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Suh J, Amato AA. Management of immune-mediated necrotizing myopathy. Muscle Nerve 2024; 70:166-172. [PMID: 38801022 DOI: 10.1002/mus.28114] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/14/2024] [Accepted: 04/23/2024] [Indexed: 05/29/2024]
Abstract
The immune-mediated necrotizing myopathies (IMNM) are autoimmune myositides clinically characterized by proximal predominant weakness and elevated creatine kinase (CK). They may be associated with autoantibodies (anti-HMGCR, anti-SRP), triggered by statin use (e.g., anti-HMGCR myopathy), associated with cancer, or may be idiopathic. Immunotherapy is required to improve strength and decrease the CK level, but no therapies are currently approved by the U.S. Food and Drug Administration for the treatment of IMNM. The optimal treatment strategy for IMNM is currently unknown and wide practice variation exists in the management of this condition. However, observational studies and expert opinion suggest that certain therapies may be more effective for the different serological subtypes of IMNM. HMGCR IMNM often responds favorably to intravenous immunoglobulin (IVIG) even as monotherapy. Signal recognition peptide and seronegative IMNM typically require combination immunotherapy, most often consisting of an oral immunosuppressant, corticosteroids, and IVIG or rituximab. Patients often remain on immunotherapy for years and relapse is common during tapering of immunotherapy. Further studies are needed to guide the optimal management of these patients.
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Affiliation(s)
- Joome Suh
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Anthony A Amato
- Department of Neurology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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2
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Bax C, Aghdasi C, Fiorentino D. Novel therapeutic targets in dermatomyositis. J Dermatol 2024; 51:920-926. [PMID: 38433369 DOI: 10.1111/1346-8138.17170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/12/2024] [Indexed: 03/05/2024]
Abstract
Dermatomyositis (DM) is a systemic autoimmune disease with variable clinical presentations, including inflammation in the skin, muscle, lungs, and/or joints. Current therapeutic strategies in DM typically include broad immunosuppression; however, the currently used modalities are not universally effective and are associated with various side effects, including risk of infection. There is currently a highly unmet need for more effective and well-tolerated therapies. Recent years have witnessed increased interest in pharmaceutical development of new therapeutic strategies for DM. This review aims to summarize the landscape of therapies that are currently being tested or planned in patients with DM. These therapies have a wide variety of immunological targets, including T cells, B cells, inflammatory signaling pathways, type I interferons, autoantibodies, and other targets.
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Affiliation(s)
- Christina Bax
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
| | - Carmel Aghdasi
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
| | - David Fiorentino
- Department of Dermatology, Stanford University School of Medicine, Redwood City, California, USA
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Koumas C, Michelassi F. Immune-Mediated Necrotizing Myopathies: Current Landscape. Curr Neurol Neurosci Rep 2024; 24:141-150. [PMID: 38589696 DOI: 10.1007/s11910-024-01337-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/11/2024] [Indexed: 04/10/2024]
Abstract
PURPOSE OF REVIEW Immune-mediated necrotizing myopathy (IMNM), characterized by acute or subacute onset, severe weakness, and elevated creatine kinase levels, poses diagnostic and therapeutic challenges. This article provides a succinct overview of IMNM, including clinical features, diagnostic strategies, and treatment approaches. RECENT FINDINGS Recent insights highlight the different clinical presentations and therapeutic options of IMNM stratified by autoantibody positivity and type. Additionally, recent findings call into question the reported link between statin use and IMNM. This review synthesizes current knowledge on IMNM, emphasizing its distinct clinical features and challenging management. The evolving understanding of IMNM underscores the need for a comprehensive diagnostic approach that utilizes a growing range of modalities. Early and aggressive immunomodulatory therapy remains pivotal. Ongoing research aims to refine diagnostic tools and therapeutic interventions for this challenging muscle disorder, underscoring the importance of advancing our understanding to enhance patient outcomes.
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Affiliation(s)
- Christoforos Koumas
- Department of Neurology, Columbia University Medical Center, New York, NY, USA.
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Fang DW, Chen YM. Immune-Mediated Necrotizing Myopathy Associated With Anti-signal Recognition Particle Antibody Complicated With Acute Respiratory Distress Syndrome: A Report of Two Cases. Cureus 2024; 16:e60477. [PMID: 38883031 PMCID: PMC11180360 DOI: 10.7759/cureus.60477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2024] [Indexed: 06/18/2024] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) represents a rare category of inflammatory myopathies characterized by more severe and rapid progression of symmetrical proximal muscle weakness. It is also marked by notably elevated serum muscle enzyme levels and distinct histological features, setting it apart from other types of myositis. Moreover, acute chronic lung respiratory dysfunction is a major comorbidity of great concern. We herein present two cases of IMNM associated with anti-signal recognition particle antibodies complicated by acute respiratory distress syndrome.
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Affiliation(s)
- Da-Wei Fang
- Neurology, Mackay Memorial Hospital, Taipei City, TWN
| | - Yi-Min Chen
- Neurology, Mackay Memorial Hospital, Taipei City, TWN
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Sun H, Wang Z, Han Y, Wei X, Wang Y, Yu X. CD163+ macrophage density in perimysial connective tissue associated with prognosis in IMNM. Ann Clin Transl Neurol 2024; 11:1267-1279. [PMID: 38651547 PMCID: PMC11093240 DOI: 10.1002/acn3.52065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Revised: 03/18/2024] [Accepted: 03/28/2024] [Indexed: 04/25/2024] Open
Abstract
OBJECTIVE The pathological features of immune-mediated necrotizing myopathy (IMNM) are dominated by the infiltration of macrophages. We aimed to perform a histopathologic semiquantitative analysis to investigate the relationship between macrophage markers and prognosis. METHODS Semiquantitative analysis of histologic features was performed in 62 samples of IMNM. Independent risk factors were identified through univariate and multivariate regression analysis. Cluster analysis was performed using the partitioning around the medoids (PAM) method. Decision tree modeling was utilized to efficiently determine cluster labels for IMNM patients. The validity of the developmental cohort was assessed by accuracy in comparison with the validation cohort. RESULTS The most enriched groups in patients with IMNM were macrophages expressing CD206 and CD163. In the multivariate logistic regression model, the high density of CD163+ macrophages in perimysial connective tissue increased the risk of unfavorable prognosis (p = 0.025, OR = 1.463, 95% CI: 1.049-2.041). In cluster analysis, patients in Cluster 1, with lower CD163+ macrophage density and inflammatory burden, had a more favorable prognosis. Conversely, patients in Cluster 3, which were enriched for CD163+ macrophages in the perimysial connective tissue, had the most severe clinical features and the worst prognosis. Correlations were found between the density of CD163+ macrophages in connective tissue and symptom duration (R2 = 0.166, p < 0.001), dysphagia (p = 0.004), cardiac involvement (p = 0.021), CK (R2 = 0.067, p = 0.042), CRP (R2 = 0.117, p < 0.001), and ESR (R2 = 0.171, p < 0.001). CONCLUSION The density of CD163+ macrophages in perimysial connective tissue may serve as a potential marker for the prediction of IMNM prognosis.
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Affiliation(s)
- Hui Sun
- Department of Neurology and Neuroscience CenterThe First Hospital of Jilin University, Jilin UniversityChangchunChina
- Center for Rare DiseasesThe First Hospital of Jilin University, Jilin UniversityChangchunChina
| | - Zi‐Yi Wang
- Department of Neurology and Neuroscience CenterThe First Hospital of Jilin University, Jilin UniversityChangchunChina
| | - Ye Han
- Department of Neurology and Neuroscience CenterThe First Hospital of Jilin University, Jilin UniversityChangchunChina
- Center for Rare DiseasesThe First Hospital of Jilin University, Jilin UniversityChangchunChina
| | - Xiao‐Jing Wei
- Department of Neurology and Neuroscience CenterThe First Hospital of Jilin University, Jilin UniversityChangchunChina
- Center for Rare DiseasesThe First Hospital of Jilin University, Jilin UniversityChangchunChina
| | - Yong‐Chun Wang
- Department of Neurology and Neuroscience CenterThe First Hospital of Jilin University, Jilin UniversityChangchunChina
| | - Xue‐Fan Yu
- Department of Neurology and Neuroscience CenterThe First Hospital of Jilin University, Jilin UniversityChangchunChina
- Center for Rare DiseasesThe First Hospital of Jilin University, Jilin UniversityChangchunChina
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Martínez-Rodríguez P, Escribano-Iglesias M, Crisolino-Pozas ÁP, Cubino-Boveda N, López-Parra M, Marcos M, Chamorro AJ. Plasma Exchange in Anti-Signal Recognition Particle Myopathy: A Systematic Review and Combined Analysis of Patient Individual Data. J Pers Med 2024; 14:461. [PMID: 38793043 PMCID: PMC11122241 DOI: 10.3390/jpm14050461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2024] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/26/2024] Open
Abstract
Anti-signal recognition particle myopathy (anti-SRP myopathy) is a rare subtype of immune-mediated inflammatory myopathy characterized by muscle weakness and anti-SRP autoantibodies. Although plasma exchange (PE) is used in severe cases, its role remains unclear. A systematic review was conducted following PRISMA guidelines, identifying 23 patients with anti-SRP myopathy treated with PE. Data on demographics, clinical features, laboratory findings, treatments, and outcomes were analyzed combining individual patient data if available. Sixteen (69.6%) patients were male, with muscle weakness as the predominant symptom in 100% of cases. After PE, most patients showed improvement in symptoms, and the proportion of patients with muscle weakness was reduced (p = 0.001). Relapse occurred in 17.4% of the cases. The incidence of adverse events was low (8.7%). Despite limitations, including a small sample size and heterogeneous data, our systematic review suggests that PE may be effective in inducing remission and controlling symptoms in anti-SRP myopathy, particularly in severe cases. Since evidence on PE in anti-SRP myopathy is limited, further research, including prospective multicenter studies, is warranted to understand better its efficacy and safety and establish its role in treatment algorithms.
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Affiliation(s)
- Pablo Martínez-Rodríguez
- Connective Tissue Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37001 Salamanca, Spain; (P.M.-R.); (Á.-P.C.-P.); (N.C.-B.); (M.M.)
- Department of Medicine, Faculty of Medicine, University of Salamanca, 37001 Salamanca, Spain
| | | | - Ángel-P. Crisolino-Pozas
- Connective Tissue Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37001 Salamanca, Spain; (P.M.-R.); (Á.-P.C.-P.); (N.C.-B.); (M.M.)
| | - Noelia Cubino-Boveda
- Connective Tissue Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37001 Salamanca, Spain; (P.M.-R.); (Á.-P.C.-P.); (N.C.-B.); (M.M.)
- Department of Medicine, Faculty of Medicine, University of Salamanca, 37001 Salamanca, Spain
| | - Miriam López-Parra
- Department of Hematology, University Hospital of Salamanca-IBSAL, 37001 Salamanca, Spain;
| | - Miguel Marcos
- Connective Tissue Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37001 Salamanca, Spain; (P.M.-R.); (Á.-P.C.-P.); (N.C.-B.); (M.M.)
