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Clinical and autoantibody phenotypes of juvenile dermatomyositis. Reumatologia 2022; 60:281-291. [PMID: 36186835 PMCID: PMC9494788 DOI: 10.5114/reum.2022.119045] [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: 05/12/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
Juvenile dermatomyositis (JDM) is a heterogeneous autoimmune inflammatory myositis with symmetrical proximal muscle weakness and a characteristic rash. Juvenile dermatomyositis is characterized by variable presentation and phenotypes. Detection of myositis autoantibodies is useful in improving JDM diagnosis and predicting the prognosis. In this literature review based on case series we analyze clinical and autoantibody phenotypes of JDM in four patients who were hospitalized in one regional center in Ukraine during the last 3 years and three of them presented in the time of the COVID-19 pandemic. The reviewed literature showed the last updates for the JDM diagnosis and the role of myositis autoantibodies in the prediction of disease course, systemic involvement, and malignancy risk. The presence of anti-synthetase syndrome in all presented patients, mainly due to anti-PL-7 autoantibodies, encourages further study with more patients and with detection of other myositis-specific autoantibodies to identify or refute certain regional features.
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Li Y, Izem R. Novel clinical trial design and analytic methods to tackle challenges in therapeutic development in rare diseases. ANNALS OF TRANSLATIONAL MEDICINE 2022; 10:1034. [PMID: 36267797 PMCID: PMC9577738 DOI: 10.21037/atm-21-5496] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 02/28/2022] [Indexed: 12/03/2022]
Abstract
While only a fraction of the worldwide population may have a particular rare disorder, millions of people worldwide are affected across the over 6,000 rare disorders and do not have a safe and effective approved therapy to help them live or manage complications from the disorder. Challenges to clinical development of new therapies in rare disorders include difficulty in powering and recruiting into a study in small and often heterogenous population, scarcity of natural history data informing critical design elements such as endpoint selection and study duration, and ethical and recruitment challenges in randomizing patients to a placebo arm. In this review, we describe some existing and novel strategies to tackle these challenges, by efficient utilization of available resources. We discuss the role of natural history studies and endpoint selection as they remain critical features that apply across designs and disorders. We also review some novel clinical trial designs including incorporating external control and/or longitudinal measures, master protocol designs, and adaptive designs. Additionally, we review some analytic strategies that are often associated with these designs, such as the use of causal inference methods, and Bayesian methods. We hope this review will raise awareness of these novel approaches and encourage their use in studies of rare diseases.
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Affiliation(s)
- Yimei Li
- Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania Perelman School of Medicine, PA, USA
| | - Rima Izem
- Statistical Methodology and Consulting, Novartis, Basel, Switzerland
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Elahmar H, Feldman BM, Johnson SR. Management of calcinosis cutis in rheumatic diseases. J Rheumatol Suppl 2022; 49:980-989. [PMID: 35569832 DOI: 10.3899/jrheum.211393] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/05/2022] [Indexed: 11/22/2022]
Abstract
Calcinosis (hydroxyapatite and calcium phosphate crystal deposition) within the extracellular matrix of the dermis and subcutaneous tissue is a frequent manifestation of adult and pediatric systemic autoimmune rheumatic diseases, specifically systemic sclerosis, dermatomyositis, mixed connective tissue disease and systemic lupus erythematosus. In this article, we review classification of calcinosis, highlight mechanisms that may contribute to the pathogenesis of calcinosis and summarize the evidence evaluating non-pharmacologic and pharmacologic interventions for the treatment of calcinosis.
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Affiliation(s)
- Hadiya Elahmar
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
| | - Brian M Feldman
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
| | - Sindhu R Johnson
- Hadiya Elahmar MD, Dermatologist at U-turn Dermatology Clinic, Kuwait; Dermatology and Venerology, Ain Shams University, Cairo, Egypt. Brian M Feldman MD MSc, Pediatrics, Medicine, Institute of Health Policy Management and Evaluation, University of Toronto, The Hospital for Sick Children, Toronto, Ontario, Canada. Sindhu R Johnson MD PhD, Toronto Scleroderma Program, Mount Sinai Hospital, Toronto Western Hospital, Institute of Health Policy Management and Evaluation, University of Toronto, Toronto, Ontario, Canada. Funding: Dr. Johnson is supported by a Canadian Institutes of Health Research New Investigator Award, Gurmej Kaur Dhanda Scleroderma Research Award, and the Oscar and Elanor Markovitz Scleroderma Research Fund. Dr. Feldman holds the Ho Family Chair in Autoimmune Diseases. Corresponding Author. Dr. Sindhu Johnson, Division of Rheumatology, Ground Floor, East Wing, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario, Canada, M5T 2S8. Phone 1-416-603-6417 Fax.1-416-603-4348.
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Orandi AB, Fotis L, Lai J, Morris H, White AJ, French AR, Baszis KW. Favorable outcomes with reduced steroid use in juvenile dermatomyositis. Pediatr Rheumatol Online J 2021; 19:127. [PMID: 34404425 PMCID: PMC8369654 DOI: 10.1186/s12969-021-00615-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 06/14/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND High-intensity glucocorticoid regimens are commonly used to induce and maintain remission in Juvenile Dermatomyositis but are associated with several adverse side-effects. Evidence-based treatment guidelines from North American and European pediatric rheumatology research societies both advocate induction with intravenous pulse steroids followed by high dose oral steroids (2 mg/kg/day), which are then tapered. This study reports the time to disease control with reduced glucocorticoid dosing. METHODS We retrospectively reviewed the records at a single tertiary-care children's hospital of patients diagnosed with Juvenile Dermatomyositis between 2000 and 2014 who had a minimum of 2 years of follow-up. The primary outcome measure was time to control of muscle and skin disease. Additional outcome measures included glucocorticoid dosing, effect of treatment on height, frequency of calcinosis, and complications from treatment. RESULTS Of the 69 patients followed during the study period, 31 fulfilled inclusion criteria. Median length of follow-up was 4.58 years, (IQR 3-7.5). Myositis control was achieved in a median of 7.1 months (IQR 0.9-63.4). Cutaneous disease control was achieved in a median of 16.7 months (IQR 4.3-89.5). The median starting dose of glucocorticoids was 0.85 mg/kg/day, (IQR 0.5-1.74). The median duration of steroid treatment was 9.1 months, (IQR 4.7-17.4), while the median duration of any pharmacotherapy was 29.2 months (IQR 10.4 to 121.3). Sustained disease control off medications was achieved in 21/31 (68%) patients by the end of review. Persistent calcinosis was identified in only one patient (3%). CONCLUSION Current accepted treatment paradigms for Juvenile Dermatomyositis include oral glucocorticoids beginning at 2 mg/kg/day and reduced over a prolonged time period. However, our results suggest that treatment using reduced doses and duration with early use of steroid-sparing agents is comparably effective in achieving favorable outcomes in Juvenile Dermatomyositis.
