Which of the following is NOT used in the treatment of sarcoidosis: corticosteroids, hydroxychloroquine, vitamin D, anti‑TNF agents, or methotrexate?

Vitamin D is NOT Administered for Sarcoidosis Treatment

Vitamin D is the correct answer—it is NOT used as a treatment for sarcoidosis and is actually contraindicated or used with extreme caution due to the risk of hypercalcemia and hypercalciuria. 1, 2

Why Vitamin D is NOT Used

• Sarcoidosis patients have dysregulated vitamin D metabolism with extrarenal production of 1,25-dihydroxyvitamin D by granulomas, leading to substrate-dependent 1-α hydroxylase activity that can cause dangerous calcium elevations 2

• Hypercalcemia and hypercalciuria are real risks that have been documented even in recent studies attempting vitamin D supplementation, where hypercalciuria occurred in 1 out of 13 and 2 out of 16 patients 2

• Vitamin D deficiency must be ruled out as a cause of fatigue in sarcoidosis patients, but this is diagnostic evaluation, not treatment 1

• No established role in treatment algorithms: The 2021 ERS guidelines and treatment algorithms make no mention of vitamin D as a therapeutic agent for sarcoidosis 1, 3, 4

Agents That ARE Used for Sarcoidosis Treatment

First-Line Therapy

• Corticosteroids (cortisone/prednisone) are the established first-line treatment for symptomatic sarcoidosis at 20-40 mg daily 1, 3

Second-Line Therapy

• Methotrexate is the preferred second-line steroid-sparing agent, validated by randomized controlled trials 1, 4, 5
• Hydroxychloroquine shows efficacy particularly for cutaneous manifestations and reduces neurosarcoidosis relapse rates (HR 0.37,95% CI 0.15–0.92; p=0.03) 1, 4, 5

Third-Line Therapy

• Anti-TNF agents (infliximab preferred) are recommended for refractory disease failing glucocorticoids and methotrexate, with dosing of 5 mg/kg at weeks 0,2, and 6, then maintenance 1, 4, 5

Clinical Reasoning Algorithm

If you see vitamin D mentioned in sarcoidosis context:

1. It is for screening/ruling out deficiency as cause of fatigue, not treatment 1
2. It carries risk of worsening hypercalcemia due to granulomatous production of active vitamin D 2
3. Never use as immunosuppressive therapy unlike the other listed agents 2

Common pitfall: Confusing vitamin D's immunomodulatory effects studied in research with actual clinical use—despite theoretical benefits, the hypercalcemia risk makes it unsuitable for sarcoidosis treatment 2