- Department of Medicine, Faculty of Medicine, University of Salamanca, 37001 Salamanca, Spain
| | - Antonio-J. Chamorro
- Connective Tissue Diseases Unit, Department of Internal Medicine, University Hospital of Salamanca-IBSAL, 37001 Salamanca, Spain; (P.M.-R.); (Á.-P.C.-P.); (N.C.-B.); (M.M.)
- Department of Medicine, Faculty of Medicine, University of Salamanca, 37001 Salamanca, Spain
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Marder G, Quach T, Chadha P, Nandkumar P, Tsang J, Levine T, Schiopu E, Furie R, Davidson A, Narain S. Belimumab treatment of adult idiopathic inflammatory myopathy. Rheumatology (Oxford) 2024; 63:742-750. [PMID: 37326854 PMCID: PMC10907809 DOI: 10.1093/rheumatology/kead281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 05/16/2023] [Accepted: 05/31/2023] [Indexed: 06/17/2023] Open
Abstract
OBJECTIVE To evaluate belimumab addition to the standard of care in patents with refractory idiopathic inflammatory myopathy (IIM). METHODS We conducted a 40-week multicentre, randomized, double-blind, placebo-controlled trial with 1:1 IV belimumab 10 mg/kg or placebo randomization and a 24-week open-label extension. Clinical responses were measured by the definition of improvement (DOI) and total improvement score (TIS). Flow cytometry analyses were performed on available samples before randomization, at 24 and 60-64 weeks. Descriptive statistics, t-test, Fisher's exact test and analysis of variance tests were used. RESULTS A total of 17 patients were randomized, 15 received five or more doses of belimumab or placebo and were included in the intention-to-treat analysis. More belimumab patients vs placebo attained a TIS ≥40 [55.5% vs 33.3%; P = non-significant (NS)] and achieved the DOI (33.3% vs 16.7%; P = NS) at weeks 40 and 64; the mean TIS was similar among groups. Two patients achieved major responses (TIS = 72.5) after week 40 in the belimumab arm and none in the placebo arm. No improvement in the placebo arm after switching to the open-label phase was observed. There was no steroid-sparing effect. No new safety signals were detected. Although total B cells were not reduced, belimumab induced naïve B cell depletion while enhancing the number and frequency memory B cells. CONCLUSION The study did not meet the primary endpoint and no statistically significant differences were observed in clinical responses between arms. More patients achieved sustained TIS ≥40 and reached the DOI. Most patients who received belimumab for >40 weeks had clinical improvement. Phenotypic changes in B cell populations were not associated with clinical responses. CLINICAL TRIAL REGISTRATION NUMBER Clinicaltrials.gov (https://clinicaltrials.gov/), NCT02347891.
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Affiliation(s)
- Galina Marder
- Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine, Great Neck, NY, USA
| | - Tam Quach
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Priyal Chadha
- Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine, Great Neck, NY, USA
| | - Preeya Nandkumar
- Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine, Great Neck, NY, USA
| | - Jimmy Tsang
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Todd Levine
- Phoenix Neurological Associates, Phoenix, AZ, USA
| | - Elena Schiopu
- Division of Rheumatology, University of Michigan, Ann Arbor, MI, USA
| | - Richard Furie
- Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine, Great Neck, NY, USA
| | - Anne Davidson
- Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine, Great Neck, NY, USA
- Institute of Molecular Medicine, Feinstein Institutes for Medical Research, Northwell Health, Manhasset, NY, USA
| | - Sonali Narain
- Division of Rheumatology, Northwell Health, Donald and Barbara Zucker School of Medicine, Great Neck, NY, USA
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Dandasena T, Ingle V, Singhai A, Saigal S. Anti-SRP-positive necrotising myopathy concurrent with breast malignancy. BMJ Case Rep 2023; 16:e254702. [PMID: 38081733 PMCID: PMC10729263 DOI: 10.1136/bcr-2023-254702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2023] Open
Abstract
Anti-signal recognition particle (anti-SRP)-positive necrotising myopathy causes severe progressive proximal weakness with a propensity to involve pharyngeal, laryngeal and respiratory muscles. It is one of the aggressive inflammatory myopathies. First-line treatment is with high-dose steroids followed by other immunosuppressants, but this conventional therapy is often ineffective. Second-line treatment involves use of either rituximab or intravenous immunonoglobulin (IVIG). Anti-SRP-positive necrotising myopathy is frequently treated as refractory myositis due to its poor responsiveness to steroid monotherapy and conventional immunosuppressive therapies. Therefore, anti-SRP-positive necrotising myopathy differs from immune-mediated myopathy. Although anti-SRP autoantibody is found in only 4-6% of patients with idiopathic inflammatory myopathy, the actual proportion of patients with refractory anti-SRP-positive necrotising myopathy is unknown. We describe a patient with multiple comorbidities who had subacute-onset anti-SRP-positive immune-mediated necrotising myopathy (IMNM). After failing steroids, methotrexate and IVIG therapy, she made a considerable recovery with rituximab. She was later diagnosed to have breast malignancy. Malignancy-associated anti-SRP-positive IMNM is rarely reported.
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Affiliation(s)
- Tarini Dandasena
- Department of General Medicine, All India Institute of Medical Science-Bhopal, Bhopal, India
| | - Vaibhav Ingle
- All India Institute of Medical Science-Bhopal, Bhopal, India
| | - Abhishek Singhai
- All India Institute of Medical Science-Bhopal, Bhopal, Madhya Pradesh, India
| | - Saurabh Saigal
- All India Institute of Medical Science-Bhopal, Bhopal, India
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Connolly CM, Paik JJ. Clinical pearls and promising therapies in myositis. Expert Rev Clin Immunol 2023; 19:797-811. [PMID: 37158055 PMCID: PMC10330909 DOI: 10.1080/1744666x.2023.2212162] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 05/05/2023] [Indexed: 05/10/2023]
Abstract
INTRODUCTION Idiopathic inflammatory myopathies (IIMs) represent a diverse group of systemic autoimmune disorders with variable clinical manifestations and disease course. Currently, the challenges of IIMs are multifold, including difficulties in timely diagnosis owing to clinical heterogeneity, limited insights into disease pathogenesis, as well as a restricted number of available therapies. However, advances utilizing myositis-specific autoantibodies have facilitated the definition of subgroups as well as the prediction of clinical phenotypes, disease course, and response to treatment. AREAS COVERED Herein we provide an overview of the clinical presentations of dermatomyositis, anti-synthetase syndrome, immune-mediated necrotizing myopathy, and inclusion body myositis. We then provide an updated review of available and promising therapies for each of these disease groups. We synthesize current treatment recommendations in the context of case-based construct to facilitate application to patient care. Finally, we provide high-yield, clinical pearls relevant to each of the subgroups that can be incorporated into clinical reasoning. EXPERT OPINION There are many exciting developments on the horizon for IIM. As insights into pathogenesis evolve, the therapeutic armamentarium is expanding with many novel therapies in development, holding promise for more targeted treatment approaches.
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Affiliation(s)
- Caoilfhionn M. Connolly
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Julie J. Paik
- Division of Rheumatology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
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Tariq S, Goriparthi L, Ismail D, Kankeu Tonpouwo G, Thapa M, Khalid K, Cooper AC, Jean-Charles G. Correlates of Myopathy in Diabetic Patients Taking Statins. Cureus 2023; 15:e37708. [PMID: 37206522 PMCID: PMC10191392 DOI: 10.7759/cureus.37708] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/16/2023] [Indexed: 05/21/2023] Open
Abstract
Diabetes is one of the most common chronic ailments; its incidence has reached epidemic proportions in the 21st century. Diabetes significantly increases micro and macrovascular complications, which are effectively managed with statins. Therefore, statins' pharmacokinetics, pharmacodynamics, and pharmacogenetics have been extensively studied. Although statins act as a keystone in preventing cardiovascular complications, at the same time, they pose a threat to the quality of life of diabetics due to the resulting muscular side effects. This article summarizes the prevalence, clinical manifestations, pathophysiology, and risk factors of statin-induced myopathy in diabetic patients. Among the diverse predisposing risk factors, the primary variables identified for causing myopathy in diabetic patients include age, gender, ethnicity, duration and severity of illness, comorbid conditions, level of physical activity, alcohol use, cholecalciferol (vitamin D3) levels, type and dose of statins, and anti-diabetic drugs or other drugs used concomitantly. In addition, cardiovascular risk quotients also potentially impact diabetic patients making them more vulnerable to developing myopathy from statins. Therefore, this study highlights the importance of managing statin-associated myopathic side effects by providing consensus guidelines on diagnostic, monitoring, and treatment strategies. We also discussed statins' prognostic value in reducing cardiovascular events in diabetic individuals.
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Affiliation(s)
- Sara Tariq
- Internal Medicine, Mayo Hospital, Lahore, PAK
- Internal Medicine, JC (Jean-Charles) Medical Center, Orlando, USA
| | - Lakshmi Goriparthi
- General Surgery, Osmania Medical College, Hyderabad, IND
- Internal Medicine, JC (Jean-Charles) Medical Center, Orlando, USA
| | - Dina Ismail
- Internal Medicine, JC (Jean-Charles) Medical Center, Orlando, USA
- Family Medicine, University Hassan II of Casablanca Faculty of Medicine and Pharmacy, Casablanca, MAR
| | - Gauvain Kankeu Tonpouwo
- Internal Medicine, Faculty of Medicine, University of Lubumbashi, Plaine Tshombé, Lubumbashi, COD
| | - Milan Thapa
- Internal Medicine, Monmouth Medical Center, Long Branch, USA
| | - Khizer Khalid
- Internal Medicine, JC (Jean-Charles) Medical Center, Orlando, USA
| | | | - Gutteridge Jean-Charles
- Internal Medicine, AdventHealth Orlando Hospital, Orlando, USA
- Internal Medicine, JC (Jean-Charles) Medical Center, Orlando, USA
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Dallevet CA, Benveniste O, Allenbach Y. Pathogenesis and Treatment in IMNM. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2023. [DOI: 10.1007/s40674-023-00201-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023]
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12
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Almaghrabi M, Almatrafi SB, Alzahrani A, Alharbi M. Marked Efficacy of a Therapeutic Strategy in a Patient With Necrotizing Myopathy Associated With Anti-signal Recognition Particle (SRP) Autoantibodies. Cureus 2023; 15:e35471. [PMID: 36999097 PMCID: PMC10043635 DOI: 10.7759/cureus.35471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/25/2023] [Indexed: 03/01/2023] Open
Abstract
Necrotizing autoimmune myopathy (NAM) is a rare muscular disorder characterized by severe proximal muscle weakness. Risk factors include statin use, malignancy, and connective tissue diseases. The current study presents the first case of NAM in Saudi Arabia in a 26-year-old female who presented with proximal upper and lower limb weakness, dysphagia, dysarthria, and dyspnea with no previous medical or surgical history and was not on medication. Targeted myopathic antibody analysis revealed antibodies to signal recognition particles (SRP), and the serum creatinine kinase level reached 9308 U/L. A diagnosis of NAM was made, and the patient was started on the management plan. We discussed an interesting case progression and adverse effect challenges, as well as the management of these difficult-to-treat conditions.
