehensive scoring system that incorporates data on demographics, pulmonary function, and organ involvement 6
Diagnostic Approach
A multidisciplinary approach is recommended for the diagnosis and management of sarcoidosis, as it is a systemic disease with heterogeneous clinical manifestations 3, 5
- The pulmonologist is often the referral physician for diagnosis and management, as the lungs are frequently involved 3
- A comprehensive diagnostic work-up and monitoring protocol should be proposed, including regular follow-up to monitor changes in the disease 3
Treatment Considerations
Treatment is not always indicated, unless the disease is symptomatic or causes progressive organ damage/dysfunction 2
- Glucocorticoids are the cornerstone of treatment, although evidence from randomized controlled studies is lacking 2
- Glucocorticoid-sparing agents and biologic agents may be used as second- and third-line therapy for patients who do not respond to glucocorticoids or experience serious adverse effects 2