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Affiliation(s)
- Amir B. Orandi
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA ,grid.66875.3a0000 0004 0459 167XPresent Address: Department of Pediatric and Adolescent Medicine, Division of Pediatric Rheumatology, Mayo Clinic, Rochester, MN USA
| | - Lampros Fotis
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA ,grid.5216.00000 0001 2155 0800Present Address: Department of Pediatrics, Division of Pediatric Rheumatology, National and Kapodistrian University of Athens, Athens, Greece
| | - Jamie Lai
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA ,grid.39382.330000 0001 2160 926XPresent Address: Department of Pediatrics, Division of Pediatric Rheumatology, Baylor College of Medicine, Houston, TX USA
| | - Hallie Morris
- grid.4367.60000 0001 2355 7002Department of Pediatrics, Washington University School of Medicine, St. Louis, MO USA ,grid.253615.60000 0004 1936 9510Present Address: Division of Neonatology, George Washington University School of Medicine and Health Science, Washington, D.C, USA
| | - Andrew J. White
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
| | - Anthony R. French
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
| | - Kevin W. Baszis
- grid.4367.60000 0001 2355 7002Division of Pediatric Rheumatology/Immunology, Washington University of School of Medicine, St Louis, MO USA
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Kobayashi I, Akioka S, Kobayashi N, Iwata N, Takezaki S, Nakaseko H, Sato S, Nishida Y, Nozawa T, Yamasaki Y, Yamazaki K, Arai S, Nishino I, Mori M. Clinical practice guidance for juvenile dermatomyositis (JDM) 2018-Update. Mod Rheumatol 2020; 30:411-423. [PMID: 31955618 DOI: 10.1080/14397595.2020.1718866] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Juvenile dermatomyositis is the most common type of juvenile idiopathic inflammatory myopathy mainly affecting the skin and proximal muscles. We have published the Japanese version of 'Clinical practice guidance for juvenile dermatomyositis (JDM) 2018 'consisting of a review of articles in the field and evidence-informed consensus-based experts' opinion on the treatment strategy in collaboration with The Pediatric Rheumatology Association of Japan and The Japan College of Rheumatology under the financial support by 'Research on rare and intractable diseases, Health and Labor Sciences Research Grants'. This article is a digest version of the Japanese guidance.
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Affiliation(s)
- Ichiro Kobayashi
- Center for Pediatric Allergy and Rheumatology, KKR Sapporo Medical Center, Sapporo, Japan
| | - Shinji Akioka
- Department of Pediatrics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Norimoto Kobayashi
- Department of Pediatrics, Shinshu University School of Medicine, Matsumoto, Japan
| | - Naomi Iwata
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | | | - Haruna Nakaseko
- Department of Infection and Immunology, Aichi Children's Health and Medical Center, Obu, Japan
| | - Satoshi Sato
- Division of Infectious Disease and Immunology, Saitama Children's Medical Center, Omiya, Japan
| | - Yutaka Nishida
- Department of Pediatrics, School of Medicine, Gunma University, Maebashi, Japan
| | - Tomo Nozawa
- Department of Pediatrics, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Yuichi Yamasaki
- Department of Pediatrics, Kagoshima University Hospital, Kagoshima, Japan
| | - Kazuko Yamazaki
- Department of Pediatrics, Saitama Medical Center, Saitama Medical University, Kawagoe, Japan
| | - Satoru Arai
- Department of Dermatology, St. Luke's International Hospital, Tokyo, Japan
| | - Ichizo Nishino
- Department of Neuromuscular Research, National Institute of Neuroscience, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Masaaki Mori
- Lifetime Clinical Immunology, Tokyo Medical and Dental University, Tokyo, Japan
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de Souza FHC, de Araújo DB, Vilela VS, Bezerra MC, Simões RS, Bernardo WM, Miossi R, da Cunha BM, Shinjo SK. Guidelines of the Brazilian Society of Rheumatology for the treatment of systemic autoimmune myopathies. Adv Rheumatol 2019; 59:6. [PMID: 30670084 DOI: 10.1186/s42358-019-0048-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 01/09/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Recommendations of the Myopathy Committee of the Brazilian Society of Rheumatology for the management and therapy of systemic autoimmune myopathies (SAM). MAIN BODY The review of the literature was done in the search for the Medline (PubMed), Embase and Cochrane databases including studies published until June 2018. The Prisma was used for the systematic review and the articles were evaluated according to the levels of Oxford evidence. Ten recommendations were developed addressing the management and therapy of systemic autoimmune myopathies. CONCLUSIONS Robust data to guide the therapeutic process are scarce. Although not proven effective in controlled clinical trials, glucocorticoid represents first-line drugs in the treatment of SAM. Intravenous immunoglobulin is considered in induction for refractory cases of SAM or when immunosuppressive drugs are contra-indicated. Consideration should be given to the early introduction of immunosuppressive drugs. There is no specific period determined for the suspension of glucocorticoid and immunosuppressive drugs when individually evaluating patients with SAM. A key component for treatment in an early rehabilitation program is the inclusion of strength-building and aerobic exercises, in addition to a rigorous evaluation of these activities for remission of disease and the education of the patient and his/her caregivers.
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Affiliation(s)
| | | | | | | | - Ricardo Santos Simões
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | | | - Renata Miossi
- Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, São Paulo, SP, Brazil
| | | | - Samuel Katsuyuki Shinjo
- Disciplina de Reumatologia, Faculdade de Medicina, Universidade de Sao Paulo, Av. Dr. Arnaldo, 455, 3° andar, sala 3150 - Cerqueira César, Sao Paulo, CEP: 01246-903, Brazil.