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Oshima R, Matsuhisa T, Kondo T, Sato M, Sato J, Yamamura M. Strongyloidiasis presenting during treatment of low-dose glucocorticoid plus rituximab for anti-signal recognition particle antibody-positive polymyositis: A case report. Mod Rheumatol Case Rep 2023; 7:113-116. [PMID: 36264196 DOI: 10.1093/mrcr/rxac083] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 09/30/2022] [Accepted: 10/18/2022] [Indexed: 11/13/2022]
Abstract
Strongyloidiasis, an intestinal parasitic infection caused by Strongyloides stercoralis, rarely occurs in Japan. When treated with immunosuppressive drugs, two potentially lethal conditions, hyperinfection and dissemination, may develop in asymptomatic carriers of this parasite. We report the development of strongyloidiasis during treatment of polymyositis with glucocorticoids plus rituximab (RTX). A 44-year-old woman had been diagnosed with anti-signal recognition particle antibody-positive polymyositis with interstitial pneumonia 6 years previously, for which she had recently been receiving prednisolone at 5 mg/day and RTX at 375 mg/m2 twice every 3 months. Her condition appeared to be well controlled. She was admitted to our hospital with a 1-month history of chronic diarrhoea and epigastric pain. Standard microscopic examination of a sample of faeces revealed the presence of S. stercoralis; however, serologic testing for parasites was negative. Treatment with ivermectin alleviated her inflammatory diarrhoea and eradicated the faecal parasites. We believe that our patient had an exacerbation of S. stercoralis infection (hyperinfection syndrome) that was exacerbated by low-dose glucocorticoids plus RTX. Strongyloidiasis should be considered in immunocompromised individuals with unexplained diarrhoea, even in non-endemic areas.
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Affiliation(s)
- Ryo Oshima
- Department of Infectious Diseases, Gifu Prefectural General Medical Center, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takaharu Matsuhisa
- Department of Infectious Diseases, Gifu Prefectural General Medical Center, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Takeshi Kondo
- Center for Postgraduate Clinical Training and Career Development, Nagoya University Hospital, Nagoya, Aichi, Japan
| | - Motoki Sato
- Department of Infectious Diseases, Gifu Prefectural General Medical Center, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Juichi Sato
- Department of Infectious Diseases, Gifu Prefectural General Medical Center, Nagoya University Graduate School of Medicine, Nagoya, Aichi, Japan
| | - Masahiro Yamamura
- Department of Rheumatology and Collagen Disease Centre, Okayama Saiseikai General Hospital, Okayama, Japan
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14
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Wang CH, Liang WC. Pediatric immune-mediated necrotizing myopathy. Front Neurol 2023; 14:1123380. [PMID: 37021281 PMCID: PMC10067916 DOI: 10.3389/fneur.2023.1123380] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 03/03/2023] [Indexed: 04/07/2023] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a type of inflammatory myopathy. Most patients with IMNM produce anti-3-hydroxy-3-methylglutaryl coenzyme A reductase or anti-signal-recognition particle autoantibodies. IMNM is much rarer in children than in adults. We conducted this mini review focusing on pediatric IMNM to present current evidence regarding its epidemiology, clinical characteristics, diagnosis, and treatment. Our findings indicate that pediatric IMNM often causes severe muscle weakness and is refractory to corticosteroids alone. Furthermore, delayed diagnosis is common because of the clinicopathological similarity between IMNM and inherited myopathy. Raising awareness regarding pediatric IMNM may facilitate early diagnosis and effective treatment.
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Affiliation(s)
- Chen-Hua Wang
- Department of Pediatrics, Kaohsiung Municipal Hsiao-Kang Hospital, Kaohsiung, Taiwan
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Wen-Chen Liang
- Department of Pediatrics, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Pediatrics, School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Graduate Institute of Clinical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- *Correspondence: Wen-Chen Liang,
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15
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Cole C, Amber KT. Off-Label Uses of Rituximab in Dermatology. CURRENT DERMATOLOGY REPORTS 2022; 11:209-220. [PMID: 36217351 PMCID: PMC9534735 DOI: 10.1007/s13671-022-00375-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/26/2022] [Indexed: 11/26/2022]
Abstract
Purpose of Review Rituximab has transformed the treatment of B-cell malignancies and rheumatoid arthritis in the past 2 decades. More recently, this anti-CD20 monoclonal antibody has seen increasing usage in the field of dermatology. This review highlights the evidence supporting its use in several important dermatologic conditions. Recent Findings Key recent findings include the 2018 FDA approval of rituximab for the treatment of moderate-to-severe pemphigus. Summary Data from randomized controlled trials have demonstrated the efficacy of rituximab in pemphigus, ANCA-associated vasculitis, and cryoglobulinemic vasculitis. More limited data suggests its use in recalcitrant cases of diseases such as pemphigoid, epidermolysis bullosa acquisita, and dermatomyositis. There is scarce evidence and mixed results for rituximab when studied in cutaneous polyarteritis nodosa and cutaneous lupus erythematosus.
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Affiliation(s)
- Connor Cole
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
| | - Kyle T. Amber
- Division of Dermatology, Rush University Medical Center, Chicago, IL USA
- Department of Internal Medicine, Rush University Medical Center, Chicago, IL USA
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16
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Casal-Dominguez M, Pinal-Fernández I, Mammen AL. Utility of Myositis-Specific Autoantibodies for Treatment Selection in Myositis. CURRENT TREATMENT OPTIONS IN RHEUMATOLOGY 2022. [DOI: 10.1007/s40674-022-00198-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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17
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Current and new targets for treating myositis. Curr Opin Pharmacol 2022; 65:102257. [PMID: 35724455 DOI: 10.1016/j.coph.2022.102257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Accepted: 05/17/2022] [Indexed: 11/17/2022]
Abstract
As treatment of refractory idiopathic inflammatory myopathies (IIM) has been challenging, there is growing interest in assessing new therapies that target various pathways implicated in the pathogenesis of IIM. In the largest clinical trial to date, rituximab was studied in adult and juvenile myositis, but the primary outcome was not met despite 83 percent of subjects with refractory myositis meeting the definition of improvement. The U.S. Food and Drug Administration (FDA) has recently granted approval to Octagam 10% immune globulin intravenous (IVIg), for the treatment of adult dermatomyositis based on impressive results from a double-blind placebo-controlled trial. Anti-tumor necrosis factor (anti-TNF) utility in IIM is not recommended and recent reports suggest this therapy may induce systemic autoimmune disease including myositis. Further, anti-IL6 therapy cannot be recommended as a recent trial of tocilizumab failed to reach its primary endpoint. Further studies are needed to assess the role of newer therapies such as abatacept (inhibition of T cell co-stimulation), sifalimumab (anti-IFNα), Janus kinase [JAK] inhibitors, apremilast (phosphodiesterase 4 inhibitor), and KZR-616 (selective inhibitor of the immunoproteasome) given their biological plausibility and encouraging recent small-case series results. The future of IIM therapy will depend on exploring biomarkers implicated in the etiopathogenesis of IIM, improvements in myositis classification based on serological and histopathological features, and well-designed controlled clinical trials using validated consensus outcome measures.
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18
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Barrons R. Statin-Associated Autoimmune Myopathy: Review of the Literature. J Pharm Pract 2022; 36:383-393. [PMID: 35707933 DOI: 10.1177/08971900211040291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Statin-associated autoimmune myopathy (SAAM) is a rare adverse event characterized by progressive muscle symptoms despite discontinuation, requiring immunosuppressive therapy for remission. The objective of this review was to characterize SAAM, for timely detection, while examining the literature for effective treatment considerations. METHODS PubMed search was conducted from 2010 to 2020 was for relevant case series and studies of at least 8 patients displaying muscle discomfort or weakness, anti-HMGCR antibodies, exposure to statins, and biopsies consistent with SAAM. RESULTS Three case series and 3 case cohort studies identified 199 patients with SAAM. Exhibiting a mean age of 63.74 years, patients were more likely Caucasian (81%) and female (1.2X), and required a mean duration of 4.75 years before symptomatic. The presentation involved proximal muscle weakness (94%), myalgias (37%) and dysphagia (23%), accompanied by a mean creatinine kinase of 6383 IU/L. Most patients (57%) required 2 or more immunosuppressive (IMS) agents to achieve 62% remission. After 2 years of treatment, 15% of patients without remission reported symptomatic improvement, while another 12% were refractory to treatment. CONCLUSION Delayed onset of SAAM greater than 4 years from statin initiation may create a low index of suspicion. However, progression of symptoms beyond 2 months from statin discontinuation and positive anti-HMGCR antibodies requires immunosuppressive agents. Data and expert opinion support use of at least two IMS medications upon diagnosis for a minimum of 2 years. Therapy success depends on timely recognition and initiation of IMS combinations to achieve earlier remission and symptomatic improvement.
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Affiliation(s)
- Robert Barrons
- School of Pharmacy, 15543Wingate University, Wingate, NC, USA
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19
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Zeng R, Glaubitz S, Schmidt J. Antibody Therapies in Autoimmune Inflammatory Myopathies: Promising Treatment Options. Neurotherapeutics 2022; 19:911-921. [PMID: 35394612 PMCID: PMC9294121 DOI: 10.1007/s13311-022-01220-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/10/2022] [Indexed: 12/29/2022] Open
Abstract
Inflammatory myopathies, including polymyositis (PM), dermatomyositis (DM), inclusion body myositis (IBM), necrotizing myopathy (NM), antisynthetase syndrome (ASS) and overlap myositis (OM), in short myositis, are rare diseases. All forms of myositis have progressive muscle weakness in common, with each subtype characterized by different autoantibody profiles, histological findings and extramuscular manifestations. Due to better understanding of the pathogenesis of the muscle inflammation in myositis, new molecular pathways for targeted therapy have been discovered. Current therapies aim at different components of the innate or the adaptive immune response. Additionally, non-inflammatory mechanisms in myositis have come into focus as possible treatment targets. The use of therapeutical antibodies in myositis has been examined in various clinical studies, several of them randomized controlled ones: Depletion of B-cells by rituximab has been established as treatment of refractory myositis. IVIG, an antibody therapy in the wider sense, has now been licensed for DM following a recent positive clinical trial. Negative study results were reported in randomized trials with infliximab, sifalimumab and bimagrumab. Studies on basiliximab and eculizumab are currently underway, and are expected to yield results in a couple of years. Despite some promising results of clinical studies with antibody therapy in myositis, further research is crucial to optimize the treatment for this debilitating disease and to find treatment alternatives for treatment-refractory patients.
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Affiliation(s)
- Rachel Zeng
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Stefanie Glaubitz
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Muscle Immunobiology Group, Neuromuscular Center, Department of Neurology, University Medical Center Göttingen, Göttingen, Germany.
