Azathioprine, leflunomide, and the TNF-alpha inhibitor infliximab are reserved for those who cannot tolerate corticosteroids or those with refractory symptoms and disease progression.3,4 Those with severe pulmonary disease failing treatment or those progressing to pulmonary fibrosis in stage IV need prompt referral and evaluation for lung transplantation.3 Treatment is also aimed at regular screening for and treatment of complications such as cardiac sarcoidosis and heart disease as well as pulmonary hypertension. Here, TNF is linked to pulmonary hypertension.