This protocol applies to patients with sarcoidosis who have hypercalcemia or hypercalciuria in the setting of a normal parathyroid hormone, and whose serum and urinary calcium did not normalize on initial management.
First-line management — hydroxychloroquine combined with dietary calcium restriction, increased fluid intake, and sun avoidance — did not achieve normalization of serum and urinary calcium. Failure to reach that target is the criterion for escalating to this protocol.
Granuloma-mediated vitamin D activation in sarcoidosis can drive increased intestinal calcium absorption, leading to hypercalciuria and, in some patients, overt hypercalcemia. The parathyroid hormone level is normal, which distinguishes this mechanism from primary hyperparathyroidism. Hypercalciuria is more common; frank hypercalcemia occurs in a smaller proportion of patients.
When conservative first-line measures are insufficient, corticosteroid therapy becomes the central intervention. Depending on the clinical picture, a second agent targeting vitamin D metabolism may be added as an adjunct. The complete regimen, decision criteria, and sequencing are detailed in the full protocol.
Reduction in hypercalcemia within 1–2 months of initiating therapy.