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8
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Galimberti F, Kooistra L, Li Y, Chatterjee S, Fernandez AP. Intravenous immunoglobulin is an effective treatment for refractory cutaneous dermatomyositis. Clin Exp Dermatol 2018; 43:906-912. [DOI: 10.1111/ced.13607] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2017] [Indexed: 01/03/2023]
Affiliation(s)
- F. Galimberti
- Cleveland Clinic Lerner College of Medicine; Cleveland OH USA
| | - L. Kooistra
- Case Western Reserve University College of Medicine; Cleveland OH USA
| | - Y. Li
- Cleveland Clinic Lerner College of Medicine; Cleveland OH USA
| | - S. Chatterjee
- Department of Rheumatic and Immunologic Diseases; Cleveland Clinic; Cleveland OH USA
| | - A. P. Fernandez
- Department of Dermatology; Cleveland Clinic; Cleveland OH USA
- Department of Pathology; Cleveland Clinic; Cleveland OH USA
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9
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Abstract
Idiopathic inflammatory myopathies (IIMs) are heterogeneous disorders that affect the skeletal muscles. Polymyositis, dermatomyositis, and inclusion body myositis are major IIM subsets. Immune-mediated necrotizing myopathy became recognized as a potentially new IIM subset. Since the new classification criteria published by the International Myositis Classification Criteria Project have higher sensitivity and specificity for IIM classification and subclassification than the previous criteria, they should help precise diagnosis. It should be noted that several tests available in current clinical practice, such as electromyography, magnetic resonance imaging, and other myositis-specific autoantibodies than anti-Jo-1 antibodies, were not included in the new criteria. As for treatment, glucocorticoids are used empirically as the first-line treatment despite their various adverse effects. Concomitant treatment with steroid-sparing immunosuppressive agents, including methotrexate, azathioprine, calcineurin inhibitors, mycophenolate mofetil, and cyclophosphamide, reduces successfully initial glucocorticoid doses for the remission induction, the relapse risk during glucocorticoid tapering, and adverse effects of glucocorticoids. Treatment with biologics, including rituximab and abatacept, seems promising in some IIM patients. Multi-target treatment with glucocorticoids and several steroid-sparing immunosuppressive agents is effective in refractory IIM patients. Considering proven steroid-sparing efficacy and tolerability of multi-target treatment in patients with other autoimmune diseases, it should be a good therapeutic option for IIMs.
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Affiliation(s)
- Hirokazu Sasaki
- a Department of Rheumatology, Graduate School of Medical and Dental Sciences , Tokyo Medical and Dental University (TMDU) , Tokyo , Japan
| | - Hitoshi Kohsaka
- a Department of Rheumatology, Graduate School of Medical and Dental Sciences , Tokyo Medical and Dental University (TMDU) , Tokyo , Japan
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10
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Abstract
Juvenile dermatomyositis (JDM) is a rare autoimmune disease mainly characterized by muscle and skin involvement. Vasculopathy is considered central to the pathogenesis of the disease. The exact nature of vasculopathy is not yet understood but it is a complex process with both an inflammatory and a non-inflammatory, occlusive component. Impaired function of JDM vasculature includes immune complex deposition, altered expression of cell adhesion molecules predominantly inducing Th17 cell infiltration, and endothelial cell dysfunction. Development of vasculopathy is associated with the severe extra-muscular manifestations of JDM, such as gastrointestinal and cardiac manifestations, interstitial lung disease, ulcerative skin disease or development of calcinosis, and portends a poor prognosis. Correlation of histopathological findings, autoantibodies, and extensive diagnostic workup represent key elements to the early detection of vasculopathic features and early aggressive treatment. Monitoring of vasculopathy remains challenging due to the lack of non-invasive biomarkers. Current treatment approaches provide variable benefit, but better understanding of the essential pathogenic mechanisms should help lead to improved outcomes. Whilst acknowledging that evidence is limited, this review aims to describe the vasculopathy of JDM in the context of pathophysiology, clinical features, and treatment of disease.
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Affiliation(s)
- Charalampia Papadopoulou
- Infection, Inflammation, and Rheumatology Section, UCL Great Ormond Street Institute of Child Health, London, United Kingdom.,Great Ormond Street Hospital NHS Foundation Trust, London, United Kingdom
| | - Liza J McCann
- Department of Pediatric Rheumatology, Alder Hey Children's NHS Foundation Trust, Liverpool, United Kingdom
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11
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Isak V, Jorizzo JL. Recent developments on treatment strategies and the prognosis of dermatomyositis: a review. J DERMATOL TREAT 2017; 29:450-459. [DOI: 10.1080/09546634.2017.1403549] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Affiliation(s)
- Verena Isak
- Department of Dermatology, Wake Forest School of Medicine, Winston Salem, New York, NY, USA
- Medical University of Vienna, Vienna, Austria
| | - Joseph L. Jorizzo
- Department of Dermatology, Wake Forest School of Medicine, Winston Salem, New York, NY, USA
- Department of Dermatology, Weill Cornell Medical College, New York, NY, USA
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12
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Abstract
The idiopathic inflammatory myopathies of childhood consist of a heterogeneous group of autoimmune diseases characterised by proximal muscle weakness and pathognomonic skin rashes. The overall prognosis of juvenile myositis has improved significantly over recent years, but the long-term outcome differs substantially from patient to patient, suggestive of distinct clinical phenotypes with variable responses to treatment. High doses of corticosteroids remain the cornerstone of therapy along with other immunosuppressant therapies depending on disease severity and response. The advent of biological drugs has revolutionised the management of various paediatric rheumatologic diseases, including inflammatory myopathies. There are few data from randomised controlled trials to guide management decisions; thus, several algorithms for the treatment of juvenile myositis have been developed using international expert opinion. The general treatment goals now include elimination of active disease and normalisation of physical function, so as to preserve normal growth and development, and to prevent long-term damage and deformities. This review summarises the newer and possible future therapies of juvenile inflammatory myopathies, including evidence supporting their efficacy and safety.
