Evolving management of sarcoidosis in the real world

Purpose of review The management of sarcoidosis has relied mainly on glucocorticoids for over 80 years. Innumerable review articles, as well as all current guidelines, position systemic steroids as first line therapy for moderate and severe sarcoidosis. Despite accumulating evidence of short term (mostly overt) and long term (often unrecognized) toxicities of steroids, and the example of specialists treating diseases like rheumatoid arthritis and inflammatory bowel disease, the treatment paradigm for sarcoidosis has remained stubbornly affixed to steroids. Recent findings In 2025, there is now compelling evidence to relegate steroids to a lesser role in the management of sarcoidosis. Nonsteroid agents, especially methotrexate, can be used as first line therapy for many patients. Summary As steroid use diminishes, the development and implementation of additional steroid-sparing agents will assume increased importance.