Cardiac Sarcoidosis Randomized Trial

Subjects meeting the study inclusion/exclusion criteria will be randomized equally to receive
either:

1. Prednisone 0.5 mg kg/day for 6-months (MAX dose 30 mg per day) or

2. Methotrexate 15-20 mg po, sc, or IM once a week for 6-months + Folic Acid 2 mg OD for 6
months + Prednisone 20 mg day for 1 month, then 10 mg OD for 1 month, then 5 mg OD for
one month then STOP

Methotrexate will be initiated at a dose of 15 mg once a week and increased to 20 mg once a
week after 4 weeks if tolerated. In case of Methotrexate-induced side-effects general
guidelines will be provided, however specific management will be left to the treating
physicians. Folic acid will be taken to help reduce methotrexate side-effects.

Prior to randomization and study treatment all subjects will have the following baseline
tests done: baseline safety blood work; FDG-PET scan with myocardial perfusion imaging; ECG;
echo; and a bone scan. Cardiac MRI (CMR) is optional but strongly encouraged. Blood will be
obtained for biomarker core-lab analysis. Biomarkers to be assayed will include highly
sensitive Troponin I. Samples will be stored for future novel biomarker discovery. Quality of
LIfe (QOL) questionnaires (KSQ, SAT and SF-36) will be completed prior to treatment start.

After therapy initiation subjects will be seen at 4 weeks, 8 weeks (methotrexate arm only),
and 12 weeks, with a final visit at 6 months. Safety bloodwork and assessment for medication
side effects, using a medication side-effect questionnaire, will be completed at all visits.
At 12 weeks QOL questionnaires will be completed. The primary endpoint will be assessed at
6-months, when FDG-PET with myocardial perfusion imaging, ECG, echo, bone scan, QOL
questionnaires, blood for biomarkers and device interrogation will be done. CMR may be
repeated. Skin, muscle strength testing and neuropsychiatric assessment will be completed at
6 months as part of the composite glucocorticoid toxicity index.

After the 6 month visit. further management will be at the treating physician's discretion.
Details of the physicians planned treatment following the 6-month PET scan will be collected.

Standardized protocols for all aspects of FDG-PET scans (i.e. patient preparation, image
acquisition, image processing, transfer to the core lab and analysis at core lab) will be
followed.

Inclusion Criteria:

(i) Cardiac sarcoidosis presenting with one or more of the following clinical findings:

- advanced conduction system disease (defined as Mobitz II AV block or third degree AV
block)

- significant sinus node dysfunction (defined as average HR less than 40bpm when awake
and/or sustained atrial arrhythmias)

- non- sustained or sustained ventricular arrhythmia

- left ventricular dysfunction (LVEF < 50%)

- right ventricular dysfunction (RVEF < 40%)

AND

(ii) No alternative explanation for clinical features

AND

(iii) FDG-PET uptake suggestive of active CS within two months of enrollment (confirmed by
PET core lab read)

AND ONE OR BOTH OF FOLLOWING

(iv) Positive biopsy for Sarcoid (either EMB or extra-cardiac)

(v) CT Chest showing features consistent with pulmonary sarcoidosis and/or mediastinal
and/or hilar lymphadenopathy

Exclusion Criteria:

1. Current or recent (within two months) non-topical treatment for sarcoidosis

2. Currently taking Methotrexate or Prednisone for another health condition

3. Intolerance or contra-indication to Methotrexate or Prednisone

4. Patient does not meet all of the above listed inclusion criteria

5. Patient is unable or unwilling to provide informed consent

6. Patient is included in another randomized clinical trial

7. Patient has a contraindication to PET imaging or is unlikely to tolerate due to severe
claustrophobia

8. Pregnancy (all women of child bearing age and potential will have a negative BHCG test
before enrollment)

9. Breastfeeding

10. Women of childbearing age who refuse to use a highly effective and medically
acceptable form of contraception throughout the study

11. Patients for whom the investigator believes that the trial is not in the interest of
the patient