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13
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Spencer CH, Rouster-Stevens K, Gewanter H, Syverson G, Modica R, Schmidt K, Emery H, Wallace C, Grevich S, Nanda K, Zhao YD, Shenoi S, Tarvin S, Hong S, Lindsley C, Weiss JE, Passo M, Ede K, Brown A, Ardalan K, Bernal W, Stoll ML, Lang B, Carrasco R, Agaiar C, Feller L, Bukulmez H, Vehe R, Kim H, Schmeling H, Gerstbacher D, Hoeltzel M, Eberhard B, Sundel R, Kim S, Huber AM, Patwardhan A. Biologic therapies for refractory juvenile dermatomyositis: five years of experience of the Childhood Arthritis and Rheumatology Research Alliance in North America. Pediatr Rheumatol Online J 2017; 15:50. [PMID: 28610606 PMCID: PMC5470177 DOI: 10.1186/s12969-017-0174-0] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 05/17/2017] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND The prognosis of children with juvenile dermatomyositis (JDM) has improved remarkably since the 1960's with the use of corticosteroid and immunosuppressive therapy. Yet there remain a minority of children who have refractory disease. Since 2003 the sporadic use of biologics (genetically-engineered proteins that usually are derived from human genes) for inflammatory myositis has been reported. In 2011-2016 we investigated our collective experience of biologics in JDM through the Childhood Arthritis and Rheumatology Research Alliance (CARRA). METHODS The JDM biologic study group developed a survey on the CARRA member experience using biologics for Juvenile DM utilizing Delphi consensus methods in 2011-2012. The survey was completed online by the CARRA members interested in JDM in 2012. A second survey was similarly developed that provided more opportunity to describe their experiences with biologics in JDM in detail and was completed by CARRA members in Feb 2013. During three CARRA meetings in 2013-2015, nominal group techniques were used for achieving consensus on the current choices of biologic drugs. A final survey was performed at the 2016 CARRA meeting. RESULTS One hundred and five of a potential 231 pediatric rheumatologists (42%) responded to the first survey in 2012. Thirty-five of 90 had never used a biologic for Juvenile DM at that time. Fifty-five of 91 (denominators vary) had used biologics for JDM in their practice with 32%, 5%, and 4% using rituximab, etanercept, and infliximab, respectively, and 17% having used more than one of the three drugs. Ten percent used a biologic as monotherapy, 19% a biologic in combination with methotrexate (mtx), 52% a biologic in combination with mtx and corticosteroids, 42% a combination of a biologic, mtx, corticosteroids (steroids), and an immunosuppressive drug, and 43% a combination of a biologic, IVIG and mtx. The results of the second survey supported these findings in considerably more detail with multiple combinations of drugs used with biologics and supported the use of rituximab, abatacept, anti-TNFα drugs, and tocilizumab in that order. One hundred percent recommended that CARRA continue studying biologics for JDM. The CARRA meeting survey in 2016 again supported the study and use of these four biologic drug groups. CONCLUSIONS Our CARRA JDM biologic work group developed and performed three surveys demonstrating that pediatric rheumatologists in North America have been using multiple biologics for refractory JDM in numerous scenarios from 2011 to 2016. These survey results and our consensus meetings determined our choice of four biologic therapies (rituximab, abatacept, tocilizumab and anti-TNFα drugs) to consider for refractory JDM treatment when indicated and to evaluate for comparative effectiveness and safety in the future. Significance and Innovations This is the first report that provides a substantial clinical experience of a large group of pediatric rheumatologists with biologics for refractory JDM over five years. This experience with biologic therapies for refractory JDM may aid pediatric rheumatologists in the current treatment of these children and form a basis for further clinical research into the comparative effectiveness and safety of biologics for refractory JDM.
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Affiliation(s)
- CH Spencer
- 0000 0004 0392 3476grid.240344.5Nationwide Children’s Hospital and Ohio State University, Columbus, OH USA
| | - K Rouster-Stevens
- 0000 0001 0941 6502grid.189967.8Emory University School of Medicine, Atlanta, GA USA
| | - H Gewanter
- Pediatric and Adolescent Health Partners, Richmond, VA USA
| | - G Syverson
- 0000 0001 2167 3675grid.14003.36University of Wisconsin-Madison, Madison, WI USA
| | - R Modica
- 0000 0004 1936 8091grid.15276.37University of Florida, Gainesville, FL USA
| | - K Schmidt
- 0000 0001 2113 1622grid.266623.5University of Louisville, Louisville, KY USA
| | - H Emery
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - C Wallace
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - S Grevich
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - K Nanda
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - YD Zhao
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - S Shenoi
- 0000000122986657grid.34477.33Seattle Children’s Hospital, University of Washington, Seattle, WA USA
| | - S Tarvin
- Riley Hospital for Children, Indiana University Medical Center, Indianapolis, IN India
| | - S Hong
- grid.412984.2University of Iowa Health Care, Iowa City, IA USA
| | - C Lindsley
- 0000 0001 2177 6375grid.412016.0University of Kansas Medical Center, Kansas City, KS USA
| | - JE Weiss
- 0000 0004 0407 6328grid.239835.6Sanzari Children’s Hospital, Hackensack University Medical Center, Hackensack, NJ USA
| | - M Passo
- 0000 0000 9075 106Xgrid.254567.7University of South Carolina, Charleston, SC USA
| | - K Ede
- 0000 0001 0381 0779grid.417276.1Phoenix Children’s Hospital, Phoenix, AZ USA
| | - A Brown
- 0000 0001 2200 2638grid.416975.8Texas Children’s Hospital, Houston, TX USA
| | - K Ardalan
- 0000 0004 0388 2248grid.413808.6Lurie Children’s Hospital, Chicago, IL USA
| | - W Bernal
- 0000 0001 2297 6811grid.266102.1University of California, San Francisco, San Francisco, CA USA
| | - ML Stoll
- 0000000106344187grid.265892.2University of Alabama at Birmingham, Birmingham, AL USA
| | - B Lang
- 0000 0004 1936 8200grid.55602.34WK Health Center and Dalhousie University, Halifax, NS Canada
| | - R Carrasco
- Dell Children’s Hospital, Austin, TX USA
| | - C Agaiar
- Children’s Hospital of The Kings Daughter, Norfolk, VA USA
| | - L Feller
- Inland Rheumatology, Waterville, ME USA
| | - H Bukulmez
- 0000 0001 0035 4528grid.411931.fMetro Health Medical Center and Case Western Reserve University, Cleveland, OH USA
| | - R Vehe
- 0000000419368657grid.17635.36University of Minnesota, Minneapolis, MN USA
| | - H Kim
- 0000 0001 2237 2479grid.420086.8National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD USA
| | - H Schmeling
- 0000 0004 1936 7697grid.22072.35Alberta Children’s Hospital, Cumming School of Medicine, University of Calgary, Calgary, AB Canada
| | - D Gerstbacher
- 0000000419368956grid.168010.eLucille Packard Children’s Hospital, Stanford University, Stanford, CA USA
| | - M Hoeltzel
- 0000000086837370grid.214458.eMott Children’s Hospital, University of Michigan, Ann Arbor, MI USA
| | - B Eberhard
- grid.415338.8Cohen Children’s Medical Center of New York, New york, USA
| | - R Sundel
- 0000 0004 0378 8438grid.2515.3Boston Children’s Hospital and Harvard Medical School, Boston, MA USA
| | - S Kim
- 0000 0001 2297 6811grid.266102.1University of California, San Francisco, San Francisco, CA USA
| | - AM Huber
- 0000 0004 1936 8200grid.55602.34WK Health Center and Dalhousie University, Halifax, NS Canada
| | - A Patwardhan
- 0000 0001 2162 3504grid.134936.aSchool of Medicine, University of Missouri, Columbia, MO USA
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Pagnini I, Vitale A, Selmi C, Cimaz R, Cantarini L. Idiopathic Inflammatory Myopathies: an Update on Classification and Treatment with Special Focus on Juvenile Forms. Clin Rev Allergy Immunol 2015; 52:34-44. [DOI: 10.1007/s12016-015-8512-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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15
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Suzuki S, Noda K, Ohira Y, Shikino K, Ikusaka M. Finger stiffness or edema as presenting symptoms of eosinophilic fasciitis. Rheumatol Int 2015; 35:1769-72. [PMID: 26248532 DOI: 10.1007/s00296-015-3338-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 07/30/2015] [Indexed: 11/24/2022]
Abstract
To investigate the clinical features and finger symptoms of eosinophilic fasciitis (EF), we reviewed five patients with EF. The chief complaint was pain, edema and/or stiffness of the extremities. The distal extremities were affected in all patients, and there was also proximal involvement in one patient. One patient had asymmetrical symptoms. All four patients with upper limb involvement had limited range of motion of the wrist joints, and three of them complained of finger symptoms. Two of these three patients showed slight non-pitting edema of the hands, and the other one had subcutaneous induration of the forearm. All four patients with lower limb symptoms had limited range of motion of the ankle joints, and two showed edema or induration of the legs. Inflammatory changes in the joints were not detected in any of the patients. Two patients displayed neither objective induration nor edema, and two patients had muscle tenderness. In conclusion, finger symptoms of patients with EF might be caused by fasciitis of the forearms, which leads to dysfunction of the long finger flexors and extensors as well as slight edema of hands. Limited range of motion of wrist and/or ankle joints indicates sensitively distal muscle dysfunction caused by fasciitis.