- Department of Neurology and Pain Treatment, Immanuel Klinik Rüdersdorf, University Hospital of the Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany.
- Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany.
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20
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Kocoloski A, Martinez S, Moghadam-Kia S, Lacomis D, Oddis CV, Ascherman DP, Aggarwal R. Role of Intravenous Immunoglobulin in Necrotizing Autoimmune Myopathy. J Clin Rheumatol 2022; 28:e517-e520. [PMID: 34581697 DOI: 10.1097/rhu.0000000000001786] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND/OBJECTIVE Immune-mediated necrotizing myopathy (IMNM) is a subtype of myositis that is associated with a refractory phenotype and poorer prognosis. The aim of the study was to provide single large center experience of outcomes of intravenous immunoglobulin (IVIg) for patients with IMNM using longitudinally collected data. METHODS This case series longitudinally evaluated 4 of the 6 myositis core set measures at baseline and at 3 and 6 months after IVIg on 20 adult IMNM patients from 2014 to 2019 at the University of Pittsburgh. We assessed patients for improvement in core set measures, prednisone dose, adverse effects, and by the "limited" ACR/EULAR 2016 myositis response criteria. The mean differences in CK and manual muscle testing (MMT-8) were compared using a paired t test. A clinically significant response was defined as a >10% absolute improvement in the MMT-8 and a >50% absolute reduction in serum CK at 6 months of IVIg. RESULTS Intravenous immunoglobulin treatment was associated with marked improvement in IMNM patients, with 85% of patient meeting clinically significant response. The median (interquartile range) relative percent improvement in CK level was 96% (85%-98%) and in MMT was 29% (14%-36%) at 6 months.There was a significant reduction in the mean (SD) dose of prednisone at 6 months and had minimal adverse effects. In addition, with IVIg, most (13/14) patients had at least minimal improvement as per ACR/EULAR 2016 myositis response criteria. CONCLUSIONS Based on objective, meaningful improvement in MMT-8 and CK as well as marked reduction in prednisone doses with acceptable tolerability, early implementation of IVIg should be considered in adult IMNM.
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Affiliation(s)
- Amanda Kocoloski
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Silvia Martinez
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Siamak Moghadam-Kia
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - David Lacomis
- Departments of Neurology and Pathology (Neuropathology), University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Chester V Oddis
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Dana P Ascherman
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
| | - Rohit Aggarwal
- From the Division of Rheumatology and Clinical Immunology, Department of Medicine
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21
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Kruse RL, Albayda J, Vozniak SO, Lawrence CE, Goel R, Lokhandwala PM, Ness PM, Tobian AAR, Bloch EM, Crowe EP. Therapeutic plasma exchange for the treatment of refractory necrotizing autoimmune myopathy. J Clin Apher 2022; 37:253-262. [PMID: 35119135 PMCID: PMC9303676 DOI: 10.1002/jca.21968] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/04/2022] [Accepted: 01/14/2022] [Indexed: 11/30/2022]
Abstract
Introduction Necrotizing autoimmune myopathy (NAM) is strongly associated with pathognomonic autoantibodies targeting 3‐hydroxy‐3‐methylglutaryl‐coenzyme A reductase (HMGCR) or signal recognition particle (SRP), whose levels in turn are correlated with serum creatine kinase (CK) and necrosis. Thus, NAM may be amenable to therapeutic plasma exchange (TPE) to remove pathogenic antibodies and improve patient symptoms. Methods A retrospective case series and literature review of patients presenting with NAM and undergoing treatment with TPE was performed. Clinical data including patient demographics, symptoms, physical exam findings, muscle biopsy, lower extremity imaging, prior therapy, and duration from diagnosis to TPE initiation were collected retrospectively for adult patients with NAM treated with TPE after failing to respond to immunomodulatory therapy. Laboratory data including change in CK levels and myositis‐specific antibody titers from baseline were measured in some patients. Results Six patients (median age at diagnosis 52.5 years, interquartile range [IQR] 35.8‐64.5 years, four male/two female) underwent a median of 7.5 (IQR: 5‐10) TPE procedures with 5% albumin as replacement. All patients exhibited a statistically significant reduction in CK level from pre‐TPE baseline (range: 43.0%‐58.7% reduction). Responses in this cohort were best in patients with antibodies targeting HMGCR and SRP, which are most strongly associated with NAM. These results compare favorably to a literature review of NAM patients (n = 19) treated with TPE, who also exhibited positive clinical and laboratory responses across varying treatment lengths. Conclusion TPE can play a role in the management of NAM, particularly in patients with HMGCR or SRP antibodies who are refractory to pharmacologic immunosuppression.
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Affiliation(s)
- Robert L Kruse
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Jemima Albayda
- Division of Rheumatology, Department of Medicine, Johns Hopkins Bayview Medical Center, Baltimore, Maryland, USA
| | - Sonja O Vozniak
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Courtney E Lawrence
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Ruchika Goel
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,Division of Hematology Oncology, Department of Internal Medicine, Simmons Cancer Institute at Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Parvez M Lokhandwala
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA.,American Red Cross, Baltimore, Maryland, USA
| | - Paul M Ness
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Aaron A R Tobian
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Evan M Bloch
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Elizabeth P Crowe
- Division of Transfusion Medicine, Department of Pathology, Johns Hopkins Hospital, Baltimore, Maryland, USA
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22
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Treatment and Management of Autoimmune Myopathies. Neuromuscul Disord 2022. [DOI: 10.1016/b978-0-323-71317-7.00022-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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23
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Cui BB, Tian YR, Ma XY, Yin G, Xie Q. Belimumab for Immune-Mediated Necrotizing Myopathy Associated With Anti-SRP Antibodies: A Case Report and Retrospective Review of Patients Treated With Anti-B-Cell Therapy in a Single Center and Literature. Front Immunol 2021; 12:777502. [PMID: 34925350 PMCID: PMC8675000 DOI: 10.3389/fimmu.2021.777502] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2021] [Accepted: 11/08/2021] [Indexed: 02/05/2023] Open
Abstract
Background Immune-mediated necrotizing myopathy (IMNM) is characterized by markedly elevated creatinine kinase and histologically scattered necrotic muscle fibers and generally associated with autoantibodies against signal recognition particle (SRP) or 3-hydroxy-3-methylglutaryl-coA-reductase (HMGCR). Poor clinical response to conventional therapies and relapses commonly occur in severe cases. Anti-B-cell therapies have been used in refractory/relapsing cases. Methods The characteristics of a patient with IMNM associated with anti-SRP antibodies including physical examination, laboratory tests, and disease activity assessment were evaluated. Conventional therapy, belimumab treatment schedule, and follow-up data were recorded. Medical records of IMNM patients treated in our department from September 2014 to June 2021 were reviewed to evaluate the efficacy and safety of anti-B-cell therapy for anti-SRP IMNM. A literature review of patients with anti-SRP IMNM treated with anti-B-cell therapies was performed. Results We describe a case of a 47-year-old woman with IMNM associated with anti-SRP antibodies who relapsed twice after conventional therapy but showed good response and tolerance to belimumab at 28 weeks follow-up. In this review, three patients from our department were treated with rituximab. Two of the three patients rapidly improved after treatment. Twenty patients and five retrospective studies were included in the literature review. All patients were administered rituximab as an anti-B-cell drug. Conclusion Despite a lack of rigorous clinical trials, considerable experience demonstrated that anti-B-cell therapy might be effective for patients with IMNM associated with anti-SRP antibodies. Belimumab in association with steroids might be an encouraging option for refractory/relapsing cases.
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Affiliation(s)
- Bei-Bei Cui
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Yun-Ru Tian
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Xin-Yue Ma
- West China School of Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Geng Yin
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
| | - Qibing Xie
- Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China
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24
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Lundberg IE, Fujimoto M, Vencovsky J, Aggarwal R, Holmqvist M, Christopher-Stine L, Mammen AL, Miller FW. Idiopathic inflammatory myopathies. Nat Rev Dis Primers 2021; 7:87. [PMID: 34857780 PMCID: PMC10425161 DOI: 10.1038/s41572-021-00325-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Idiopathic inflammatory myopathies (IIM), also known as myositis, are a heterogeneous group of autoimmune disorders with varying clinical manifestations, treatment responses and prognoses. Muscle weakness is usually the classical clinical manifestation but other organs can be affected, including the skin, joints, lungs, heart and gastrointestinal tract, and they can even result in the predominant manifestations, supporting that these are systemic inflammatory disorders. Different myositis-specific autoantibodies have been identified and, on the basis of clinical, histopathological and serological features, IIMs can be classified into several subgroups — dermatomyositis (including amyopathic dermatomyositis), antisynthetase syndrome, immune-mediated necrotizing myopathy, inclusion body myositis, polymyositis and overlap myositis. The prognoses, treatment responses and organ manifestations vary among these groups, implicating different pathophysiological mechanisms in each subtype. A deeper understanding of the molecular pathways underlying the pathogenesis and identifying the autoantigens of the immune reactions in these subgroups is crucial to improve outcomes. New, more homogeneous subgroups defined by autoantibodies may help define disease mechanisms, and will also be important in future clinical trials to develop targeted therapies and in identifying biomarkers to guide treatment decisions for the individual patient.
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Affiliation(s)
- Ingrid E. Lundberg
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, and Karolinska University Hospital. Stockholm, Sweden
| | - Manabu Fujimoto
- Department of Dermatology, Osaka University Graduate School of Medicine, Suita, Japan
| | - Jiri Vencovsky
- Institute of Rheumatology, Prague, Czech Republic
- Deptartment of Rheumatology, 1st Medical Faculty, Charles University, Prague, Czech Republic
| | - Rohit Aggarwal
- UPMC Myositis Center, Division of Rheumatology and Clinical Immunology, University of Pittsburgh, Pittsburgh, PA, USA
| | - Marie Holmqvist
- Division of Rheumatology, Department of Medicine, Solna, Karolinska Institutet, and Karolinska University Hospital. Stockholm, Sweden
- Clinical Epidemiology Division, Department of Medicine, Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Lisa Christopher-Stine
- Johns Hopkins Myositis Center, Division of Rheumatology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Andrew L. Mammen
- National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, Maryland, USA
- Departments of Neurology and Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frederick W. Miller
- Clinical Research Branch, National Institute of Environmental Health Sciences, National Institutes of Health, Research Triangle Park, NC, USA
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25
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Abstract
Idiopathic inflammatory myopathies (IIM), also known as myositis, are a heterogeneous group of autoimmune disorders with varying clinical manifestations, treatment responses and prognoses. Muscle weakness is usually the classical clinical manifestation but other organs can be affected, including the skin, joints, lungs, heart and gastrointestinal tract, and they can even result in the predominant manifestations, supporting that IIM are systemic inflammatory disorders. Different myositis-specific auto-antibodies have been identified and, on the basis of clinical, histopathological and serological features, IIM can be classified into several subgroups - dermatomyositis (including amyopathic dermatomyositis), antisynthetase syndrome, immune-mediated necrotizing myopathy, inclusion body myositis, polymyositis and overlap myositis. The prognoses, treatment responses and organ manifestations vary among these groups, implicating different pathophysiological mechanisms in each subtype. A deeper understanding of the molecular pathways underlying the pathogenesis and identifying the auto-antigens of the immune reactions in these subgroups is crucial to improving outcomes. New, more homogeneous subgroups defined by auto-antibodies may help define disease mechanisms and will also be important in future clinical trials for the development of targeted therapies and in identifying biomarkers to guide treatment decisions for the individual patient.
