PURPOSE OF REVIEW: Although glucocorticosteroids are considered the first-line 
treatment in sarcoidosis, refractory cases require alternatives, such as 
methotrexate (MTX). The aim of this study was to develop, on behalf of the World 
Association of Sarcoidosis and Other Granulomatous Disorders (WASOG), 
multinational evidence-based recommendations for the use of MTX in sarcoidosis 
for routine clinical practice.
RECENT FINDINGS: A systematic literature search was conducted and combined with 
the opinions of sarcoidosis experts worldwide to formulate the recommendations. 
An online survey concerning 10 clinical questions was sent through the WASOG 
newsletter to sarcoidosis experts. Agreement about the recommendations amongst 
the world's leading sarcoidologists was evaluated. A total of 237 articles were 
identified, 43 of which were included. Randomized controlled trial evidence 
supporting the use of MTX in sarcoidosis was limited. Forty-five per cent (113 
of 250) of the sarcoidosis experts contacted completed the survey (Europe 55%, 
North America 26% and Asia 12%). Ten recommendations were formulated concerning 
the indications for use, starting dose, folic acid, work-up, contraindications, 
monitoring, administration options in case of adverse gastrointestinal effects, 
hepatotoxicity, long-term safety and use during pregnancy and breast feeding.
SUMMARY: Ten multinational evidence-based recommendations for the use of MTX in 
sarcoidosis were developed, which are supported by the world's foremost 
sarcoidosis experts.