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Affiliation(s)
- Shingo Suzuki
- Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan.
| | - Kazutaka Noda
- Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Yoshiyuki Ohira
- Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Kiyoshi Shikino
- Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
| | - Masatomi Ikusaka
- Department of General Medicine, Chiba University Hospital, 1-8-1 Inohana, Chuo-ku, Chiba-shi, Chiba, 260-8677, Japan
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Rider LG, Dankó K, Miller FW. Myositis registries and biorepositories: powerful tools to advance clinical, epidemiologic and pathogenic research. Curr Opin Rheumatol 2014; 26:724-41. [PMID: 25225838 PMCID: PMC5081267 DOI: 10.1097/bor.0000000000000119] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Clinical registries and biorepositories have proven extremely useful in many studies of diseases, especially rare diseases. Given their rarity and diversity, the idiopathic inflammatory myopathies, or myositis syndromes, have benefited from individual researchers' collections of cohorts of patients. Major efforts are being made to establish large registries and biorepositories that will allow many additional studies to be performed that were not possible before. Here, we describe the registries developed by investigators and patient support groups that are currently available for collaborative research purposes. RECENT FINDINGS We have identified 46 myositis research registries, including many with biorepositories, which have been developed for a wide variety of purposes and have resulted in great advances in understanding the range of phenotypes, clinical presentations, risk factors, pathogenic mechanisms, outcome assessment, therapeutic responses, and prognoses. These are now available for collaborative use to undertake additional studies. Two myositis patient registries have been developed for research, and myositis patient support groups maintain demographic registries with large numbers of patients available to be contacted for potential research participation. SUMMARY Investigator-initiated myositis research registries and biorepositories have proven extremely useful in understanding many aspects of these rare and diverse autoimmune diseases. These registries and biorepositories, in addition to those developed by myositis patient support groups, deserve continued support to maintain the momentum in this field as they offer major opportunities to improve understanding of the pathogenesis and treatment of these diseases in cost-effective ways.
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Affiliation(s)
- Lisa G. Rider
- Environmental Autoimmunity Group, Program of Clinical Research, National Institute of Environmental Health Sciences, National Institutes of Health (NIH), DHHS, Bethesda, MD
| | - Katalin Dankó
- Division of Immunology, 3rd Dept. of Internal Medicine, Medical and Health Science Center, University of Debrecen, Debrecen, Hungary
| | - Frederick W. Miller
- Environmental Autoimmunity Group, Program of Clinical Research, National Institute of Environmental Health Sciences, National Institutes of Health (NIH), DHHS, Bethesda, MD
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Clinical course and outcomes of Iranian children with juvenile dermatomyositis and polymyositis. Clin Rheumatol 2014; 33:1113-8. [PMID: 24878926 DOI: 10.1007/s10067-014-2675-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Revised: 05/09/2014] [Accepted: 05/12/2014] [Indexed: 12/23/2022]
Abstract
This study evaluated the clinical features, course, and outcomes of Iranian children with juvenile dermatomyositis (JDM), juvenile polymyositis (JPM), and other uncommon connective tissue disorders. A chart review of 85 Iranian children with JDM and JPM was performed during a 10-year period from 2003 to 2013. The patients' clinical signs and symptoms, laboratory data, and other factors affecting clinical outcomes were recorded using questionnaires. Statistical analysis was performed using SPSS software version 20. In all, 40 boys and 45 girls were included in the study (F/M, 1.1:1). Disease frequency was significantly higher in boys aged <5 years (F/M, 0.4:1) and girls aged >5 years (F/M, 1.6:1). The combined mean age at diagnosis was 7.5 years. Muscle weakness, particularly in the proximal muscles of lower extremities (96 %); fatigue (83 %); and heliotrope rash (71 %) were the most frequently recorded symptoms. Elevated lactate dehydrogenase level was the most common enzyme disturbance (98 %). Monocyclic course was seen in 60 % of patients. The mean treatment duration was 3 years. The incidence rate of complications such as calcinosis, lipodystrophy, and growth disturbances was 20, 9, and 30 %, respectively. The occurrence of these complications in patients with monocyclic disease was significantly lower. Vital organ involvement led to the death of four patients. The incidence of calcinosis was significantly lower in patients having a shorter interval between disease onset and treatment. Two important complications, failure to thrive and lipodystrophy, were significantly higher in patients having antinuclear antibodies. The incidence of the above three complications was higher in patients with polycyclic or continuous chronic disease. Respiratory failure was the most common cause of patient mortality.
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Rider LG, Katz JD, Jones OY. Developments in the classification and treatment of the juvenile idiopathic inflammatory myopathies. Rheum Dis Clin North Am 2013; 39:877-904. [PMID: 24182859 PMCID: PMC3817412 DOI: 10.1016/j.rdc.2013.06.001] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This review updates recent trends in the classification of the juvenile idiopathic inflammatory myopathies (JIIM) and the emerging standard of treatment of the most common form of JIIM, juvenile dermatomyositis. The JIIM are rare, heterogeneous autoimmune diseases that share chronic muscle inflammation and weakness. A growing spectrum of clinicopathologic groups and serologic phenotypes defined by the presence of myositis autoantibodies are now recognized, each with differing demographics, clinical manifestations, laboratory findings, and prognoses. Although daily oral corticosteroids remain the backbone of treatment, disease-modifying anti-rheumatic drugs are almost always used adjunctively and biologic therapies may benefit patients with recalcitrant disease.