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26
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Zeng R, Glaubitz S, Schmidt J. Inflammatory myopathies: shedding light on promising agents and combination therapies in clinical trials. Expert Opin Investig Drugs 2021; 30:1125-1140. [PMID: 34779311 DOI: 10.1080/13543784.2021.2003776] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Due to new insights into the pathogenesis of inflammatory myopathies - in short myositis - and the urgent need for new treatment options in patients who are refractory to standard therapy, multiple novel drugs have been developed and studied in clinical trials. In light of this exciting development, a critical evaluation of the present data is necessary in order to identify the best pathway to future treatment of inflammatory myopathies. AREAS COVERED This review focuses on the current evidence from clinical trials in myositis and encompasses dermatomyositis, polymyositis, necrotizing myopathy, antisynthetase-syndrome, overlap myositis, and inclusion body myositis. The results of studies on new therapeutic agents are summarized, in particular larger cohort studies and randomized trials from recent years. When such data were not available, earlier and smaller representative studies were included instead. EXPERT OPINION Current studies in most myositis subtypes have shown positive effects of novel biologicals such as abatacept, sifalimumab, JAK-Inhibitors as well as known agents such as rituximab, but further studies are needed to confirm these observations. In inclusion body myositis, the eagerly awaited recent therapeutic trials have missed their primary endpoints, except for the phase 2 study with rapamycin, which has demonstrated significant improvements in secondary endpoints. Future trials will also need to focus on combination therapies of multiple immunomodulatory agents.
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Affiliation(s)
- Rachel Zeng
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Stefanie Glaubitz
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Muscle Immunobiology Group, Department of Neurology, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany.,Department of Neurology and Pain Treatment, University Hospital of the Medical School Brandenburg, Immanuel Klinik Rüdersdorf, Rüdersdorf bei Berlin, Germany.,Faculty of Health Sciences Brandenburg, Brandenburg Medical School Theodor Fontane, Rüdersdorf bei Berlin, Germany
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27
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Abstract
Purpose of Review The idiopathic inflammatory myopathies are a heterogeneous group of autoimmune disorders characterized by skeletal muscle inflammation leading to chronic muscle weakness. Immune-mediated necrotizing myopathy (IMNM) is a distinct subgroup of inflammatory myopathy typically characterized by myofiber necrosis with minimal inflammatory infiltrates on muscle biopsy, highly elevated creatine kinase levels, and infrequent extra-muscular involvement. This review provides an overview of currently recommended treatment strategies for IMNM, including discussion of disease activity monitoring and recommended first-line immunomodulatory agents depending on clinical phenotype and autoantibody status. Recent Findings IMNM can be divided into three subtypes based on autoantibody positivity: anti-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) IMNM, anti-signal recognition particle (SRP) IMNM, and antibody negative IMNM. Autoantibody status in IMNM has considerable correlation with clinical phenotype, prognosis, and recommended choice of immunosuppressive agent. Patients with anti-HMGCR IMNM tend to respond well to intravenous immunoglobulin (IVIG), and IVIG monotherapy may be sufficient treatment for certain patients. In anti-SRP IMNM, early rituximab is commonly favored. More generally, prompt initiation of aggressive immunosuppression is often indicated, as both anti-SRP and anti-HMGCR IMNM can potentially cause debilitating weakness, and muscle atrophy and irreversible fatty replacement happen early in the disease course. Patients with IMNM frequently require combination therapy to achieve disease control, and have a high rate of relapse when tapering immunosuppression. Young age of onset is a poor prognostic factor. Summary IMNM can be severely disabling and often requires aggressive immunosuppression. For any given patient, the treatment strategy should be informed by the severity of their presenting features and autoantibody status. While our ability to treat IMNM has certainly improved, there remains a need for more prospective trials to inform optimal treatment strategies.
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28
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Egeli BH, Ergun S, Cetin A, Gursoy YK, Ugurlu S. Rituximab as a glucocorticoid-sparing agent in idiopathic inflammatory myopathies: a retrospective single-center cohort study. Clin Rheumatol 2021; 41:123-127. [PMID: 34387760 DOI: 10.1007/s10067-021-05871-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Revised: 07/17/2021] [Accepted: 07/24/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Idiopathic inflammatory myopathies (IIM) are essentially treated aiming to improve muscle function and extra muscular disease manifestations. Rituximab is potentially a glucocorticoid-sparing agent which was reviewed in multiple studies with small sample sizes due to the rarity of the disease. Higher statistical power can enhance the trustworthiness of alternative treatment modalities yielding the main objective of this study. METHODS This retrospective study was conducted at a tertiary rheumatology center. Patients were diagnosed with an idiopathic inflammatory myopathy (dermatomyositis (DM), polymyositis (PM)) and were treated with rituximab to be included in this study. Parameters of disease activity including acute phase reactants, muscle enzyme levels, and disease-specific autoantibodies were analyzed. The primary study endpoint was the improvement of the patient symptoms. The secondary endpoint was the decrease in the creatinine kinase level. RESULTS The study includes 26 patients (19 DM, 7 PM). The age of diagnosis was 42.04 ± 15.22 years; the follow-up duration was 64.84 ± 71.91 months. The mean corticosteroid dose decreased from 32.895 ± 24.399 to 8.44 ± 11.29 (p < 0.001). Other treatment methods were methotrexate (n = 18), intravenous immunoglobulin (IVIG) (n = 7), and cyclophosphamide (n = 2). Two patients were lost to follow-up. CONCLUSION Rituximab is shown to be effective in treating myositis along with corticosteroids as well as a corticosteroid-sparing agent in retrospective studies and open-label clinical trials; however, lack of statistical power should be underlined. Long-term decrease in steroid use and decrease in disease activity markers hint the effective use of rituximab as a glucocorticoid-sparing agent as well as its safety with minimal side effects. Key Points • Long-term decrease in steroid use and decrease in disease activity markers hint the effective use of rituximab as a glucocorticoid-sparing agent as well as its safety with minimal side effects.
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Affiliation(s)
- Bugra Han Egeli
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey.,Department of Pediatrics, Children's Hospital of Los Angeles, University of Southern California, Los Angeles, CA, USA
| | - Sercan Ergun
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Arya Cetin
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Yahya Kerem Gursoy
- Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey
| | - Serdal Ugurlu
- Division of Rheumatology, Department of Internal Medicine, Cerrahpasa Medical Faculty, Istanbul University-Cerrahpasa, Istanbul, Turkey.
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29
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Lundberg IE. Expert Perspective: Management of Refractory Inflammatory Myopathy. Arthritis Rheumatol 2021; 73:1394-1407. [PMID: 33844450 DOI: 10.1002/art.41762] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Accepted: 04/06/2021] [Indexed: 11/10/2022]
Abstract
The idiopathic inflammatory myopathies (IIMs) are chronic disorders characterized by inflammation in skeletal muscle but also in other organs such as the skin, lungs, joints, gastrointestinal tract, and heart. The effect of immunosuppressive treatment varies between individual patients and between organ manifestations within the same individual. Many patients respond poorly to first-line treatment with glucocorticoids and other immunosuppressive agents such as methotrexate or azathioprine, with symptoms persisting in the muscles, skin, and lungs, leading to refractory disease. Management of refractory IIM is a clinical challenge, and a systematic approach is proposed to better understand the lack of treatment response, in order to guide disease management. The first step in the management of refractory IIM is to recognize whether remaining symptoms are caused by persistent inflammation in the affected tissue or whether the symptoms may be attributable to damage preceding inflammation. Thus, a second diagnostic examination is recommended. Second, in particular for patients with remaining muscle weakness, it is important to ascertain whether the diagnosis of myositis is correct or whether another underlying muscle disorder could explain the symptoms. Third, with confirmation of remaining inflammation in the tissues, a strategy to change treatment needs to be undertaken. Few controlled trials are available to guide our treatment strategies. Furthermore, different subgroups of patients may benefit from different therapies, and different organ manifestations may respond to different therapies. In this context, subgrouping of patients with IIM based on autoantibody profile may be helpful, as there are emerging data from open studies and case series to support the notion of a varying treatment response in different autoantibody-defined subgroups of IIM patients.
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Affiliation(s)
- Ingrid E Lundberg
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
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Lim K, Park JS, Yoon BA, Han SH. Necrotizing myopathy presenting as congestive heart failure and life-threatening ventricular arrhythmias: a case report. EUROPEAN HEART JOURNAL-CASE REPORTS 2021; 5:ytab075. [PMID: 34142007 PMCID: PMC8207167 DOI: 10.1093/ehjcr/ytab075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/05/2020] [Revised: 10/22/2021] [Accepted: 02/10/2021] [Indexed: 11/14/2022]
Abstract
Background Necrotizing autoimmune myopathy is a rare subtype of idiopathic inflammatory myopathy; however, it can be associated with fatal cardiac manifestations. Case summary A 58-year-old female patient was referred for congestive heart failure with dysrhythmia. Electrocardiograms showed ventricular arrhythmias of various QRS complex morphologies and coupling intervals with beat-to-beat differences. Despite optimal medical therapy for heart failure, the patient was admitted for the progression of dyspnoea and generalized motor weakness. The burden of non-sustained ventricular tachycardia gradually increased, and ventricular fibrillation eventually occurred. In view of a differential diagnosis of an inflammatory myocardial diseases such as sarcoidosis, a cardiac biopsy was performed. However, pathologic examinations revealed only necrotic muscle fibres without granuloma. Further examinations revealed proximal dominant motor weakness, an elevated serum creatinine-phosphokinase level, myogenic potentials on needle electromyography, and biceps muscle biopsy findings that were compatible with necrotizing autoimmune myopathy. High-dose steroid therapy improved the patient's motor weakness, including her respiratory impairment, and successfully suppressed ventricular arrhythmias. Discussion This case suggests that intensive immunosuppressive therapy with high-dose steroid could be useful in the necrotizing autoimmune myopathy manifested as congestive heart failure and life-threatening ventricular arrhythmias.
