LAUSR

This British Thoracic Society (BTS) Clinical Statement addresses the diagnosis, evaluation and management of pulmonary sarcoidosis, with each section summarised with key clinical practice points. In an era in which medical practice is increasingly determined by evidence-based guidelines, it must be acknowledged from the outset that current evidence in sarcoidosis, especially with regard to treatment, is weak. Thus, a number of the conclusions in this Statement are based on expert opinion and accumulated clinical experience. The diagnosis of pulmonary sarcoidosis is often challenging, with ongoing evolution in clinician views on the need for a tissue diagnosis. Historically, a biopsy diagnosis was considered mandatory and we provide guidance on when to offer bronchoscopy and which bronchoscopic procedure to perform. We also stress that decisions made by individual patients to decline bronchoscopy, when there is a highly probable but not definite clinical diagnosis, should be supported in most cases, with careful subsequent monitoring. The document includes sections on the diagnosis of cardiac sarcoidosis and pulmonary hypertension as either disorder may present to respiratory physicians as ‘symptomatic pulmonary sarcoidosis’. Traditional treatment algorithms and their reported application in the medical literature tend to be based on a ‘one size fits all’ approach and this has often led to over-treatment and major steroid-related comorbidity. However, a great many patients do not need to be treated: the broad indications for initiating therapy are (1) a high risk of mortality or disability due to major organ involvement; and (2) unacceptable loss of quality of life. In this statement, we focus on the management of pulmonary disease; the management of concurrent cardiac sarcoidosis or pulmonary hypertension requires referral to expert subspecialist teams. Key pulmonary management considerations are discussed in this Statement. While higher dose treatment regimens may be required in high-risk disease, a highly flexible patient-centred approach is …