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Affiliation(s)
- Lisa G Rider
- Environmental Autoimmunity Group, Program of Clinical Research, National Institute of Environmental Health Sciences, National Institutes of Health, CRC 4-2352, MSC 1301, 10 Center Drive, Bethesda, MD 20892-1301, USA; Myositis Center, Division of Rheumatology, Department of Medicine, George Washington University, G-400, 2150 Pennsylvania Avenue Northwest, Washington, DC 20037, USA.
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Tournadre A. [Therapeutic strategy in inflammatory myopathies (polymyositis, dermatomyositis, overlap myositis, and immune-mediated necrotizing myopathy)]. Rev Med Interne 2013; 35:466-71. [PMID: 24144868 DOI: 10.1016/j.revmed.2013.09.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2013] [Accepted: 09/21/2013] [Indexed: 11/16/2022]
Abstract
Inflammatory myopathies (IM) are a heterogeneous group of autoimmune muscle disorders of unknown origin that share clinical symptoms such as muscle weakness and histological features with the presence in muscle of inflammatory infiltrate. Based on clinical, histological and serological characteristics, IM can be divided into polymyositis, dermatomyositis, overlap myositis, cancer-associated myositis, immune-mediated necrotizing myopathy, and inclusion-body myositis. Because of their resistance to corticosteroids and immunosuppressive drugs, inclusion-body myositis will be treated separately in this issue. Major obstacles in conducting high quality randomized controlled trials in inflammatory myopathies include the low prevalence and the heterogeneity of these diseases as well as the lack of international consensus on the outcome measures. In the absence of adequate controlled therapeutic trials, treatment of these disorders remains largely empirical. Corticosteroids are the cornerstone therapy. Due to the chronic course of the disease, there is a frequent need to use additional immunosuppressive treatment both to improve the disease response and to reduce the side effects of corticosteroids. Intravenous immunoglobulin infusion is a costly treatment option that is reserved in the presence of refractory dermatomyositis based on a trial showing superior efficacy against control in patients with impaired swallowing or with contraindications to immunosuppressive drugs. In patients who fail second-line therapy, which usually consists of methotrexate plus corticosteroids, the diagnosis should be carefully reassessed before considering other treatment options including methotrexate plus azathioprine or biological agents such as rituximab.
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Affiliation(s)
- A Tournadre
- Service de rhumatologie, hôpital Gabriel-Montpied, CHU de Clermont-Ferrand, 63003 Clermont-Ferrand, France.
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Femia A, Vleugels RA. Pediatric Autoimmune Connective Tissue Diseases: An Update on Disease Characteristics, Associations, and Management. CURRENT DERMATOLOGY REPORTS 2013. [DOI: 10.1007/s13671-013-0058-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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Hasija R, Pistorio A, Ravelli A, Demirkaya E, Khubchandani R, Guseinova D, Malattia C, Canhao H, Harel L, Foell D, Wouters C, De Cunto C, Huemer C, Kimura Y, Mangge H, Minetti C, Nordal EB, Philippet P, Garozzo R, Martini A, Ruperto N. Therapeutic approaches in the treatment of juvenile dermatomyositis in patients with recent-onset disease and in those experiencing disease flare: an international multicenter PRINTO study. ACTA ACUST UNITED AC 2013; 63:3142-52. [PMID: 21647864 DOI: 10.1002/art.30475] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To evaluate response to therapy over a 24-month period in a large prospective international cohort of patients with juvenile dermatomyositis (DM). METHODS The study included 145 patients with recent-onset juvenile DM and 130 juvenile DM patients experiencing disease flare, all of whom were <18 years old. Disease activity parameters and therapeutic approaches in 4 geographic areas were analyzed at baseline and at 6, 12, and 24 months. Response was assessed according to the Pediatric Rheumatology International Trials Organization (PRINTO) juvenile DM response criteria, and data were reported "as observed" and in the intent-to-treat (ITT) population. RESULTS Patients with recent-onset juvenile DM at baseline had higher baseline disease activity and greater improvement over 24 months when compared to juvenile DM patients experiencing disease flare at baseline. Methotrexate (MTX) or high-dose corticosteroids were administered more frequently to patients with recent-onset juvenile DM, compared to juvenile DM patients experiencing disease flare, who were more likely to receive cyclosporine. Compared to patients from Western and Eastern Europe, a higher proportion of patients from South and Central America and North America received pulse steroids, and the average steroid dosage was higher in the North American and South and Central American patients. The use of MTX was similar in all 4 regions, while cyclosporin A was more frequently used in Western Europe. In the "as observed" analysis, 57.9% of the patients with recent-onset juvenile DM and 36.4% of the patients experiencing disease flare (P<0.001) reached at least a 70% response by PRINTO criteria at 6 months; these proportions had increased at month 24 to 78.4% and 51.2%, respectively (P<0.001). Corresponding results of the ITT analysis were much lower, with only one-third of the patients able to maintain the initial assigned therapy over 24 months. CONCLUSION Patients with recent-onset juvenile DM are more likely to achieve significant clinical improvement over 24 months, when compared to patients experiencing flares of juvenile DM. Internationally, various therapeutic approaches are used to treat this disease.
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Martin N, Li CK, Wedderburn LR. Juvenile dermatomyositis: new insights and new treatment strategies. Ther Adv Musculoskelet Dis 2012; 4:41-50. [PMID: 22870494 DOI: 10.1177/1759720x11424460] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Juvenile dermatomyositis (JDM) is a rare but complex and potentially life-threatening autoimmune disease of childhood, primarily affecting proximal muscles and skin. Although the cause of JDM remains unknown it is clear that genetic and environmental influences play a role in the aetiology. In contrast to adults with dermatomyositis, children with JDM are more likely to have complications that are thought to indicate a vasculopathic process, such as severe skin disease, with ulceration or calcinosis, gut vasculopathy or central nervous system disease. New treatments are much needed and are becoming available and being tested through international multicentre trials. This review will focus on recent insights into pathogenesis, the assessment of the disease in children and the modern approach to its treatment.