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Affiliation(s)
- Kyunghee Lim
- Department of Cardiology, Dong-A University Hospital, 32 Daesingongwon-ro, Seo-gu, Busan 49202, Korea
| | - Jong Sung Park
- Department of Cardiology, Dong-A University Hospital, 32 Daesingongwon-ro, Seo-gu, Busan 49202, Korea
| | - Byeol-A Yoon
- Department of Neurology, Dong-A University Hospital, 32 Daesingongwon-ro, Seo-gu, Busan 49202, Korea
| | - Song-Hee Han
- Department of Pathology, Dong-A University Hospital, 32 Daesingongwon-ro, Seo-gu, Busan 49202, Korea
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Mazeda C, Cunha R, Ferreira PG, Barcelos A, Aguiar R. Myopathy associated with anti-signal recognition particle antibodies with pulmonary involvement and response to rituximab. Rheumatol Int 2021; 42:1265-1269. [PMID: 34086073 DOI: 10.1007/s00296-021-04904-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 05/22/2021] [Indexed: 10/21/2022]
Abstract
The authors present the case of a 76-year-old female patient with progressive decrease in proximal muscle strength, fatigue, dyspnea, diffuse hand edema and painful triphasic Raynaud's phenomenon. Anti-SRP and anti-SSA antibodies were detected, muscle biopsy revealed changes consistent with necrotizing myopathy and capillaroscopy had findings compatible with systemic sclerosis. High-resolution chest computed tomography revealed interstitial lung disease with a non-specific interstitial pneumonia pattern. Lung function tests demonstrated a forced vital capacity 93% and a diffusing capacity for carbon monoxide of 65% predicted. After multidisciplinary discussion, she was diagnosed with immune-mediated necrotizing myopathy/systemic sclerosis overlap syndrome with pulmonary involvement. Initially, dual immunomodulation therapy with high-dose steroids and intravenous immunoglobulin was started, but after 4 weeks, the patient had clinical and analytical deterioration. At this time, she was started on rituximab, with an excellent and sustained response at both muscle and lung, sustained after 12 months.
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Affiliation(s)
- Carolina Mazeda
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal.
| | - Rita Cunha
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
| | | | - Anabela Barcelos
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal.,NOVA National School of Public Health, Public Health Research Centre, NOVA University of Lisboa, Lisboa, Portugal.,Comprehensive Health Research Center, NOVA University of Lisboa, Lisboa, Portugal
| | - Renata Aguiar
- Rheumatology Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal
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Patwardhan A, Spencer CH. Biologics in refractory idiopathic inflammatory myositis (IIM): What experience in juvenile vs adult myositis tells us about the use of biologics in pediatric IIM. Mod Rheumatol 2021; 31:933-948. [PMID: 33499694 DOI: 10.1080/14397595.2021.1881027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Juvenile dermatomyositis (JDM) is an extremely heterogeneous orphan disease with limited amount of dedicated research on the subject matter. Recent research suggests that JDM may not just be the classic antibody driven complements mediated microangiopathy as was thought to be in the past. The etiopathogenesis of JDM also involves inappropriate stimulation of innate immune system followed by dysregulation of the adaptive immune response through dendritic cells. Many variable immune factors such as genetics, major histocompatibility complex expressions, immunohistochemical variabilities, and diversity in specific and associated autoantibodies may make individual IIM and JDM cases unique. The diversity in IIM and JDM also explains individual variability in response to specific therapies. Classifying and matching the right patients to the right treatment is crucial to the successful treatment of these patients with better outcomes. Sub-type specific biologic therapy may be the best current treatment that can match the patient to the best treatment options. A PubMed search was performed to find all the available cases of refractory myositis patients treated with biologics up to July 2020. Using this search this article reviews all the current biologic treatment options and experiences for both adults and children in the context of recent basic science to assist pediatric rheumatologists in choosing the optimal biologic therapy for a child with recalcitrant JDM.
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Affiliation(s)
| | - Charles H Spencer
- University of Mississippi Medical Center, Batson Children's Hospital, Jackson, MS, USA
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Xiong A, Yang G, Song Z, Xiong C, Liu D, Shuai Y, He L, Zhang L, Guo Z, Shuai S. Rituximab in the treatment of immune-mediated necrotizing myopathy: a review of case reports and case series. Ther Adv Neurol Disord 2021; 14:1756286421998918. [PMID: 33786066 PMCID: PMC7958167 DOI: 10.1177/1756286421998918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 02/02/2021] [Indexed: 12/20/2022] Open
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a group of immune-related myopathies characterized by progressive proximal muscle weakness, extremely high serum creatine kinase (CK) levels, and necrotic muscle fibers with a relative lack of inflammation. Treatment of IMNM is challenging, with most cases refractory to high-dose steroids in combination with multiple immunotherapies. The role of rituximab (RTX) for IMNM has been explored in isolated case reports and small series. The aim of this article was to perform a literature review of patients with IMNM treated with RTX and to evaluate RTX efficacy and safety. A total of 34 patients with IMNM were reviewed: 52.9% (18/34) with anti-signal recognition particle (SRP) antibodies and 47.1% (16/34) with anti-3-hydroxy-3-methylglutaryl-CoA reductase (HMGCR) antibodies. Patient age at onset varied from 11 years to 81 years (mean 41 years). The majority of patients presented as a severe proximal muscle weakness and the peak level of CK varied from 3900 IU/L to 56,000 IU/L (mean 18,440 IU/L). Prior to RTX administration, all patients were treated with high-dose steroids and most were treated with multiple immunotherapies. The reason for initiating RTX was that 64.7% (22/34) of patients showed no improvement after previous treatments, and 35.3% (12/34) of patients relapsed when attempting to wean steroids or other immunosuppressive agents. With regard to RTX efficacy, 61.8% (21/34) of patients presented a response to RTX. Our data may support the use of RTX as an effective treatment strategy against IMNM resistant to steroids and multiple immunotherapies. Meanwhile, RTX as a first-line therapy could be a choice in IMNM, particularly in African Americans with anti-SRP antibody-positive subsets. ANA, antinuclear antibody; CK, creatine kinase; HMGCR, 3-hydroxy-3-methylglutaryl-CoA reductase; IMNM, immune-mediated necrotizing myopathy; MAC, membrane attack complex; MHC-I, major histocompatibility complex-I; RTX, rituximab; SRP, signal recognition particle.
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Affiliation(s)
- Anji Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, No.97, Renmin Nan Lu, Nanchong, Sichuan, China
| | - Guancui Yang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, The Second Clinical Medical College, North Sichuan Medical College, No.97,Renmin Nan Lu, Nanchong, Sichuan, China
| | - Zhuoyao Song
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Chen Xiong
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Deng Liu
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Yu Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Linqian He
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Liangwen Zhang
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Zepeng Guo
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
| | - Shiquan Shuai
- Department of Rheumatology and Immunology, Nanchong Central Hospital, Nanchong, Sichuan, China
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Zhao L, Wang Q, Zhou B, Zhang L, Zhu H. The Role of Immune Cells in the Pathogenesis of Idiopathic Inflammatory Myopathies. Aging Dis 2021; 12:247-260. [PMID: 33532139 PMCID: PMC7801271 DOI: 10.14336/ad.2020.0410] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 04/10/2020] [Indexed: 12/15/2022] Open
Abstract
Idiopathic inflammatory myopathies (IIMs) are chronic autoimmune disorders involving multiple organs, such as the muscle, skin, lungs and joints. Although the detailed pathogenesis of IIMs remains unclear, immune mechanisms have long been recognised as of key importance. Immune cells contribute to many inflammatory processes via intercellular interactions and secretion of inflammatory factors, and many studies have demonstrated the participation of a variety of immune cells, such as T cells and B cells, in the development of IIMs. Here, we summarise the current knowledge regarding immune cells in IIM patients and discuss their potential roles in IIM pathogenesis.
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Affiliation(s)
- Lijuan Zhao
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, Hunan, China.
| | - Qi Wang
- Department of Radiology, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China.
| | - Bin Zhou
- Department of Nephrology, The Affiliated Hospital of Qingdao University, Qingdao, China.
| | - Lihua Zhang
- Department of Rheumatology, Hunan Provincial People's Hospital and The First Affiliated Hospital of Hunan Normal University, Changsha, Hunan, China.
| | - Honglin Zhu
- Department of Rheumatology, Xiangya Hospital, Central South University, Changsha, Hunan, China.
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Dalakas MC. Inflammatory myopathies: update on diagnosis, pathogenesis and therapies, and COVID-19-related implications. ACTA MYOLOGICA : MYOPATHIES AND CARDIOMYOPATHIES : OFFICIAL JOURNAL OF THE MEDITERRANEAN SOCIETY OF MYOLOGY 2020; 39:289-301. [PMID: 33458584 PMCID: PMC7783437 DOI: 10.36185/2532-1900-032] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/09/2020] [Indexed: 12/11/2022]
Abstract
The inflammatory myopathies constitute a heterogeneous group of acquired myopathies that have in common the presence of endomysial inflammation. Based on steadily evolved clinical, histological and immunopathological features and some autoantibody associations, these disorders can now be classified in five characteristic subsets: Dermatomyositis (DM) Polymyositis (PM), Necrotizing Autoimmune Myositis (NAM), Anti-synthetase syndrome-overlap myositis (Anti-SS-OM), and Inclusion-Body-Myositis (IBM). Each inflammatory myopathy subset has distinct immunopathogenesis, prognosis and response to immunotherapies, necessitating the need to correctly identify each subtype from the outset to avoid disease mimics and proceed to early therapy initiation. The review presents the main clinicopathologic characteristics of each subset highlighting the importance of combining expertise in clinical neurological examination with muscle morphology and immunopathology to avoid erroneous diagnoses and therapeutic schemes. The main autoimmune markers related to autoreactive T cells, B cells, autoantibodies and cytokines are presented and the concomitant myodegenerative features seen in IBM muscles are pointed out. Most importantly, unsettled issues related to a role of autoantibodies and controversies with reference to possible triggering factors related to statins are clarified. The emerging effect SARS-CoV-2 as the cause of hyperCKemia and potentially NAM is addressed and practical guidelines on the best therapeutic approaches and concerns regarding immunotherapies during COVID-19 pandemic are summarized.
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Affiliation(s)
- Marinos C Dalakas
- Department of Neurology, Thomas Jefferson University, Philadelphia, PA USA and the Neuroimmunology Unit, National and Kapodistrian University University of Athens Medical School, Athens, Greece
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36
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Supervised Physical Therapy and Polymyositis/Dermatomyositis-A Systematic Review of the Literature. Neurol Int 2020; 12:77-88. [PMID: 33255200 PMCID: PMC7768488 DOI: 10.3390/neurolint12030015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 05/28/2020] [Indexed: 11/23/2022] Open
Abstract
Objective: to find the most up-to-date evidence of the effectiveness and safety of supervised physical therapy in polymyositis/dermatomyositis patients. Methods: a systematic review of the literature in the main scientific databases was carried out. We searched for randomized controlled trials concerning supervised physical therapy and polymyositis/dermatomyositis. The PICOS method was used for the formulation of the clinical query. Methodological quality and the level of evidence of the included studies were assessed using the modified Jadad scale and the Oxford Centre for Evidence-Based Medicine Levels of Evidence guide, respectively. Results: a total of 2591 articles were found. By applying the inclusion/exclusion criteria, six randomized controlled clinical trials were admitted to the final phase of the review. The compared approaches concerned supervised exercise programs based on strategies of muscle strengthening or aerobic work. Following these exercises, an increase in the maximum rate of oxygen consumption, a decrease in creatine phosphokinase levels, an enhancement in the patient’s aerobic performance and an improvement in the quality of life indexes were registered. The methodological quality of the included studies ranged from 3 to 4.5. All the studies were classified as presenting an evidence level of 2b. Conclusions: supervised physical therapy in polymyositis/dermatomyositis is an effective, safe and free-of-contraindications tool to be used both in the acute and in the established phases of the pathology. However, further and higher-quality studies are necessary to confirm those findings, to clarify the timing of exercise delivery and to guide the choice towards different types of muscle contraction exercises.
