The indications for the treatment of sarcoidosis: Wells Law

volved with sarcoidosis and the variable presentations of the disease, the indications for the treatment of sarcoidosis can be boiled down to only two: fear of danger and significant impairment in quality of life. This maxim was put forward by one of the coauthors (AW) and espoused at a World Association of Sarcoidosis and Other Granulomatous meeting a few years ago. At first glance, one could argue that the indication for sarcoidosis therapy is primarily to decrease the granuloma burden and/or improve physiology or organ function impaired by granulomatous inflammation. However, a critical examination of this issue suggests that this is not the case. The granulomatous inflammation of sarcoidosis may not cause a significant physiologic derangement nor result in a significant reduction in quality of life (1). Common clinical situations where this is the case include asymptomatic bilateral hilar lymphadenopathy (2, 3), and liver sarcoidosis, which requires treatment less than 12% of the time (4). Even when the granulomatous inflammation of sarcoidosis does cause physiologic abnormalities, they are often minor (4-6) and do not always lead to appreciable symptoms (6). In addition, the correlation between pulmonary dysfunction and pulmonary symptoms is poor in pulmonary sarcoidosis (7-9). Over time, the sarcoidosis community has embraced this concept, and the logic of basing the treatment of sarcoidosis on potential danger and/or quality of life impairment has solidified. Table 1 lists the examples of danger and quality of life indications for treatment in sarcoidosis patients. It is important to understand that danger is most accurately recognized by the health care provider, based on knowledge of published outcome data, whereas only the patient has a complete grasp of their individual loss of quality of life (8). These considerations have a major impact on doctor-patient dynamics. Treatment decisions made in order to minimize danger can reasonably be based on medical experience, supplemented by the evidence-base. By contrast, interventions to address loss of quality are more likely to be successful if the patient has a very major role, both in decisions to institute therapy and changes in treatment titrated against symptomatic benefits. The indications for the treatment of sarcoidosis: Wells Law