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Twilt M, Feldman BM. An update on the diagnosis and management of juvenile dermatomyositis. ACTA ACUST UNITED AC 2012. [DOI: 10.2217/ijr.12.23] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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Habibi S, Ramanan AV. Juvenile dermatomyositis: A review of clinical features and management. INDIAN JOURNAL OF RHEUMATOLOGY 2012. [DOI: 10.1016/s0973-3698(12)60032-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
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Abstract
PURPOSE OF REVIEW To review recent advances in the treatment of idiopathic inflammatory myopathies (IIMs) with emphasis on new biological agents and on some less commonly used immunosuppressive drugs. RECENT FINDINGS Double-blinded comparison of oral high-dose pulse dexamethasone with standard high daily prednisolone doses showed similar efficacy in the composite score, significantly longer median time to relapse with prednisolone and fewer side effects with dexamethasone treatment. Use of intravenous immunoglobulins (IVIGs) in IIMs is associated with variable results; however, recent retrospective evaluation of IVIGs administration to steroid-resistant patients with esophageal involvement showed good effect. Whereas smaller open studies with rituximab reported a very good efficacy, even in notoriously difficult-to-treat anti-signal recognition particle-positive cases, the double-blind trial has not reached the primary endpoint. Studies with TNF neutralization are reporting results ranging from only a modest or no effect to a promising outcome in the most recent trial with etanercept. Pilot studies suggest efficacy of alemtuzumab in inclusion body myositis and allogeneic mesenchymal stem cell transplantation in polymyositis/dermatomyositis. SUMMARY Unmet need for efficacious therapy in IIMs exists and therefore a coordinated effort is necessary to properly evaluate various new classical and biological agents.
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Zouagui A, Abourazzak S, Idrissi ML, Souilmi FZ, Chaouki S, Atmani S, Bouharrou A, Hida M. Actuality of juvenile dermatomyositis. Joint Bone Spine 2011; 78:235-40. [PMID: 21276742 DOI: 10.1016/j.jbspin.2010.12.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/31/2010] [Indexed: 10/18/2022]
Abstract
Juvenile dermatomyositis is a rare disorder, but remains the most commonly occurring chronic inflammatory myopathy among children. Other than the proximal muscles and skin, which are routinely affected, vasculopathy may affect other viscera and can be multisystemic. A redefinition of the diagnostic criteria is currently underway and is likely to lead to other clinical signs and to sensitive and non-invasive examinations such as MRI. The impact of juvenile dermatomyositis on health and quality of life remains significant despite systemic corticosteroid therapy and immunosuppressor treatment, which have considerably improved the prognosis. Numerous predictors for favourable and pejorative evolution have been identified. The standardisation and the generalisation of clinical assessment tools will make it possible to carry out the clinical trials required to determine the relevance of the new therapeutic options available for children.
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Affiliation(s)
- Amine Zouagui
- Service de Pédiatrie, Hôpital Mère-Enfant, CHU Hassan II, route de Sidi Hrazem, 30000 Fez, Morocco.
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Tournadre A, Dubost JJ, Soubrier M. Treatment of inflammatory muscle disease in adults. Joint Bone Spine 2010; 77:390-4. [DOI: 10.1016/j.jbspin.2010.04.007] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/04/2010] [Indexed: 11/16/2022]
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Stringer E, Bohnsack J, Bowyer SL, Griffin TA, Huber AM, Lang B, Lindsley CB, Ota S, Pilkington C, Reed AM, Scuccimarri R, Feldman BM. Treatment approaches to juvenile dermatomyositis (JDM) across North America: The Childhood Arthritis and Rheumatology Research Alliance (CARRA) JDM Treatment Survey. J Rheumatol 2010; 37:1953-61. [PMID: 20595275 DOI: 10.3899/jrheum.090953] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVE There are a number of different approaches to the initial treatment of juvenile dermatomyositis (JDM). We assessed the therapeutic approaches of North American pediatric rheumatologists to inform future studies of therapy in JDM. METHODS A survey describing clinical cases of JDM was sent to pediatric rheumatologists. The cases described children with varying severity of typical disease, disease with atypical features, or refractory disease. Three open-ended questions were asked following each case: (1) What additional investigations would you order; (2) What medicine(s) would you start (dose, route, frequency, adjustment over time); and (3) What nonmedication treatment(s) would you start. RESULTS The response rate was 84% (141/167). For typical cases of JDM, regardless of severity, almost all respondents used corticosteroids and another medication, methotrexate (MTX) being the most commonly used. The route and pattern of corticosteroid administration was variable. Intravenous immunoglobulin (IVIG) was used more frequently for more severe disease, for refractory disease, and for prominent cutaneous disease. Hydroxychloroquine was often used in milder cases and cases principally characterized by rash. Cyclophosphamide was reserved for ulcerative disease and JDM complicated by lung disease. CONCLUSION For the majority of North American pediatric rheumatologists, corticosteroids and MTX appear to be the standard of care for typical cases of JDM. There is variability, however, in the route of administration of corticosteroids and use of IVIG and hydroxychloroquine.
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Affiliation(s)
- Elizabeth Stringer
- IWK Health Centre, 5850 University Avenue, Halifax, Nova Scotia B3K 6R8.
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Huber AM, Giannini EH, Bowyer SL, Kim S, Lang B, Lindsley CB, Pachman LM, Pilkington C, Reed AM, Rennebohm RM, Rider LG, Wallace CA, Feldman BM. Protocols for the initial treatment of moderately severe juvenile dermatomyositis: results of a Children's Arthritis and Rheumatology Research Alliance Consensus Conference. Arthritis Care Res (Hoboken) 2010; 62:219-25. [PMID: 20191521 DOI: 10.1002/acr.20071] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To use juvenile dermatomyositis (DM) survey data and expert opinion to develop a small number of consensus treatment protocols, which reflect current initial treatment of moderately severe juvenile DM. METHODS A consensus meeting was held in Toronto, Ontario, Canada on December 1-2, 2007. Nominal group technique was used to achieve consensus on treatment protocols, which represented typical management of moderately severe juvenile DM. Consensus was also reached as to which patients these protocols would be applicable (inclusion and exclusion criteria), which initial investigations should be done prior to initiating one of these protocols, which data should be collected to evaluate these protocols, and the concomitant interventions required or recommended. RESULTS Three protocols that described the first 2 months of treatment were developed. All protocols included corticosteroids and methotrexate. One protocol also included intravenous gamma globulin. Consensus was achieved for all issues that were addressed by conference participants, although there were some areas of controversy. CONCLUSION Despite considerable variation in clinical practice, it is possible to achieve consensus on the initial treatment of juvenile DM. Once these protocols are extended beyond 2 months, these protocols will be available for clinical use. By using methods that account for differences between patients (confounding by indication), the comparative effectiveness of the protocols will be evaluated. In the future, the goal will be to identify the optimal treatment of moderately severe juvenile DM.