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Allenbach Y, Benveniste O, Stenzel W, Boyer O. Immune-mediated necrotizing myopathy: clinical features and pathogenesis. Nat Rev Rheumatol 2020; 16:689-701. [PMID: 33093664 DOI: 10.1038/s41584-020-00515-9] [Citation(s) in RCA: 116] [Impact Index Per Article: 29.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/17/2020] [Indexed: 12/11/2022]
Abstract
Immune-mediated necrotizing myopathy (IMNM) is a group of inflammatory myopathies that was distinguished from polymyositis in 2004. Most IMNMs are associated with anti-signal recognition particle (anti-SRP) or anti-3-hydroxy-3-methylglutaryl-coA reductase (anti-HMGCR) myositis-specific autoantibodies, although ~20% of patients with IMNM remain seronegative. These associations have led to three subclasses of IMNM: anti-SRP-positive IMNM, anti-HMGCR-positive IMNM and seronegative IMNM. IMNMs are frequently rapidly progressive and severe, displaying high serum creatine kinase levels, and failure to treat IMNMs effectively may lead to severe muscle impairment. In patients with seronegative IMNM, disease can be concomitant with cancer. Research into IMNM pathogenesis has shown that anti-SRP and anti-HMGCR autoantibodies cause weakness and myofibre necrosis in mice, suggesting that, as well as being diagnostic biomarkers of IMNM, they may play a key role in disease pathogenesis. Therapeutically, treatments such as rituximab or intravenous immunoglobulins can now be discussed for IMNM, and targeted therapies, such as anticomplement therapeutics, may be a future option for patients with refractory disease.
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Affiliation(s)
- Yves Allenbach
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Inserm U974, Department of Internal Medicine and Clinical Immunology, Pitié-Salpêtrière University Hospital, Paris, France
| | - Olivier Benveniste
- Sorbonne Université, Assistance Publique - Hôpitaux de Paris, Inserm U974, Department of Internal Medicine and Clinical Immunology, Pitié-Salpêtrière University Hospital, Paris, France.
| | - Werner Stenzel
- Department of Neuropathology, Charité -Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Olivier Boyer
- Normandie University, UNIROUEN, Inserm U1234, Department of Immunology and Biotherapy, Rouen University Hospital, Rouen, France
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Soares IFZ, Comprido VF, Hsu BRRHS, Alves de Siqueira Carvalho A. Immune-mediated necrotising myopathy in asymptomatic patients with high creatine kinase. BMJ Case Rep 2020; 13:13/10/e235457. [PMID: 33033004 DOI: 10.1136/bcr-2020-235457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Subacute symmetrical proximal muscle weakness and persistent elevated creatine kinase levels are typical of immune-mediated necrotising myopathy (IMNM). These conditions are accompanied by copious myofibre necrosis, degeneration and regeneration with minimal to no inflammation on muscle biopsy. We report two cases (case 1 and case 2) of asymptomatic IMNM from different families with hyperCKaemia associated with positive anti-signal recognition particle (SRP) and anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR) antibodies, respectively, and we also reviewed the literature. There are only a few previous descriptions of patients with asymptomatic IMNM.The disease onset could be insidious and lead to delayed diagnosis and treatment. We recommend testing for the anti-HMGCR and anti-SRP antibodies in patients with idiopathic hyperCKaemia because they could show no symptoms of this disorder.
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Abstract
Purpose of review The purpose of this paper is to comprehensively evaluate secondary causes of inflammatory myopathies (myositis) and to review treatment options. Recent findings This review highlights recent advancements in our understanding of known causes of myositis, including newer drugs that may cause myositis such as checkpoint inhibitors and viruses such as influenza, HIV, and SARS-CoV2. We also discuss treatment for malignancy-associated myositis and overlap myositis, thought to be a separate entity from other rheumatologic diseases. Summary Infections, drugs, rheumatologic diseases, and malignancies are important causes of myositis and are important to diagnose as they may have specific therapies beyond immunomodulatory therapy.
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Affiliation(s)
- Sarah H Berth
- Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD USA
| | - Thomas E Lloyd
- Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, MD USA
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Barrons R, Woods JA, Humphries R. Statin Associated Autoimmune Myonecrosis: Case Report With Delayed Onset and Treatment Challenges. J Pharm Pract 2020; 35:129-134. [PMID: 32924771 DOI: 10.1177/0897190020958223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
PURPOSE A case of delayed statin associated autoimmune myopathy (SAAM) is presented along with review of clinical findings and treatment strategies. SUMMARY A 54 year old male presented with proximal extremity weakness, difficulty ambulating, and dysphagia. Symptoms began when restarting atorvastatin 40 mg daily for a recent NSTEMI, following 10 years of statin use, interrupted after diagnosis of NASH. Relevant labs included CK of 13,618 IU/L, ALT/ AST of 568/407 IU/L, while additional liver, renal, and toxicology tests were normal. Following treatment response to prednisone 40 mg daily for 3 days, outpatient testing for anti-HMGCR antibodies was ordered.Twelve days from discharge, the patient was readmitted for myalgia and dysphagia, CK = 6042 IU/L, ALT/AST = 360/112 IU/L, and positive anti-HMGCR antibodies. Newly diagnosed with SAAM, symptoms improved with methylprednisolone and intravenous immunoglobulin (IVIG), continuing outpatient as daily prednisone and monthly IVIG. Four days later, the patient relapsed with worsened weakness and dysphagia, CK = 5812 IU/L, and ALT/AST = 647/337 IU/L. After response to methylprednisolone and rituximab, the patient was discharged on a corticosteroid taper, biweekly rituximab, and monthly IVIG. Two weeks later, a final admission involved a syncopal episode and fall, with a CK = 1461 IU/L. Treatment included IVIG, rituximab, and corticosteroid taper, which lead to remission for greater than 6 months. CONCLUSION Statin associated autoimmune myopathy occurred when restarting atorvastatin, following 10 years of statin use. Clinical findings and positive anti-HMGCR antibodies confirmed the diagnosis. Recurrent relapses required triple combination therapy including addition of rituximab to achieve remission.
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Zhao Y, Zhang W, Liu Y, Wang Z, Yuan Y. Factors associated with refractory autoimmune necrotizing myopathy with anti-signal recognition particle antibodies. Orphanet J Rare Dis 2020; 15:181. [PMID: 32641139 PMCID: PMC7341563 DOI: 10.1186/s13023-020-01431-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 05/28/2020] [Indexed: 12/21/2022] Open
Abstract
Background Autoimmune necrotizing myopathy with anti-signal recognition particle antibodies (ANM-SRP) is regarded as refractory myositis, whereby some patients respond poorly to conventional immunosuppression and require B cell depletion treatment. This study aimed to evaluate factors associated with refractory ANM-SRP. Results Clinical and pathological data from 48 patients with ANM-SRP were collected. We followed up clinical symptoms and image changes over 12 months. Univariate and multivariate analyses were undertaken to determine the associations between variables of interest and poor response to therapy. Refractory ANM-SRP appeared in 32.5% of patients who showed no or minimal improvement after 12 months of steroid therapy. The clinical risk factors for refractory patients were being male (OR, 19.57; P < 0.001), severe muscle weakness (OR, 7.51; P < 0.001) and concurrent interstitial lung disease (OR, 39.70; P < 0.001). The imaging refractory-related factor was the fatty infiltration rate of thigh muscles over 3 months (P = 0.022) and the pathological factor associated with refractory ANM-SRP was the high expression of B cell activating factor receptor (BAFF-R) in muscle (P = 0.036). Conclusion Being male, severe muscle weakness, concurrent interstitial lung disease, quick development of muscle fatty infiltration and more BAFF-R and B lymphocyte infiltration in muscle indicate a poor response to immunosuppressive therapy in patients with ANM-SRP.
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Affiliation(s)
- Yawen Zhao
- Department of Neurology, Peking University First Hospital, No. 8 Xishku Street, Xicheng District, Beijing, 100034, PR China
| | - Wei Zhang
- Department of Neurology, Peking University First Hospital, No. 8 Xishku Street, Xicheng District, Beijing, 100034, PR China
| | - Yilin Liu
- Department of Neurology, Peking University First Hospital, No. 8 Xishku Street, Xicheng District, Beijing, 100034, PR China
| | - Zhaoxia Wang
- Department of Neurology, Peking University First Hospital, No. 8 Xishku Street, Xicheng District, Beijing, 100034, PR China
| | - Yun Yuan
- Department of Neurology, Peking University First Hospital, No. 8 Xishku Street, Xicheng District, Beijing, 100034, PR China.
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Thomas R, Yeoh SA, Berkeley R, Woods A, Stevens M, Marino S, Radunovic A. Initial seronegative immune-mediated necrotising myopathy with subsequent anti-HMGCR antibody development and response to rituximab: case report. BMC Rheumatol 2020; 4:29. [PMID: 32613157 PMCID: PMC7325302 DOI: 10.1186/s41927-020-00128-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 03/31/2020] [Indexed: 11/23/2022] Open
Abstract
Background Immune-mediated necrotising myopathy (IMNM) is characterised by severe muscle weakness and necrosis with a paucity of inflammation on muscle biopsy. Around 60% of cases are associated with antibodies to the signal recognition particle (SRP) or 3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR); the remainder are seronegative. IMNM is more treatment resistant than inflammatory myopathies. Case presentation A 69-year-old woman with previous statin exposure presented aged 63 with muscle weakness and raised creatinine kinase (CK). Anti-SRP and anti-HMGCR antibodies were not detected, but muscle biopsy revealed changes consistent with necrotising myopathy. Statins were discontinued, and she was treated with prednisolone and methotrexate achieving disease remission. Clinical and biochemical parameters were largely stable until 6 years after diagnosis she experienced a rapid deterioration. This was found to be associated with new development of anti-HMGCR antibody. Rituximab was commenced, resulting rapidly in remission. She has remained in remission since, following 2 cycles of rituximab. Conclusions To our knowledge, this is the first reported case of serologically negative IMNM whose subsequent rapid deterioration was associated with development of anti-HMGCR antibody. The response to rituximab and subsequent sustained remission suggests a role for early use of rituximab in aggressive cases of anti-HMGCR myopathy.
