Background: Sarcoidosis is a [chronic granulomatous disease of unknown etiology that predominantly affects the lungs but can involve virtually any organ, including the liver. Pulmonary involvement occurs in over 90% of patients, while hepatic involvement is reported in 5–25% of cases. Despite the expanding therapeutic armamentarium, evidence regarding both pulmonary efficacy and hepatic safety/efficacy of sarcoidosis therapies remains fragmented across heterogeneous studies. This systematic review synthesizes the available evidence on pharmacological therapies for sarcoidosis, with a dual focus on pulmonary outcomes (forced vital capacity, steroid-sparing, radiographic response) and hepatic outcomes (hepatotoxicity, efficacy in hepatic sarcoidosis).Methods: A comprehensive literature search was conducted across PubMed, MEDLINE, Cochrane Library, and ClinicalTrials.gov through May 2025. Studies evaluating pharmacological therapies for sarcoidosis reporting pulmonary and/or hepatic outcomes were included. Therapies were categorized as first-line (glucocorticoids, methotrexate), second-line (antimetabolites, hydroxychloroquine), third-line (anti-TNF biologics, rituximab, repository corticotropin injection), and investigational agents (JAK inhibitors, efzofitimod, antifibrotics). Data were extracted on study design, sample size, pulmonary function outcomes, hepatic efficacy, hepatotoxicity, and adverse events. Quality assessment was performed using the Cochrane Risk of Bias tool for RCTs and the Newcastle-Ottawa Scale for observational studies.Results: A total of 22 therapies across 4 treatment lines were identified with reportable pulmonary and/or hepatic outcome data. The evidence base comprised 8 randomized controlled trials, 8 single-arm trials, multiple retrospective cohort studies, and real-world database analyses. Key findings are summarized by treatment line below.Conclusions: Methotrexate has emerged as a noninferior first-line alternative to prednisone for pulmonary sarcoidosis. Anti-TNF agents, particularly infliximab, provide modest but consistent pulmonary benefit and demonstrate efficacy in hepatic sarcoidosis phenotypes. JAK inhibitors and efzofitimod represent promising investigational therapies. Hepatotoxicity remains a critical consideration across multiple drug classes, necessitating structured monitoring. Prospective studies specifically evaluating hepatic sarcoidosis outcomes are urgently needed.