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Affiliation(s)
- Adam M Huber
- IWK Health Centre and Dalhousie University, Halifax, Nova Scotia, Canada.
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Lau EH, Cowling BJ, Muller MP, Ho LM, Tsang T, Lo SV, Louie M, Leung GM. Effectiveness of ribavirin and corticosteroids for severe acute respiratory syndrome. Am J Med 2009; 122:1150.e11-21. [PMID: 19958895 PMCID: PMC7093860 DOI: 10.1016/j.amjmed.2009.07.018] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 07/23/2009] [Accepted: 07/24/2009] [Indexed: 12/23/2022]
Abstract
OBJECTIVE Ribavirin and corticosteroids were used widely as front-line treatments for severe acute respiratory syndrome; however, previous evaluations were inconclusive. We assessed the effectiveness of ribavirin and corticosteroids as the initial treatment for severe acute respiratory syndrome using propensity score analysis. METHODS We analyzed data on 1755 patients in Hong Kong and 191 patients in Toronto with severe acute respiratory syndrome using a generalized propensity score approach. RESULTS The adjusted excess case fatality ratios of patients with severe acute respiratory syndrome receiving the combined therapy of ribavirin and corticosteroids within 2 days of admission, compared with those receiving neither treatment within 2 days of admission, were 3.8% (95% confidence interval, -1.5 to 9.2) in Hong Kong and 2.1% (95% confidence interval, -44.3 to 48.5) in Toronto. CONCLUSIONS Our results add strength to the hypothesis that the combination of ribavirin and corticosteroids has no therapeutic benefit when given early during severe acute respiratory syndrome infection. Further studies may investigate the effects of these treatments later in disease course.
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Affiliation(s)
- Eric H.Y. Lau
- School of Public Health, The University of Hong Kong, Hong Kong
| | | | - Matthew P. Muller
- St Michael's Hospital, Toronto, Ontario, Canada
- Canadian Severe Acute Respiratory Syndrome Research Network, Toronto, Ontario, Canada
| | - Lai-Ming Ho
- School of Public Health, The University of Hong Kong, Hong Kong
| | - Thomas Tsang
- Center for Health Protection, Department of Health, Hong Kong
| | | | - Marie Louie
- Canadian Severe Acute Respiratory Syndrome Research Network, Toronto, Ontario, Canada
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Wedderburn LR, Rider LG. Juvenile dermatomyositis: new developments in pathogenesis, assessment and treatment. Best Pract Res Clin Rheumatol 2009; 23:665-78. [PMID: 19853831 PMCID: PMC2774891 DOI: 10.1016/j.berh.2009.07.007] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Juvenile dermatomyositis (JDM) is a rare, potentially life-threatening systemic autoimmune disease primarily affecting muscle and skin. Recent advances in the recognition, standardised assessment and treatment of JDM have been greatly facilitated by large collaborative research networks. Through these networks, a number of immunogenetic risk factors have now been defined, as well as a number of potential pathways identified in the aetio-pathogenesis of JDM. Myositis-associated and myositis-specific autoantibodies are helping to sub-phenotype JDM, defined by clinical features, outcomes and immunogenetic risk factors. Partially validated tools to assess disease activity and damage have assisted in standardising outcomes. Aggressive treatment approaches, including multiple initial therapies, as well as new drugs and biological therapies for refractory disease, offer promise of improved outcomes and less corticosteroid-related toxicity.
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Affiliation(s)
- Lucy R Wedderburn
- Rheumatology Unit, Institute of Child Health, University College London, 30 Guilford Street, London WC1N 1EH, UK.
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Ozen S, Wallace C. Editorial and introduction: new developments in paediatric rheumatic diseases. Best Pract Res Clin Rheumatol 2009; 23:583-7. [DOI: 10.1016/j.berh.2009.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Sanner H, Gran JT, Sjaastad I, Flato B. Cumulative organ damage and prognostic factors in juvenile dermatomyositis: a cross-sectional study median 16.8 years after symptom onset. Rheumatology (Oxford) 2009; 48:1541-7. [DOI: 10.1093/rheumatology/kep302] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Baudy AR, Saxena N, Gordish H, Hoffman EP, Nagaraju K. A robust in vitro screening assay to identify NF-kappaB inhibitors for inflammatory muscle diseases. Int Immunopharmacol 2009; 9:1209-14. [PMID: 19596085 DOI: 10.1016/j.intimp.2009.07.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2009] [Revised: 07/02/2009] [Accepted: 07/02/2009] [Indexed: 10/20/2022]
Abstract
Specific therapies are not available for inflammatory muscle diseases. We and others have shown that the pro-inflammatory NF-kappaB pathway is highly activated in these conditions. Since NF-kappaB is an important therapeutic target, we decided to utilize an in vitro screening assay to identify potential inhibitors that block TNF-alpha induced NF-kappaB activation in a C2C12 muscle line stably expressing an NF-kappaB luciferase reporter gene. Upon evaluation of multiple anti-inflammatory agents in undifferentiated myoblasts as well as differentiated myotubes , we found different levels of inhibition depending on the state of differentiation. Interestingly, we found that some drugs that are known to inhibit NF-kappaB in immune cells were not effective in muscle cells. Drug toxicity was assessed for using an MTT cell viability assay, and the validity of the luciferase assay was verified by immunostaining for NF-kappaB nuclear translocation in myoblasts. In conclusion, we have determined the optimal assay conditions for detecting potentially valuable NF-kappaB inhibitors for the first time in a muscle cell line that may have significant therapeutic potential for inflammatory muscle diseases.
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Affiliation(s)
- Andreas R Baudy
- Research Center for Genetic Medicine, Children's National Medical Center, Washington, DC 20010, USA
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Abstract
Intravenous supra-pharmacological doses of corticosteroids are used in various inflammatory and autoimmune conditions because they are cumulatively less toxic than sustained steroid treatment at lower quantitative dosage. Their action is supposed to be mediated through non-genomic actions within the cell. Common indications for use in children include steroid resistant and steroid dependent nephrotic syndrome, rapidly progressive glomerulonephritis, systemic vasculitis, systemic lupus erythematosus, acute renal allograft rejection, juvenile rheumatoid arthritis, juvenile dermatomyositis, pemphigus, optic neuritis, multiple sclerosis and acute disseminated encephalomyelitis. Methylprednisolone and dexamethasone show similar efficacy in most conditions. Therapy is associated with significant side effects including worsening of hypertension, infections, dyselectrolytemia and behavioral effects. Adequate monitoring is essential during usage.
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