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Affiliation(s)
- Rhys Thomas
- Department of Rheumatology, Whipps Cross Hospital, Whipps Cross University Hospital, Barts Health NHS Trust, London, E11 1NR UK
| | - Su-Ann Yeoh
- Department of Rheumatology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Rupert Berkeley
- Department of Radiology, Royal London Hospital, Barts Health NHS Trust, London, UK
| | - Andrew Woods
- Department of Immunology, Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire UK
| | - Mike Stevens
- Department of Pathology, Barts Health NHS Trust, London, UK
| | - Silvia Marino
- Department of Pathology, Barts Health NHS Trust, London, UK.,Department of Neuropathology, Barts Health NHS Trust, London, UK
| | - Aleksandar Radunovic
- Department of Neurology, Royal London Hospital, Barts Health NHS Trust, London, UK
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43
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Patwardhan A. The Value of Intravenous Immunoglobulin Therapy in Idiopathic Inflammatory Myositis in the Current Transformed Era of Biologics. Cureus 2020; 12:e7049. [PMID: 32128294 PMCID: PMC7034746 DOI: 10.7759/cureus.7049] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 01/29/2020] [Indexed: 12/26/2022] Open
Abstract
The understanding of etiology and pathogenesis of idiopathic immune myositis is fast evolving, and so is the classification of myositis subtypes. The diversity in genetics, major histocompatibility complex expressions, immunohistochemical, and specific and associated autoantibodies not only explains the individual variability in response to therapies but also begs for subtype-specific treatments. With the evolution of the new biological therapies, the treatment of idiopathic immune myositis (IIM) has greatly transformed in recent years. This article appraises the current therapeutic value of intravenous immunoglobulin (IVIg) in idiopathic immune myopathy patients in the era of transformed treatment options. This article argues why the IVIg therapy still retains its value as an unreplaceable treatment option in certain specific subtypes of idiopathic immune myositis patients as well as in certain specific clinical idiopathic immune myositis scenarios.
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Wu JQ, Lu MP, Reed AM. Juvenile dermatomyositis: advances in clinical presentation, myositis-specific antibodies and treatment. World J Pediatr 2020; 16:31-43. [PMID: 31556011 DOI: 10.1007/s12519-019-00313-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/29/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Juvenile dermatomyositis (JDM) is a chronic autoimmune disease characteristic by inflammation of small vessels within the skin, muscle and vital organs. But the clinical features and treatment of JDM have not been fully clarified. DATA SOURCES Databases underwent through PubMed for articles about the clinical features, myositis-specific antibodies of JDM and its treatment, and we selected publications written in English which were relevant to the topic of this review. RESULTS Clinical features and myositis-specific antibodies may predict the severity and prognosis of disease. Although the mortality rate has been lower with traditional treatments, such as corticosteroid, intravenous immunoglobulin, and disease-modifying anti-rheumatic drugs such as methotrexate, their usages are variable. Novel biological therapies seem to be effective for refractory JDM patients, but more clinical trials are necessary. CONCLUSIONS JDM is a sever disease of childhood. We need to better understand recent advances of JDM in the context of clinical features including skin manifestations, muscle weakness and organ damage, myositis-specific antibodies and their associated outcomes and the treatment of disease.
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Affiliation(s)
- Jian-Qiang Wu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Mei-Ping Lu
- Department of Rheumatology Immunology and Allergy, Children's Hospital, Zhejiang University School of Medicine, Hangzhou, 310052, China
| | - Ann M Reed
- Department of Pediatrics, Division of Pediatric Rheumatology, Duke University School of Medicine, Durham, 27710, USA.
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Glaubitz S, Zeng R, Schmidt J. New insights into the treatment of myositis. Ther Adv Musculoskelet Dis 2020; 12:1759720X19886494. [PMID: 31949477 PMCID: PMC6950531 DOI: 10.1177/1759720x19886494] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2019] [Accepted: 10/10/2019] [Indexed: 12/17/2022] Open
Abstract
The myositis syndromes include polymyositis, dermatomyositis (DM), necrotizing myopathy, inclusion body myositis (IBM), antisynthetase syndrome and overlap syndromes with myositis. These syndromes mostly occur in middle-aged patients, while juvenile DM occurs in children and adolescents. Patients mostly show a subacute weakness and myalgia in the upper and lower limbs, the diagnosis is based upon these clinical findings in combination with muscle biopsy results and specific serum autoantibodies. In recent years, research achieved a better understanding about the molecular mechanism underlying the myositis syndromes, as well as disease progress and extramuscular organ manifestations, such as interstitial lung disease and association with neoplasias. Treatment mainly consists of glucocorticosteroids and immunosuppressants. IBM is usually refractory to treatments. This review provides an overview of the current standards of treatment and new treatment options like monoclonal antibodies and new molecular therapies and their first results from clinical trials.
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Affiliation(s)
- Stefanie Glaubitz
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Rachel Zeng
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Göttingen, Germany
| | - Jens Schmidt
- Department of Neurology, Muscle Immunobiology Group, Neuromuscular Center, University Medical Center Göttingen, Robert-Koch-Sr. 40, 37075 Göttingen, Germany
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Nasonov EL, Beketova TV, Ananyeva LP, Vasilyev VI, Solovyev SK, Avdeeva AS. PROSPECTS FOR ANTI-B-CELL THERAPY IN IMMUNO-INFLAMMATORY RHEUMATIC DISEASES. RHEUMATOLOGY SCIENCE AND PRACTICE 2019. [DOI: 10.14412/1995-4484-2019-3-40] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Affiliation(s)
- E L. Nasonov
- V.A. Nasonova Research Institute of Rheumatology; I.M. Sechenov First Moscow State Medical University (Sechenov University), Ministry of Health of Russia
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Aggarwal R, Moghadam-Kia S, Lacomis D, Malik A, Qi Z, Koontz D, Burlingame RW, Oddis CV. Anti-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibody in necrotizing myopathy: treatment outcomes, cancer risk, and role of autoantibody level. Scand J Rheumatol 2019; 49:405-411. [PMID: 31801390 DOI: 10.1080/03009742.2019.1672782] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Objective: To evaluate clinical associations of anti-hydroxy-3-methylglutaryl-coenzyme A reductase (anti-HMGCR) antibody (Ab) and statin exposure in necrotizing myopathy (NM) patients. Methods: NM without a known myositis-specific autoantibody (MSA) was ascertained from a large single-centre myositis database between 1985 and 2012. A comparison NM cohort included 32 anti-SRP+ autoantibody patients, and other control groups included 74 non-NM myositis patients and 21 non-myositis controls. Sera from all cases and controls were tested using a validated anti-HMGCR enzyme-linked immunosorbent assay. Clinical features including statin use and anti-HMGCR Ab status were compared between cases and controls. Results: Of the 256 NM muscle biopsies reviewed, only 48 subjects with available sera were identified as traditional MSA-negative NM. Anti-HMGCR positivity was significantly (p < 0.001) associated with MSA-negative NM [48% (23/48)] compared to all of the myositis and non-myositis controls [5% (6/127)]. Most anti-HMGCR Ab-positive NM patients had high titres of anti-HMGCR (83%) and a history of statin exposure (78%), along with severe muscle weakness, high creatine kinase (CK) levels (90% ≥ 5000 IU/L), a paucity of other organ manifestations, and the need for immunosuppression with prednisone and methotrexate, but generally favourable outcomes. Anti-HMGCR serum levels were associated with baseline CK levels but not muscle weakness. Conclusion: HMGCR Ab-positive NM patients are associated with statin exposure, have severe muscle weakness and high CK at presentation, lack other organ manifestations, and generally have favourable outcomes from immunosuppression. Anti-HMGCR Abs should be assessed in MSA-negative NM patients, particularly those with a history of statin exposure.
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Affiliation(s)
- R Aggarwal
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | - S Moghadam-Kia
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | - D Lacomis
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | - A Malik
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | - Z Qi
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | - D Koontz
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh , Pittsburgh, PA, USA
| | | | - C V Oddis
- Division of Rheumatology and Clinical Immunology, Department of Medicine, University of Pittsburgh , Pittsburgh, PA, USA
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49
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Zhang W, Prince HM, Reardon K. Statin-induced anti-HMGCR antibody-related immune-mediated necrotising myositis achieving complete remission with rituximab. BMJ Case Rep 2019; 12:12/11/e232406. [PMID: 31791994 DOI: 10.1136/bcr-2019-232406] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Statin-induced immune-mediated necrotising myopathy (IMNM) is a rare but increasingly recognised myositis. Many cases have positive antibodies to 3-hydroxy-3-methylglutaryl coenzyme A reductase (anti-HMGCR). The current treatment is ceasing the statin, but often immunosuppressive therapy is required as the antibodies persist, causing muscle necrosis. Despite the use of immunosuppressive medications, most commonly prednisolone, methotrexate, plasma exchange and/or intravenous immunoglobulin, some patients do not respond. We report the successful treatment with rituximab therapy for three patients with IMNM with positive anti-HMGCR antibodies. All three patients with statin-induced IMNM were elderly, with a disease history of 7-9 years, and had failed several immunosuppressive agents. They responded well to rituximab (induction and maintenance) therapy. They remain in remission with no symptoms and normal creatine kinase. One patient had normalisation of anti-HMGCR antibody level, and one patient's antibody level reduced significantly. Rituximab is an effective immunosuppressive treatment for patients with refractory IMNM.
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Affiliation(s)
- Wenwen Zhang
- Department of Neurology and Neurological Research, St Vincent's Hospital, Fitzroy, Victoria, Australia
| | - Henry Miles Prince
- Department of Hematology, Cell Therapies, Peter MacCallum Cancer Centre, Melbourne, Victoria, Australia
| | - Katrina Reardon
- Department of Neurology and Neurological Research, St Vincent's Hospital, Fitzroy, Victoria, Australia
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Khoo T, Limaye V. Biologic therapy in the idiopathic inflammatory myopathies. Rheumatol Int 2019; 40:191-205. [PMID: 31680207 DOI: 10.1007/s00296-019-04467-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2019] [Accepted: 10/24/2019] [Indexed: 11/29/2022]
Abstract
The idiopathic inflammatory myopathies (IIM) are a group of autoimmune diseases resulting from inflammation of muscle and manifesting as weakness, though a range of extra-muscular manifestations are observed. These are often correlated closely with disease subtype and the presence of myositis-specific/myositis-associated antibodies. IIM are notoriously difficult to treat and often refractory to glucocorticoid therapy and synthetic immunosuppressants. Both the innate and adaptive immune systems are implicated in the pathogenesis of IIM. A growing understanding of the key cytokines as well as the cell-mediated and antibody effectors of disease has identified multiple potential targets for biologic therapy. The most widely used of these is B-cell depletion via rituximab though the tumour necrosis factor inhibitors and other biologic therapies used in diseases such as rheumatoid arthritis, systemic lupus erythematosus and multiple sclerosis have also been trialled. This review summarises the literature thus far on biologic therapy in IIM, highlighting both the significant trials that influence current treatment regimens and also the continuing need for further research to inform more effective therapies.
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Affiliation(s)
- Thomas Khoo
- Central Adelaide Local Health Network, Adelaide, Australia
| | - Vidya Limaye
- Rheumatology Unit, Royal Adelaide Hospital, Adelaide, Australia. .,Discipline of Medicine, School of Medicine, University of Adelaide, Adelaide, Australia.
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